Psychoses catatonic

In adult patients, the manifestations of PCP use can be grouped into nine clinical patterns of intoxication. Four of these are called major patterns because they may be associated with severe toxicity and often necessitate hospitalization. Patients with major patterns are usually unpredictable symptoms wax and wane, and the patient may abruptly change from one pattern of intoxication to another. Five other symptom complexes are designated as minor patterns since toxicity is usually mild and of short duration. Major Patterns consist of coma, catatonic syndrome, toxic psychosis, and acute brain syndrome. Minor Patterns are lethargy, bizarre behavior, violent behavior, agitation, and euphoria (McCarron et al. 1981b). 

Toxic Psychosis. Any patient who is not catatonic but has hallucinations, delusions, paranoid ideation, or other psychiatric manifestations is classified as having toxic psychosis. These patients are often difficult to differentiate from those with acute agitated psychosis, and about 25 percent appear manic. 

The mental status examination remains an essential part of the evaluation. Often patients with schizophrenia will appear nnkempt or otherwise oddly dressed. Sometimes they will be friendly and affable, but when they are paranoid, they can be angry and hostile. Patients may have odd stereotypical movements that can become extreme in catatonic states. The patient with schizophrenia is usually quite alert and well oriented to his/her surroundings. This observation helps to distinguish the psychosis of schizophrenia from that of a delirium due to a medical illness or substance use. 

Psychosis A severe loss of contact with reality evidenced by delusions, hallucinations, disorganized speech patterns, and bizarre or catatonic behaviors. 

Catatonia (withdrawn type) is characterized by prolonged immobility, waxy flexibility, posturing, and grimacing. Because catatonic symptoms can also occur in other types of psychosis, they are not specific to schizophrenia. 

In one case, glucocorticoid-induced catatonic psychosis unexpectedly responded to etomidate (104). 

Catatonic schizophrenia is a controversial syndrome, and there is debate about its etiology and treatment. There has been a report of two cases of catatonic schizophrenia successfully treated with clozapine a 49-year-old woman and a 19-year-old man (18). Both responded to clozapine despite being resistant to several conventional and atypical antipsychotic drugs and, in the second case, a course of electroconvulsive therapy. These two cases are intriguing, because the dose of clozapine required to improve catatonia was about double the dose required to improve psychosis significantly (600 mg/day and 750 mg/day). The two patients had common adverse effects of clozapine the first had mild nocturnal hypersalivation and mild/moderate constipation, and the second had moderate nocturnal hypersalivation. 

Dursun SM, Hallak JE, Haddad P, Leahy A, Byrne A, Strickland PL, Anderson IM, Zuardi AW, Deakin JF. Clozapine monotherapy for catatonic schizophrenia should clozapine be the treatment of choice, with catatonia rather than psychosis as the main therapeutic index J Psychopharmacol 2005 19 432-3. 

Four major and five minor clinical patterns of acute phencyclidine intoxication have been described in 1000 patients (7). Major patterns were acute brain syndrome (24.8%), toxic psychosis (16.6%), catatonic syndrome (11.7%), and coma (10.6%). Minor patterns included lethargy or stupor (3.8%) and combinations of bizarre behavior, violence, agitation, and euphoria in patients who were alert and oriented (32.5%). Patients with major patterns of toxicity usually required hospitalization and had most of the complications. Patients with minor patterns generally had mild intoxication and did not require hospitalization, except for treatment of injuries or autonomic effects of phencyclidine. There were various types of injuries in 16%, and aspiration pneumonia in 1.0%. There were 22 cases of rhabdomyolysis (2.2%), and three patients required dialysis for renal insufficiency. One patient who had been comatose died suddenly with a pulmonary embolism. 

Behavioral effects of PCP range from sleep to catatonic detachment to paranoid psychosis to violent hostility. Users are sometimes amnestic for events that occur under the influence of the drug. Psychoses sometimes last for weeks. Users with a previous history of schizophrenia are especially susceptible to the psychotomimetic effects of the drug. The only truly characteristic behavioral effect of PCP use is its high unpredictability. The signs and symptoms of PCP intoxication are summarized in Table 64-4. 

Optimize the dose of mood stabilizing medication(s) before adding on lithium, lamotrigine or antidepressant (e.g., bupropion or an SSRI) if psychotic features are present, add on an antipsychotic ECT used for severe or treatment-resistant depressive episodes or for psychosis or cataton ia... 

Fourth, if response is inadequate, consider ECT for treatment-refractory illness and depression with psychosis or cataton ia ... 

Psychosis is a disorder that is characterized by a number of symptoms. These include difficulty processing information and reaching a conclusion experiencing delusions or hallucinations being incoherent or in a catatonic state or demonstrating aggressive violent behavior. 

Look for evidence of an underlying disorder (e.g. mania, psychosis), plus catatonic symptoms ... 

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