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allowing control of psychotic symptoms with a low dosage of neuroleptics If the dyskinesic syndrome recurs and it is necessary to continue neuroleptic drugs to control psychotic symptoms, informed consent should be obtained Benzodiazepines, buspirone (in doses of 15 60 mg/d), phosphatidylcholine, clonidine, calcium channel blockers, vitamin E, and propranolol all have had limited usefulness in treating the dyskinetic side effects
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In any psychosis, in the large majority of patients the prognosis is excellent for alleviation of positive symptoms such as hallucinations or delusions treated with medication Negative symptoms such as diminished affect and sociability are much more difficult to treat but appear responsive to atypical antipsychotics Unavailability of structured work situations and lack of family therapy are two other reasons why the prognosis is so guarded in such a large percentage of schizophrenic patients Psychosis connected with a history of serious drug abuse has a guarded prognosis because of the central nervous system damage, usually from the drugs themselves and associated medical illnesses
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Freedman R Schizophrenia N Engl J Med 2003 Oct 30;349 (18):1738 49 [PMID: 14585943] Koro CE et al Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population-based nested case-control study BMJ 2002 Aug 3;325(7358):243 [PMID: 12153919] Lieberman JA et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators Effectiveness of antipsychotic drugs in patients with chronic schizophrenia N Engl J Med 2005 Sep 22;353(12):1209 23 [PMID: 16172203] Newcomer JW Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review CNS Drugs 2005;19 Suppl 1:1 93 [PMID: 15998156] Wang PS et al Risk of death in elderly users of conventional vs atypical antipsychotic medications N Engl J Med 2005 Dec 1;353(22):2335 41 [PMID: 16319382]
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Environmental considerations are most important in the individual with a chronic illness, who usually has a history of repeated hospitalizations, a continued low level of functioning, and symptoms that never completely remit Family rejection and work failure are common In these cases, board and care homes staffed by personnel experienced in caring for psychiatric patients are most important There is frequently an inverse relationship between stability of the living situation and the amounts of required antipsychotic drugs, since the most salutary environment is one that reduces stimuli Nonresidential self-help groups such as Recovery, Inc, should be utilized whenever possible They provide a setting for sharing, learning, and mutual support and are frequently the only social involvement with which this type of patient is comfortable Vocational rehabilitation and work agencies (eg, Goodwill Industries, Inc) provide assessment, training, and job opportunities at a level commensurate with the person s clinical condition
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The need for psychotherapy varies markedly depending on the patient s current status and history In a person with a single psychotic episode and a previously good level of adjustment, supportive psychotherapy may help the patient reintegrate the experience, gain some insight into antecedent problems, and become a more self-observant individual who can recognize early signs of stress Insight-oriented psychotherapy is often counterproductive in this type of disorder Research suggests that cognitive behavioral therapy in conjunction with medication management may have some efficacy in the treatment of symptoms of schizophrenia Cognitive behavioral therapy for schizophrenia involves helping the individual challenge psychotic thinking and alters response to hallucinations Family therapy should be given concomitantly to help alleviate the patient s stress and to assist relatives in coping with the patient
MOOD DISORDERS (DEPRESSION & MANIA)
Present in most depressions:
Lowered mood, varying from mild sadness to intense feelings of guilt, worthlessness, and hopelessness Difficulty in thinking, including inability to concentrate, ruminations, and lack of decisiveness Loss of interest, with diminished involvement in work and recreation Somatic complaints such as headache; disrupted, lessened, or excessive sleep; loss of energy; change in appetite; decreased sexual drive Anxiety
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Behavioral techniques (see above) are most frequently used in therapeutic settings such as day treatment centers, but there is no reason why they cannot be incorporated into family situations or any therapeutic setting Many behavioral techniques (eg, positive reinforcement whether it be a word of praise or an approving nod after some positive behavior), can be a powerful instrument for helping a person learn behaviors that will facilitate social acceptance Music from portable digital players with earphones is one of many ways to divert the patient s attention from auditory hallucinations
Present in some severe depressions:
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