Schizophrenia and the Psychotic Disorders

Of all the psychotic disorders, schizophrenia is often considered the most devastating (Breier, 1996) and to date no known prevention or cure exists (Carpenter, 1996). At a conference to update professionals on the newer antipsychotic medications several speakers who were psychiatrists stated that because of managed care and its handling of those clients few professionals would compete to serve psychotic disordered clients. The authors sadly concur with the truth of these statements, as there is indeed little interest in building practices that primarily assist clients who suffer from this type of mental illness. 

Clients who suffer from psychosis vary greatly in their responses to medication and other forms of intervention. Therefore, most primary-care practitioners steer away from prescribing medicine for these individuals, although primary care and general medicine physicians often treat conditions such as depression. One major aspect of treatment expectations is that the client with a psychotic disorder is rarely given a prescription and sent home. After assessing the client, extensive monitoring and support 

Most of her history was obtained from medical records from the repeated admissions to mental health facilities. Eva was considered an unreliable historian. When questioned directly, her explanation of dates, times, and events was not consistent with what was obtained from the records. Eva often felt that people persecuted her deliberately and that she often had to 

This case serves to demonstrate how tortured and alienated the schizophrenic client can feel. It also describes many of the behaviors that are characteristic of this condition and how they present a scenario that requires intervention and that cannot be ignored. The unpredictable nature of the 

As we begin to discuss formulating a diagnostic impression for this disorder, two factors must be understood clearly. First, schizophrenia is probably not a single disorder as is so often assumed (Flaum, 1995 McGrath, 

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Grainger DL, Hamilton SH, Genduso LA, et al (1998a). Medical resource use and work and social outcomes for olanzapine compared with haloperidol in the treatment of schizophrenia and other psychotic disorders. Poster presented at the 21st Congress of the CINP, Gla ow, July 1998. 

The same can be said for treating clients who have schizophrenia and other psychotic disorders. They must be stabilized in order to make progress in therapy. As mentioned in Chapter 2, antipsychotic drugs now allow marked improvement among clients with schizophrenia, and the newer, atypical antipsychotic drugs have fewer side effects so clients are more likely to comply with taking their... 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Atypical Antipsychotics. The so-called atypical antipsychotics have revolutionized the treatment of schizophrenia and other psychotic disorders since their introduction in the 1990s. Similarly, they are replacing the older antipsychotics in the treatment of BPAD as well. They offer a similar degree of antimanic efficacy without a lessened long-term risk of tardive dyskinesia. For more information regarding the atypical antipsychotics, please refer to Chapter 4 Schizophrenia. 

Probably the greatest advances in psychiatric medications of the last 15 years have involved the neurotransmitter serotonin. First was the arrival of serotonin-specific antidepressants with fewer side effects and greater safety than their predecessors. More recently, atypical antipsychotics have highlighted the importance of serotonin-dopamine interactions in the optimal treatment of schizophrenia and other psychotic disorders. While these are indeed significant advances, medications that alter serotonin activity are not without their own side effect burden. 

This dilemma may have been solved in part by the atypical antipsychotic drugs described in the following section and is one of the reasons why the atypical antipsychotic agents are rapidly replacing the conventional ones in the treatment of schizophrenia and other psychotic disorders throughout the world. 

Tran PV, Hamilton SH, Kuntz AJ, Potvin JH, Andersen SW, Beasley C Jr, Tollefson GD. Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. J Clin Psychopharmacol 1997 17(5) 407-18. 

As researchers learned more about the neurologic changes involved in psychosis, drugs were developed to specifically treat disorders rather than simply sedate the patient. These antipsychotic drugs, or neuroleptics, as some clinicians refer to them, represent a major breakthrough in the treatment of schizophrenia and other psychotic disorders. 

Chlorpromazine, the first modern drug to be used in the treatment of schizophrenia and other psychotic disorders, was introduced into psychiatry in 1952 [61]. It was followed by a number of other drugs for the treatment of these conditions (e.g., haloperidol, thioridazine). These were also called neuroleptics because of their neurological side effects, such as parkinsonian syndrome and tardive dyskinesia. Tardive dyskinesia is a movement disorder characterized by involuntary movements of the face and limbs. The antipsychotic properties of these drugs were inseparable from the extrapyramidal effects. 

Cambridge, UK Cambridge University Press, 2000 Taylor D. Low-dose typical antipsychotics—a brief evaluation. Psychiatr Bull 2000 24 465-8 Taylor D, Paton C, Kerwin RW. The South London and Maudsley NHS Trust 2003 Prescribing Guidelines, 7th edn. London Martin Dunitz, 2003 Travis MJ. Schizophrenia and other psychotic disorders therapeutic armamentarium. In Biological Psychiatry (D haenen H, den Boer JA, WUlner P, eds). London John WUey, pp 685-700 2003... 

Atypical antipsychotic dmgs are used to treat schizophrenia and other psychotic disorders for patients who do not respond to the typical antipsychotic medication. 

Dittmann RW, Meyer E, Freisleder FJ, Remschmidt H, Mehler-Wex C, Junghanss J, Hagenah U, Schulte-Markwort M, Poustka F, Schmidt MH, Schulz E, Mastele A, Wehmeier PM. Effectiveness and tolerability of olanzapine in the treatment of adolescents with schizophrenia and related psychotic disorders results from a large, prospective, open-label study. J Child Adolesc Psychopharmacol 2008 18(1) 54-69. 

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. 

Although childhood cases are rare (McKenna et ah, 1994), schizophrenia has been identified in children since its earliest descriptions. Despite this, the nosological status of schizophrenia in children was controversial for many years, and the Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. (DSM-II) category childhood schizophrenia included other psychotic disorders in children as well as autistic disorder, limiting the usefulness of early studies. The landmark studies by Kolvin (1971), however, clearly differentiated schizophrenia with onset in childhood from pervasive developmental disorders. 

Schizophreniform disorder in DSM-FV is somewhat different from schizotypal disorder in ICD-10. The diagnosis of schizophreniform disorder requires the identical criteria of schizophrenia (criterion A), except for two differences the total duration of the illness is at least 1 month, but less than 6 months (criterion B), and impaired social or occupational functioning during some part of the illness is not required. The delusional disorder in DSM-IV corresponds more or less to the category persistent delusional disorder of ICD-10, and brief psychotic disorder (DSM-IV) is similar to the ICD-10 category acute and transient psychotic disorder, whereas the shared psychotic disorder of DSM-IV corresponds to induced delusional disorder of ICD-10. 

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