Psychotic symptoms

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Behavioral changes may also occur with the use of the antipsychotic drugs. These changes include an increase in the intensity of the psychotic symptoms, lethargy, hyperactivity, paranoid reactions, agitation, and confusion. A... 

Disulfiram produces a variety of adverse effects, which commonly include drowsiness, lethargy, and fatigue (Chick 1999). Other more serious adverse effects, such as optic neuritis, peripheral neuropathy, and hepatotoxicity, are rare. Psychiatric effects of disulfiram are also uncommon. They probably occur only at higher dosages of the drug and may result from the inhibition by disulfiram of a variety of enzymes in addition to ALDH. Included among the enzymes inhibited by disulfiram is dopamine P-hydroxylase, inhibition of which increases dopamine levels, which in turn can exacerbate psychotic symptoms in patients with schizophrenia and occasionally may result in psychotic or depressive symptoms in patients without schizophrenia. 

Srisurapanont M, Jarusuraisin N, Kittirattanapaiboon P Treatment for amphetamine dependence and abuse. Cochrane Database Syst Rev 4 CD003022, 2001 Srisurapanont M, Ali R, Marsden J, et al Psychotic symptoms in methamphetamine psychotic in-patients. Int J Neuropsychopharmacol 6 347-352, 2003 Substance Abuse and Mental Health Services Administration Overview of Findings From the 2002 National Survey on Drug Use and Health (DHHS Publ No SMA 03-3774). Rockville, MD, Substance Abuse and Mental Health Services Administration, 2003... 

Sensorium. Patients with PCP intoxication can have a clear sensorium, or they can be disoriented, confused, stuporous, lethargic, or comatose. Signs of cerebral stimulation, such as pressured speech, verbigerations, and echolalia, may also occur. Frank psychotic symptoms, including hallucinations, delusions, and paranoid ideation, are not unusual. 

Since early detection and intervention in schizophrenia is important for maximizing outcomes, treatment with antipsychotic medications should begin as soon as psychotic symptoms are recognized. Antipsychotic medications are the cornerstone of therapy for people with schizophrenia, and most patients are on lifelong therapy since non-adherence and discontinuation of antipsychotics are associated with high relapse rates. If other symptoms are present such as depression and anxiety, these symptoms should also be aggressively treated. Additionally, psychosocial treatments should be used concomitantly to improve patient outcomes. 

TABLE 34-2. Disorders That May Present with Psychotic Symptoms... 

Epidemiologic data show that 10% to 30% of patients with schizophrenia develop their first psychotic symptoms prior to their eighteenth birthday. Onset between puberty and age of 18 is sometimes classified as early-onset schizophrenia (EOS) or intermediate onset schizophrenia, and those presenting with symptoms before puberty are classified as very early-onset... 

Psychotic symptoms in late life (greater than 65 years of age) are generally a result of an ongoing chronic illness carried over from younger life however, a small percentage of patients develop psychotic symptoms de novo, defined as late-life schizophrenia. The 6-month prevalence rate of schizophrenia in the elderly is around 1%. However, other illnesses presenting with psychotic symptoms are common in this population, as approximately one-third of patients with Alzheimer s disease, Parkinson s disease, and vascular dementia experience psychotic symptoms. The majority of data for antipsychotic use in the elderly comes from experience treating these other disease states. 

Occasionally, severely depressed patients also will present I with psychotic symptoms ... 

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