Psychosis disorders with psychotic symptoms

The existence of a previous neurological disorder may be a risk factor for treatment-resistant psychosis in metamfetamine abusers (99). It is of particular interest that most of these patients sustained their disorder during childhood. It is not uncommon for metamfetamine patients to continue with psychotic symptoms despite extended periods of abstinence (100). These patients often are labeled as being schizophrenic. This study has shown the importance of considering a history of neurological disorders, especially during childhood, in such patients. 

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 most common indications for antipsychotic drugs are the treatment of acute psychosis and the maintenance of remission of psychotic symptoms in patients with schizophrenia. More recently, the atypical antipsychotics have become part of the standard repertoire for the treatment of bipolar disorder, as discussed in Chapter 5. Antipsychotic drugs also ameliorate psychotic symptoms associated... 

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 the usefulness of the atypical antipsychotics is best documented for the positive symptoms of schizophrenia, numerous studies are documenting the utility of these agents for the treatment of positive symptoms associated with several other disorders (discussed in Chapter 10 see Fig. 10—2). Atypical antipsychotics have become first-line acute and maintenance treatments for positive symptoms of psychosis, not only in schizophrenia but also in the acute manic and mixed manic-depressed phases of bipolar disorder in depressive psychosis and schizoaffective disorder in psychosis associated with behavioral disturbances in cognitive disorders such as Alzheimer s disease, Parkinson s disease, and other organic psychoses and in psychotic disorders in children and adolescents (Fig. 11—52, first-line treatments). In fact, current treatment standards have evolved in many countries so that atypical antipsychotics have largely replaced conventional antipsychotics for the treatment of positive psychotic symptoms except in a few specific clinical situations. 

Data from short-term clinical trials (6 weeks) suggest that quetiapine may be useful for the management of psychotic disorders in patients who do not tolerate the adverse effects of the typical antipsychotic drugs or clozapine (3). The most common adverse effects of quetiapine were dizziness, hypotension, somnolence, and weight gain. Raised hepatic enzymes have also been reported. In addition, two patients with idiopathic Parkinson s disease and psychosis were treated with quetiapine for 52 weeks (4). Psychotic symptoms were successfully controlled without worsening of motor disability. 

Older classifications of psychiatric disorder divided diseases into psychoses and neuroses. The term psychosis is still widely used to describe a severe mental illness with the presence of hallucinations, delusions or extreme abnormalities of behaviour including marked overactivity, retardation and catatonia, usually accompanied by a lack of insight. Psychotic disorders therefore include schizophrenia, severe forms of depression and mania. Psychosis may also be due to illicit substances or organic conditions. Clinical features of schizophrenia may be subdivided into positive symptoms, which include hallucinations, delusions and thought disorder and negative symptoms such as apathy, flattening of affect and poverty of speech. 

Psychotic reactions in people taking amphetamines were first reported many years ago and the question was posed whether it was due to the amphetamines or to co-existing and exacerbated paranoid schizophrenia. In one study, most of the psychotic symptoms remitted before the excretion of amines had fallen to its normal basal value (SED-9, 8). The psychotic syndrome was indistinguishable from paranoid schizophrenia, with short periods of disorientation, and could occur after a single dose (many had taken the equivalent of some 500 mg of amfetamine or metamfetamine orally) with or without simultaneous alcohol, and was most pronounced in addicts (SED-9, 9). Amfetamine psychosis was also seen in 14 people in Australia (1) the predominant hallucinations were visual, which is unusual for schizophrenia (SED-8,11). Similarly, in contrast to schizophrenia, vision was the primary sensory mode in thinking disorders and body schema distortions in 25 amfetamine addicts (50). 

In induced psychotic disorder, the person develops psychosis as a result of an intense relationship and identification with someone who is already psychotic, for example, in folie a deux. Here the person typically has poorly defined self-other boundaries and will begin to mimic psychotic symptoms seen in the other individual. (Psychotic s)nnptoms seen in severe affective disorders and mania and depressive psychoses are covered in chapters 5 and 6.)... 

A number of unapproved uses of antipsy- chotic drugs also exist. CPZ and haloperidol were used early on to treat phencyclidine (PCP)-induced psychosis. Psychoses associ- ated with depression, bipolar disorder, and Alzheimer s disease are commonly treated with haloperidol, risperidone, or olanzapine. Psychotic symptoms in Parkinson s disease patients caused by levodopa and/or dopaminergic agonists have been alleviated with quetiapine, because EPS-prone typical neuroleptics contraindicated in Parkinson s disease. 

Nonpsychotic persons also experience impaired performance as judged by a number of psychomotor and psychometric tests. Psychotic individuals, however, may actually show improvement in their performance as the psychosis is alleviated. The ability of the atypical antipsychotic drugs to improve some domains of cognition in patients with schizophrenia and bipolar disorder is controversial. Some individuals experience marked improvement and for that reason, cognition should be assessed in all patients with schizophrenia and a trial of an atypical agent considered, even if positive symptoms are well controlled by typical agents. 

FIGURE 11-52. Positive symptom pharmacy. First-line treatment of positive symptoms is now atypical antipsychotics (SDA), not only for schizophrenia but also for positive symptoms associated with bipolar disorder, Alzheimer s disease, childhood psychoses, and other psychotic disorders. However, conventional antipsychotics (D2) and benzodiazepines (BZ) are still useful for acute intramuscular administration (in case of emergency), and D2 for monthly depot injections for noncompliant patients, as well as for second-line use after several atypical agents fail. Clozapine (C), polypharmacy, and combinations (combos) are relegated to second- and third-line treatment for positive symptoms of psychosis. 

It is not clear that so-called antipsychotic drugs are superior to other types of drugs with sedative effects but different mechanisms of action. Lithium, benzodiazepines and opium have been shown to be comparable to neuroleptics in the treatment of psychotic states in some studies. The ability of the neuroleptic drugs to reduce the most characteristic symptoms of psychosis such as hallucinations, delusions and thought disorder have often been interpreted as evidence of their specifically antipsychotic or antischizophrenic action (The National Institute of Mental Health Psychopharmacology Service Center Collaborative Study... 

Up to 10% of patients have to be withdrawn from treatment because of psychiatric symptoms. Bromocriptine-induced psychosis is well known and particular caution is warranted in patients with a family history of mental disorders (109). Even very low doses of bromocriptine can cause psychotic reactions (SEDA-9, 126) (SEDA-10, 117), and well-recognized problems include confusion, hallucinations, delusions, and paranoia. 

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