Psychotic illness

The cross-national prescribing database using the same methodology provided a useful and valid comparison of patterns of prescribing psychotropic medications in mental health services in Australia, Thailand, and Malaysia (Ng et al, submitted). The study was carried out in three outpatient mental health centres in North Western Mental Health (NWMH) in Melbourne (September to November 2002), Prince of Songkla University Hospital in Hat Yai (January to March 2003), and Hospital Kuala Lumpur (January to March 2003). The proportions of outpatients treated with a primary diagnosis of a psychotic illness were 91%, 41%, and 75% in the Australian, Thai, and Malaysian samples respectively. Considering psychotropic prescriptions in schizophrenia alone, the majority of patients were prescribed antipsychotics Australia (93.7%), Thailand (92.9%), and Malaysia (97.7%). 

Yucel, M., Wood, S. J., Phillips, L. J. et al. Morphology of the anterior cingulate cortex in young men at ultra-high risk of developing a psychotic illness. Br. J. Psychiat. 182 518-524, 2003. 

They gave twenty-one male and female patients suffering from various psychotic illnesses up to 12 doses of 30-100 mg of atropine. They injected physostigmine, in doses of 8-16 mg ( ) 3A hours after the onset of coma, supplemented by 2 mg every half hour until the patient regained consciousness. They then used supplemental small oral doses of physostigmine as necessary to maintain a clear sensorium (awareness of time, place, and person). 

TABLE 4.4. Medical Illnesses that Can Produce Psychotic Illness ... 

In addition to this partial listing, a wide assortment of medical illnesses can produce a state of delirium, which though distinct from psychotic illnesses often does manifest certain psychotic symptoms like hallucinations and paranoia. 

Fortunately, there are differences between delirium and psychotic illnesses. Delirious patients will more often experience visual or tactile as opposed to auditory hallucinations. In addition, they will often be disoriented that is, they cannot tell you where they are, what time it is, or who you are. By contrast, psychotic patients more commonly experience auditory hallucinations (i.e., they hear voices), and... 

Schizophrenia is a psychotic illness and is one of the most common psychotic disorders (a mental illness in which the sufferer loses contact with reality). About half a million people in the UK suffer from schizophrenia. It affects mainly adolescents and young adults, and there is a genetic component to the disease. Lay terms that have been used for the disorder are insanity, lunacy and madness. Hospitals that catered for such patients were formerly known as lunatic asylums. 

Indications include a wide variety of psychiatric disorders, in the first place schizophrenia, organic psychoses and other acute psychotic illnesses. However they are also of use for the manic phase of bipolar affective disorder and for psychotic depression. Under antipsychotic drug therapy patients become less agitated and restless, withdrawn and autistic patients may become more communicative, aggressive and impulsive behavior diminishes and hallucinations and disordered thinking disappear. 

Surely a 480 percent increase in the number of psychiatric abnormalities over fifty years cannot result solely from dispassionate scientific discovery. The transition from disorder to disease and the proliferation of such diseases are more a function of cultural, economic, and political processes than scientific advances. In fact, the sharpest critics of psychiatry s current stance maintain that, except for a few major psychotic illnesses, there is no evidence that the multiplication of conditions listed as brain diseases in the DSM warrant that designation. 

With generally high prevalence of drug misuse, some detected use is incidental in individuals developing core psychotic illnesses... 

Although more stimulating antidepressants (e.g., bupropion, SSRIs, venlafaxine, or certain MAOIs) do not potentiate alcohol, they can produce insomnia. To minimize this problem, the dose may be given earlier in the day. TCAs may cause episodes of excitement (rare), confusion, or mania, usually in patients with an underlying psychotic illness, suggesting that a preexisting disorder must be present for these drugs to exert any psychotomimetic effects. 

Dopamine agonists are contraindicated in patients with a history of psychotic illness or recent myocardial infarction, or with active peptic ulceration. The ergot-derived agonists are best avoided in patients with peripheral vascular disease. 

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. 

FIGURE 10—2. Positive symptoms are associated not just with schizophrenia, but also with bipolar disorder, schizoaffective disorder, childhood psychotic illnesses, psychotic depression, Alzheimer s disease, and other disorders as well. 

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. 

Physicians use benzodiazepines to treat many disorders, including a number of anxiety disorders. These include acute anxiety, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. In addition, benzodiazepines can be used to treat agitation or anxiety that is caused by other psychiatric conditions such as acute mania, psychotic illness, depression, impulse control disorders, and catatonia or mutism. 

Initially, the neuroleptics were used to manage severe anxiety, agitation, and aggression in individuals with severe mental illness such as schizophrenia, a psychotic illness characterized by delusions, hallucinations, and disorganized, illogical thinking. The first neuroleptic used in schizophrenia was chlorpromazine (Thorazine) in 1952. Additional neuroleptics were later developed to treat a variety of other disorders and conditions in children and adults, including autism, attention-deficit hyperactivity disorder (ADHD), bipolar dis-... 

Buckley N, McManus P. Fatal toxicity of drugs used in the treatment of psychotic illnesses. Br J Psychiatry 1998 172 461 1. 

---