Psychoses/psychotic illness

This discussion of clusters of psychotic symptoms does not constitute diagnostic criteria for any psychotic disorder. It is given merely as a description of several types of symptoms in psychosis to give the reader an overview of the nature of behavioral disturbances associated with the various psychotic illnesses. 

Although schizophrenia is the commonest and best known psychotic illness, it is not synonymous with psychosis but is just one of many causes of psychosis. Schizophrenia affects 1% of the population, and in the United States there are over 300,000 acute schizophrenic episodes annually. Between 25 and 50% of schizophrenia patients attempt suicide, and 10% eventually succeed, contributing to a mortality rate eight times as high as that of the general population. In the United States over 20% of all Social Security benefit days are used for the care of schizophrenic patients. The direct and indirect costs of schizophrenia in the United States alone are estimated to be in the tens of billions of dollars every year. 

This chapter has provided a clinical description of psychosis, with special emphasis on the psychotic illness schizophrenia. We have explained the dopamine hypothesis of schizophrenia, which is the major hypothesis for explaining the mechanism for the positive symptoms of psychosis (delusions and hallucinations). 

The earliest effective treatments for schizophrenia and other psychotic illnesses arose from serendipitous clinical observations rather than from scientific knowledge of the neurobiological basis of psychosis or the mechanism of action of effective antipsychotic agents. Thus, the fist antipsychotic drugs were discovered by accident in the 1950s when a putative antihistamine (chlorpromazine) was serendipitously observed to have antipsychotic effects when tested in schizophrenic patients. Chlorpromazine indeed has antihistaminic activity, but its therapeutic actions in schizophrenia are not mediated by this property. Once chlorpromazine was observed to be an effective antipsychotic agent, it was tested experimentally to uncover its mechanism of antipsychotic action. 

The effect of fenfluramine is usually not one of stimulation but of calmness or drowsiness. However, in predisposed subjects, it can precipitate psychotic illness. Several published cases illustrate this (267). It is wise to avoid fenfluramine in patients prone to endogenous depression or psychosis. 

Butyrophenones are used to treat psychoses including schizophrenia, organic psychosis, paranoid syndrome, acute idiopathic psychotic illnesses, and the manic phase of manic depressive illness. Other uses... 

Developing a psychotic illness - or witnessii psychosis in a relative - can be bewilderii and desperately upsettii. The first experience of care can affect someone s view of services forever, so try to make your contact as positive as possible. Apply Eariy Intervention (El) principles (Box 23.1) to Alex s management, Miiether you are workii in an El service (p6), or a generic CMHT. 

In clinical psychiatric terms, the affective disorders can be subdivided into unipolar and bipolar disorders. Unipolar depression is also known as psychotic depression, endogenous depression, idiopathic depression and major depressive disorder. Bipolar disorder is now recognised as being heterogeneous bipolar disorder I is equivalent to classical manic depressive psychosis, or manic depression, while bipolar disorder II is depression with hypomania (Dean, 2002). Unipolar mania is where periods of mania alternate with periods of more normal moods. Seasonal affective disorder (SAD) refers to depression with its onset most commonly in winter, followed by a gradual remission in spring. Some milder forms of severe depression, often those with an identifiable cause, may be referred to as reactive or neurotic depression. Secondary depression is associated with other illnesses, such as neuro-degenerative or cardiovascular diseases, and is relatively common. 

Psychosis, or psychotic disorder A major psychiatric illness including schizophrenia... 

Brief Psychotic Disorder. This diagnosis also differs from schizophrenia by virtue of the duration of symptoms. The symptoms mnst last less than 1 month, and the patient must return to his/her previous level of social functioning when the illness subsides. Formerly called brief reactive psychosis, an episode of this illness usually arises in reaction to some markedly stressfnl event, thongh this is not always the case. 

Psychotic Disorder Due to Generai Medical Condition. Certain medical illnesses occasionally present with symptoms of paranoid delnsions or hallucinations that resemble schizophrenia (Table 4.4). When these illnesses are snccessfully treated, fnll resolntion of the psychotic symptoms invariably occnrs. All patients presenting with new-onset psychosis shonld nndergo a thorongh medical evaluation including a physical exam, family and personal medical history, and laboratory stndies inclnding electrolytes, thyroid function tests, syphilis screen, vitamin B12 and folate levels, and a CT or MRI brain scan. A lumbar puncture (spinal tap) and electroencephalogram are sometimes also warranted. 

The goals of treatment during the acute phase of illness are to reduce the positive symptoms of schizophrenia and to plan for extended treatment during the maintenance phase. Reducing the positive symptoms quickly is important for at least two reasons. First, the erratic behavior of an acutely psychotic patient can take a tremendous toll, risking arrest, loss of job, suicide, and the alienation of friends and family. Second, there is some evidence that psychosis itself is harmful to the brain. In other words, it may be that the longer the patient is actively psychotic, the worse the prognosis becomes. 

Given the available data, it is extremely important that clinicians evaluate patients with major depression for features of psychosis, because the failure to do so may result in inadequate treatment for the patient. A practical problem encountered by clinicians, however, is the subtlety of delusions. For example, it is not unusual in geriatric depression for patients to present with a somatic preoccupation that borders on delusional. These so-called near delusions may put the patient into the arena of psychotic depression. Some evidence exists that patients with depression with near delusions may respond more favorably to combinations of antidepressants and antipsychotics or ECT. Once the presence of both major depression and psychosis is determined, other psychotic disorders including bipolar disorder and schizophrenic spectrum illness must also be ruled out because this may influence long-term treatment decisions. 

The program is straightforward in its call to start drugging children in the absence of any scientific basis In the absence of treatment data, treatment of childhood bipolar illness is modeled on that of adults. Even if the child shows no signs of psychosis, the most toxic adult drugs are recommended For non-psychotic children, in descending order, treatment should be tried with lithium, divalproex, atypical antipsychotic, combining any of these approaches, and other anticonvulsants plus atypical antipsychotics or conventional antipsychotic. ... 

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