Symptoms psychotic disorders

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. 

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. 

Brief Psychotic Disorder. This disorder occurs in the immediate aftermath of a markedly stressful event (or series of events). It is marked by emotional turmoil in conjunction with one or more psychotic symptoms such as delusions, hallucinations, disorganization, or catatonia. On presentation, a brief psychotic disorder can be difficult to distinguish from psychotic depression or mania. The presence of a precipitating stressor is not always helpful, because episodes of psychotic mood disorders (especially early in the course of illness) are also commonly triggered by stressful life events. Careful evaluation for symptoms of emerging depression or... 

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. 

Delusional Disorder and Schizotypal Personality Disorder. In onr experience, patients with BPD at times resemble those with Clnster A personality disorders or those with an Axis 1 psychotic disorder. Psychotic symptoms in the BPD patient, although intense, tend to arise in the context of some stressor and to be relatively short-lived. This usually takes the form of a brief psychotic disorder. Placing the BPD patient in a structured and supportive environment usually hastens the resolution of these psychotic symptoms. By contrast, the psychotic symptoms of a patient with a delusional disorder or a Cluster A personality disorder are long-term and potentially intractable even with antipsychotic treatment. 

Antipsychotics. Paranoia has long been a recognized symptom of BPD. In addition, these patients are at risk for psychotic decompensation in the face of acute stress. This typically takes the form of an Axis I brief psychotic disorder and often quickly resolves with increased social support and the alleviation of the stressors. 

The transmethylation hypothesis depended on the psychosis of mescaline as an example of how methylated compounds similar in structure to the monoamine neurotransmitters could be psychotogenic, and demonstrated how methionine, the precursor of the methyl donor S-adenosylmethionine, could exacerbate the psychotic symptoms of schizophrenia in patients. This theory was fed by studies of the now notorious pink spot, an amine found in paper chromatography of urine extracts from schizophrenics and thought to be 3,4-dimethoxyphenylethylamine (i.e., O-methylated dopamine). Subsequent studies eventually identified this as another compound or compounds, primarily of dietary origin. Another methylated derivative erroneously proposed to be found in higher quantities in schizophrenia was dimethyltryptamine. This compound is similar in structure to LSD, the hallucinogenic nature of which was the key to the serotonin deficiency hypothesis, which proposed that the known antagonism of serotonin (5-HT) by LSD indicated that psychotic disorders such as schizophrenia may result from a hypofunction of 5-HT. 

Psychotic symptoms must be distinguished from obsessions with poor or variable insight and overvalued ideation. Other positive or negative symptoms of a psychotic disorder may be present and the nature of the obsessions is often atypical and associated with a de-... 

The most commonly used semi-structured diagnostic scale is the Structured Clinical Interview for DSM-IV Axis I Disorders (SCI I) First et al., 1997). A clinical version of the SCID (SCID-CV) is designed for use in clinical settings and covers the most commonly seen diagnoses according to DSM-IV. The research version of the SCID includes ratings for different subtypes, severity and course specifiers of mental disorders. The SCLD-CV contains six modules (A) Mood Episodes (B) Psychotic Symptoms (C) Psychotic Disorders (D) Mood Disorders (E) Substance Use Disorders fF) Anxiety and Other Disorders. 

In shared psychotic disorder (e.g., folie a deux), a close friend or relative passively accepts the delusional belief system of the more dominant member. Thus, the symptoms may not necessarily be truly delusional, and often remit when the individual is separated from the inducer or primary case. ... 

All clinically effective antipsychotics block DA receptor activity. Further, stimulation of this neurotransmitter can induce psychotic symptoms de novo or exacerbate an existing psychotic disorder. Atypical agents have differential impacts on other systems (e.g., 5-HT) in comparison with the earlier neuroleptic agents. They also selectively target specific DA tracts that may mediate the pathological condition, while sparing those tracts that mediate the unwanted adverse effects (e.g., EPS, TD). 

An important implication of this observation is the suggestion that early intervention in schizophrenia could substantially alter the natural course of the illness. To investigate this idea, early-intervention projects have been developed. In one, primary physicians were trained to recognize the early symptoms of a mental disorder and to arrange consultation with an intervention team who assessed and treated the disorder. If early symptoms were present, the functional psychotic disorder was treated with low doses of the appropriate medication, often for a relatively short period of time (i.e., several weeks), and then tapered when symptoms abated while psychosocial intervention was continued. In some patients, symptoms returned and medication was reinstituted. The psychosocial program, social skills training, and social casework were continued for some time, and all patients were monitored for at least 2 years. Epidemiological data established that over the lifetime of this project, 7.5 new cases would be expected for 100,000 patients (227, 228). 

Recent case reports have suggested that atypical antipsychotics may also benefit patients with PTSD. For example, low doses of risperidone in combination with an antidepressant or mood stabilizer were reported effective for nightmares and flashbacks in patients with treatment-refractory PTSD ( 292). Both clozapine and olanzapine have also been reported to reduce PTSD symptoms in patients with a co-morbid psychotic disorder ( 293, 294). Finally, olanzapine added to fluoxetine resulted in significant improvement of hyperarousal symptoms in a patient with treatment-refractory PTSD caused by severe childhood physical and sexual abuse (295). 

Therefore, psychosis can be considered to be a set of symptoms in which a person s mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others are impaired. Psychotic disorders have psychotic symptoms as their defining features, but there are other disorders in which psychotic symptoms may be present but are not necessary for the diagnosis. 

Those disorders that require the presence of psychosis (Table 10—1) as a defining feature of the diagnosis include schizophrenia, substance-induced (i.e., drug-induced) psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder due to a general medical condition. Disorders that may or may not have psychotic symptoms (Table 10—2) as an associated feature include mania and depression as well as several cognitive disorders such as Alzheimer s dementia. 

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. 

FIGURE 10—6. Depressive and anxious symptoms are not only a hallmark of major depressive disorder but are frequently associated with other psychiatric disorders, including bipolar disorder, schizophrenia, and schizoaffective disorder with organic causes of depression, such as substance abuse with childhood mood disorders (child) with psychotic forms of depression and with mood and psychotic disorders resistant to treatment with drugs (treatment-resistant), among others. 

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. 

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. 

SCHIZOPHRENIA A medical condition that falls under the category of psychotic disorders. People with schizophrenia suffer from a variety of symptoms, including confusion, disordered thinking, paranoia, hallucinations, emotional numbness, and speech problems. 

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