Psychotic disorders

About 1% of the population has a diagnosed psychotic disorder. These disorders affect men and women equally. They typically emerge during adolescence or early adulthood. They tend to run in families but having a parent with a psychotic illness increases a child's chance of having the same illness by only 10% compared to the general population.

Medications used to treat psychosis

Antipsychotic medications are the primary line of defense against psychosis. They help control the symptoms of psychosis (hallucinations and delusions), but they can also help prevent a psychotic episode. An overactive dopamine system may be one cause of the hallucinations and delusions of psychosis. Antipsychotics moderate and regulate the level of chemical activity so that people can live calmer, more productive lives.

Typical antipsychotics are an older group of medications that strongly block dopamine D2. but can have unpleasant and sometimes permanent side effects, such as tardive dyskinesia. They have a high rate of extrapyramidal side effects including tremor, rigidity, and akathisia (a sense of inner restlessness). They also cause some people to have irreversible (usually) involuntary movements of the face and extremities called tardive dyskinesia (TD). TD can occur months or years after an individual starts or stops these medications. First-generation antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), perphenazine (Trilafon), and haloperidol (Haldol).

Atypical antipsychotics are a newer class of medications that block serotonin receptors to a greater degree than dopamine receptors. Side effects are generally well-tolerated, but can include weight gain, the risk of diabetes, and metabolic syndrome. Although the rates of TD are much lower than with typical antipsychotics. it remains a possibility.  Second-generation antipsychotics include aripiprazole (Abilify), brexpiprazole (Rexulti), cariprazine (Vraylar), clozapine (Clozaril), olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), lurasidone (Latuda), and ziprasidone (Geodon).

Clozapine (Clozaril) stands out as being effective for treatment-resistant schizophrenia and reducing suicide risk, but it should not be the first course of action. It can reduce white blood cell counts, so patients taking it must have regular blood tests. 

Treating elders with antipsychotics requires care, because seniors are more susceptible to side-effects. Certain medications are not advised and, in general, doses are one-third to one-half that used in younger adults.

Mood stabilizers may be used in conjunction with antipsychotics to treat people with schizoaffective disorder or bipolar disorder with psychotic features.

The role of therapy in treating psychotic disorders

Many clinicians assume that people with psychotic disorders cannot benefit from psychotherapy. However, many clients whose symptoms are controlled by medication benefit from psychoeducation as well as supportive therapy. Psychoeducation can help people have more insight into their illness, be more compliant with medication, and cope better with paranoid thoughts and auditory hallucinations (hearing voices). Cognitive therapy helps clients deal with stress, which is a key trigger for psychotic episodes. It can also help clients function better "in the real world" by identifying negative ideas and replacing them with more constructive, appropriate ones. Finally, therapy allows the psychiatrist to monitor the client and make medication adjustments, with the hope of avoiding hospitalization.

Types of psychotic disorders

Schizophrenia

Schizophrenia is the most common psychotic disorder. People with this disorder usually have hallucinations and/or delusional thinking plus disorganized speech that persists more than 6 months. Doctors and researchers often talk about three types of symptoms: positive, negative, and cognitive. Positive symptoms are the psychotic symptoms that can be observed, such as delusions and hallucinations. Negative symptoms are also called deficit symptoms. These are things that the patient is lacking or limited in, such as diminished speech, decreased range of affect, and limited interests/pleasure. Cognitive symptoms are impairments in executive functions such as insight and judgment. It is the negative and cognitive symptoms that cause functional impairment.

Schizophreniform disorder

Schizophreniform disorder is diagnosed when an individual has symptoms of schizophrenia that last less than 6 months.

Schizoaffective disorder

Schizoaffective disorder is diagnosed when people have pronounced symptoms of a mood disorder (depression or mania) along with positive symptoms of schizophrenia, such as hallucinations or delusional thinking. The psychotic symptoms of schizoaffective disorder tend to come and go, but they persist in schizophrenia. The diagnosis of schizoaffective disorder requires the presence of psychotic symptoms for at least a few weeks, even when the individual is not experiencing mania or depression. People with the depressive form of this illness experience mainly depression. People with bipolar schizoaffective disorder experience both mania and depression.

Bipolar I disorder with psychosis

Psychosis can occur in those with bipolar disorder during depressive and manic episodes, but it most common during manic episodes. During a manic episode, people with this disorder may have grandiose delusions. During depressive episodes, the individual may have paranoid delusions. In both cases, delusions may be accompanied by auditory or visual hallucinations (and, less commonly, hallucinations of taste or feeling). The difference between bipolar disorder with psychotic features and schizoaffective disorder is that people with schizoaffective disorder may experience delusions or hallucinations without a change in mood. In bipolar individuals, psychosis is always accompanied by a mood change.

Brief psychotic disorder

An individual can react with a short psychotic episode to an extremely stressful event. It usually lasts less than a month and does not return.

Substance-induced psychotic disorders

Use of, or withdrawal from, substances like alcohol and methamphetamines can result in psychotic delusions and hallucinations.

Illness-related psychoses

Brain tumors or other illnesses can sometimes result in psychosis.

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