Drug for Psychoses

Psychosis does not have a single definition but is a clinical descriptor applied to someone
who is out of touch with reality. Psychotic symptoms can be associated with many illnesses,
including dementias and delirium that may have metabolic, infectious, or endocrinologic causes.
Psychotic symptoms are also common in patients with mood disorders such as major depression,
schizophrenia, and bipolar disorder. Psychosis can also be caused by many drugs (e.g.,
phencyclidine, opiates, amphetamines, cocaine, hallucinogens, anticholinergic agents, alcohol).
Psychotic disorders are characterized by loss of reality, perceptual deficits such as hallucinations
and delusions, and deterioration of social functioning. Schizophrenia is the most common of the
several psychotic disorders defined by the American Psychiatric Association in the Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition, Text Revised (DSM-IVR).
Psychotic disorders are extremely complex illnesses that are influenced by biologic,
psychosocial, and environmental circumstances. Some of the disorders require several months of
observation and testing before a final diagnosis can be determined. It is beyond the scope of this
text to discuss psychotic disorders in detail, but general types of symptoms associated with
psychotic disorders will be described. A delusion is a false or irrational belief that is firmly held
despite obvious evidence to the contrary. Delusions may be persecutory, grandiose, religious,
sexual, or hypochondriacal. Delusions of reference—in which the patient attributes a special,
irrational, and usually negative significance to other people, objects, or events, such as song
lyrics or newspaper articles, in relation to self—are common. Delusions may be defined as
“bizarre” if they are clearly irrational and do not derive from ordinary life experiences. A
common bizarre delusion is the patient’s belief that his or her thinking process, body parts, or
actions or impulses are controlled or dictated by some external force. Hallucinations are false
sensory perceptions that are experienced without an external stimulus and seem real to the
patient. Auditory hallucinations experienced as voices that are characteristically heard
commenting negatively about the patient in the third person, are prominent among patients with
schizophrenia. Hallucinations of touch, sight, taste, smell, and bodily sensation also occur.
Disorganized thinking is commonly associated with psychoses. These thought disorders may
consist of a loosening of associations or a flight of ideas so that the speaker jumps from one idea
or topic to another unrelated one (derailment) in an illogical, inappropriate, or disorganized way.
Answers to questions may be obliquely related or completely unrelated (tangentiality). At its
most serious, this incoherence of thought extends into pronunciation itself, and the speaker’s
words become garbled or unrecognizable. Speech may also be overly concrete (loss of ability to
think in abstract terms) and inexpressive; it may be repetitive and may convey little or no real
information. Disorganized behavior is another common characteristic of psychosis. Problems
may be noted with any form of goal-directed behavior, leading to difficulties with performing
activities of daily living (ADLs), such as organizing meals or maintaining hygiene. The patient
may appear markedly disheveled, may dress in an unusual manner (e.g., wearing several layers
of clothing, scarves, and gloves on a hot day), or may display clearly inappropriate sexual
behavior (e.g., public masturbation) or unpredictable, nontriggered agitation (e.g., shouting,
swearing). Disorganized behavior must be distinguished from behavior that is merely aimless or
generally not purposeful and from organized behavior that is motivated by delusional beliefs.
 Changes in effect may also be symptoms of psychosis. Emotional expressiveness is
diminished; there is poor eye contact and reduced spontaneous movement. The patient appears to
be withdrawn from others, and the face appears to be immobile and unresponsive. Speech is
often minimal, with only brief, slow, monotone replies given in response to questions. There is a
withdrawal from areas of functioning that affect interpersonal relationships, work, education, and
self-care.

Pharmacologic treatment of psychosis includes several classes of drugs. The most

specific are the first- and second-generation antipsychotic agents, but benzodiazepines are often
used to control acute psychotic symptoms. Antipsychotic (also known as neuroleptic)
medications can be classified in several ways. Traditionally, they have been divided into
phenothiazines and nonphenothiazines. Antipsychotic medications can also be classified as low-
potency or high-potency drugs. The terms low potency and high potency refer only to the
milligram doses used for these medicines and not to any difference in effectiveness (e.g., 100 mg
of chlorpromazine, a low-potency drug, is equivalent in antipsychotic activity to 2 mg of
haloperidol, a high-potency drug). Chlorpromazine and thioridazine are low-potency drugs,
whereas trifluoperazine, fluphenazine, thiothixene, haloperidol, and loxapine are high-potency
drugs. Since 1990, antipsychotic medications have also been classified as typical (first-
generation) antipsychotic agents or atypical (second-generation) antipsychotic agents based on
their mechanism of action. The atypical antipsychotic agents are aripiprazole, clozapine,
olanzapine, quetiapine, risperidone, and ziprasidone.
Patients who begin antipsychotic drug therapy can expect some therapeutic effects such
as reduced psychomotor agitation and insomnia within 1 week of starting treatment. However,
reduction in hallucinations, delusions, and thought disorders often requires 6 to 8 weeks for a full
therapeutic response to be achieved. Rapid increases in dosages of antipsychotic medications
will not reduce the antipsychotic response time but will increase the frequency of adverse effects.
Antipsychotic medicines may produce extrapyramidal effects. Tardive dyskinesia may be
reversible during its early stages, but it becomes irreversible with continued use of the
antipsychotic medication. Regular assessment for tardive dyskinesia should be performed for all
patients receiving antipsychotic drugs. Older adult patients should be observed for hypotension
as well as tardive dyskinesia.
Fluphenazine is a typical antipsychotic used for the symptomatic management of
psychosis in patients with schizophrenia. There is a long-acting fluphenazine decanoate
formulation used primarily as maintenance therapy for chronic schizophrenia and related
psychotic disorders in patients who do not tolerate oral formulations or in patients where
medication compliance is a concern of the provider. It is a first-generation antipsychotic.