Monthly Archives: April 2013

Psychosis & Schizophrenia: What’s in a name?

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Psychosis?

this way that way

In general, psychosis refers to the presence of hallucinations (false perceptions), delusions (false, fixed ideas, which carry overwhelming significance for the patient), loss of insight, ipseity disturbance and thought disorder. For over 100 years the psychoses have been divided into organic and functional categories.

Organic denotes an identifiable systemic or central pathology. Organic psychoses can be secondary to endocrine disorders (thyroid disease); metabolic disease (acute intermittent porphyria); autoimmune disorders (paraneoplastic limbic encephalitis, NMDA receptor encephalitis [Link]); infection (herpes simplex encephalitis); seizures (temporal lobe epilepsy); space-occupying lesions; stroke; head-injury; demyelinating diseases (metachromatic leukodystrophy); neurodegenerative disease (Lewy-body dementia); basal ganglia disorders (Wilson’s disease); nutritional deficiencies (B12 deficiency); medications (acyclovir); environmental toxins (thallium); and psychoactive drugs (LSD, ketamine, cannabis and stimulants [Link]).

The identification of an organic psychosis depends upon a thorough history, physical examination and the prudent use of laboratory investigations. Identification of an organic cause of the psychosis can dramatically change the subsequent management and prognosis.

Functional psychoses are diagnoses of exclusion (i.e. exclusion of identifiable organic pathology). There are as yet no diagnostic tests. Diagnosis is made of clinical grounds (symptoms/signs) according to the criteria in the Diagnostic & Statistical Manual of the American Psychiatric Association (APA, DSM-IV-TR) or the International Classification of Diseases of the World Health Organisation (WHO, ICD-10) [Link]. The two classification systems are broadly similar. They subdivide the functional psychoses into schizophrenia (paranoid type, disorganised/hebephrenic type, catatonic, undifferentiated, residual [and simple in ICD-10]); persistent delusional disorders, schizophreniform disorder (DSM-IV-TR), brief psychotic disorders and schizoaffective disorder. Psychotic symptoms can also occur in bipolar disorder and major depressive disorder.

Schizophrenia?

For a DSM-IV-TR diagnosis of schizophrenia, the following criteria must be met: 1.The presence of characteristic symptoms [at least two, (or one if delusions are bizarre/or if auditory hallucinations form a running commentary or discuss the patient.)] for most of the time for one month (or less if treated), which can be delusions, hallucinations, disorganised speech, grossly disorganised behaviour or negative symptoms (blunted affect, alogia or avolition). 2. Social or occupational dysfunction. 3. Continuous signs of disturbance for six months (including one month of psychotic symptoms). Caveats are that the symptoms cannot be secondary to a mood disorder, a pervasive developmental disorder, or as a result of an identifiable organic illness – (the last of which would takes us back to the top of the page here).

 

Guidelines for the Management of Bipolar Disorder.

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The first German-language guidelines for the management of bipolar disorder were published in 2012, and now, an abbreviated English translation is available online for free [link].

The German Society for Bipolar Disorder (DGBS) and the German Association for Psychiatry & Psychotherapy (DGPPN) set up a project group, a steering group and 6 working groups made up of psychiatrists, psychotherapists, patients and their families. Devoid of any industry funding, their intention was to provide “decision-making support for patients, their families, and therapists“. Following an extensive literature review, and ten consensus conferences they concluded:

“Bipolar disorder should be diagnosed as early as possible. The most extensive evidence is available for pharmacological monotherapy; there is little evidence for combination therapy, which is nonetheless commonly given. The appropriate treatment may include long-term maintenance treatment, if indicated. The treatment of mania should begin with one of the recommended mood stabilizers or antipsychotic drugs; the number needed to treat (NNT) is 3 to 13 for three weeks of treatment with lithium or atypical antipsychotic drugs. The treatment of bipolar depression should begin with quetiapine (NNT = 5 to 7 for eight weeks of treatment), unless the patient is already under mood-stabilizing treatment that can be optimized. Further options in the treatment of bipolar depression are the recommended mood stabilizers, atypical antipsychotic drugs, and antidepressants. For maintenance treatment, lithium should be used preferentially (NNT = 14 for 12 months of treatment and 3 for 24 months of treatment), although other mood stabilizers or atypical antipsychotic drugs can be given as well. Psychotherapy (in addition to any pharmacological treatment) is recommended with the main goals of long-term stabilization, prevention of new episodes, and management of suicidality. In view of the current mental health care situation in Germany and the findings of studies from other countries, it is clear that there is a need for prompt access to need-based, complex and multimodal care structures. Patients and their families need to be adequately informed and should participate in psychiatric decision-making“.

The abridged guidelines (in English) are available here.

 

Baclofen & Topiramate for Alcohol Dependence?

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A new paper appraises promising strategies for the treatment of drug addiction in general. The authors consider agents which target GABA transmission, ion-channels and the emerging technique of repetitive transcranial magnetic stimulation (rTMS). In their elegant review of the field, perhaps the most noteworthy findings involve the treatment of alcohol dependence with either baclofen or topiramate.

Baclofen

Baclofen is a GABA-b agonist, which has been used in neurology for years. Several open-label studies, and 2 out of 3 randomised controlled trials (RCTs) have suggested that baclofen is effective in alcohol dependence by reducing cravings and promoting abstinence. Baclofen is safe (even in subjects with liver cirrhosis) and is generally well tolerated with sedation being the most notable side-effect. Higher doses of baclofen appear to be more effective, but this needs confirmation in further RCTs.

Topiramate

Topiramate enhances inhibitory and dampens excitatory currents in neurons, and has been used as an anticonvulsant for years. In 2 relatively large RCTs, topiramate was effective in alcohol dependence, by reducing cravings and the severity of dependence, and improving physical and psychosocial outcomes. Topiramate is generally well tolerated, although cognitive side effects can occur, and it should be avoided in pregnancy.

The full paper can be read here.