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Psychotic disorder — Clinical Guidelines

Overview

Psychotic disorders involve significant disturbances in perception and higher mental functions, characterized by symptoms such as delusions and hallucinations, often seen in conditions like schizophrenia and bipolar disorder 1 19.

Diagnosis

Clinical Presentation: Presence of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms 1 14.

Recommended Tests: Neuroimaging (e.g., MRI) may reveal cerebellar vermis alterations in some cases 1.

Assessment Tools: Structured interviews (e.g., SCID, MINI) for diagnostic criteria 14.

Management

First-Line Treatments:

- Antipsychotics: Amisulpride showed modest efficacy compared to other antipsychotics in cognitive performance 7. - Mood Stabilizers: Valproic acid (VPA) used as a second-line mood stabilizer; predictors of steady-state levels include patient demographics and concomitant medications 2.

Adjunctive Treatments:

- Clozapine: Effective but requires close monitoring for cardiotoxicity and other side effects 13. - Polypharmacy: Avoided due to increased risk of nonadherence and side effects; consider individual patient response 9 16.

Special Populations

Pediatrics: Antipsychotic polypharmacy prevalence varies; careful monitoring for side effects and adherence 15.

Elderly: Increased risk of side effects; careful titration and monitoring of polypharmacy 12.

Comorbidities: Substance use disorders associated with specific personality traits; integrated treatment approaches recommended 8.

Key Recommendations

Utilize Structured Interviews for Diagnosis: Employ standardized tools like SCID or MINI for accurate diagnosis of psychotic disorders (Evidence: Strong 14).

Monitor Serum Levels of Valproic Acid: Regularly assess VPA levels in patients to ensure therapeutic efficacy and minimize side effects (Evidence: Moderate 2).

Exercise Caution with Antipsychotic Polypharmacy: Avoid unnecessary polypharmacy due to risks of nonadherence and increased side effects; tailor treatment based on individual response (Evidence: Moderate 9 16).

Consider Clozapine with Vigilant Monitoring: Use clozapine for treatment-resistant cases but monitor for cardiotoxicity and other adverse effects closely (Evidence: Moderate 13).

Evaluate Personality Traits in Comorbid Substance Use: Assess personality traits in patients with dual diagnosis to inform treatment strategies (Evidence: Moderate 8).

References

1 Dusi N, Esposito CM, Delvecchio G, Prunas C, Brambilla P. Case report and systematic review of cerebellar vermis alterations in psychosis. International clinical psychopharmacology 2024. link 2 Avrahami M, Liwinski T, Eckstein Z, Peskin M, Perlman P, Sarlon J et al.. Predictors of valproic acid steady-state serum levels in adult and pediatric psychiatric inpatients: a comparative analysis. Psychopharmacology 2024. link 3 Fusaroli M, Simonsen A, Borrie SA, Low DM, Parola A, Raschi E et al.. Identifying Medications Underlying Communication Atypicalities in Psychotic and Affective Disorders: A Pharmacovigilance Study Within the FDA Adverse Event Reporting System. Journal of speech, language, and hearing research : JSLHR 2023. link 4 Guerrero-Jiménez M, Carrillo de Albornoz Calahorro CM, Girela-Serrano B, Bodoano Sánchez I, Gutiérrez-Rojas L. Post-Psychotic Depression: An Updated Review of the Term and Clinical Implications. Psychopathology 2022. link 5 Cotes RO, Janjua AU, Broussard B, Lazris D, Khan A, Jiao Y et al.. A Comparison of Attitudes, Comfort, and Knowledge of Clozapine Among Two Diverse Samples of US Psychiatrists. Community mental health journal 2022. link 6 Dijkstra L, Vermeulen J, de Haan L, Schirmbeck F. Meta-analysis of cognitive functioning in patients with psychotic disorders and obsessive-compulsive symptoms. European archives of psychiatry and clinical neuroscience 2021. link 7 Baldez DP, Biazus TB, Rabelo-da-Ponte FD, Nogaro GP, Martins DS, Kunz M et al.. The effect of antipsychotics on the cognitive performance of individuals with psychotic disorders: Network meta-analyses of randomized controlled trials. Neuroscience and biobehavioral reviews 2021. link 8 Oh H, Jang SK, Lee HS, Lee EB, Choi KH. Personality Traits in Individuals with the Dual Diagnosis of Psychosis and Substance Use Disorders: A Comprehensive Review and Meta-Analysis. Journal of dual diagnosis 2021. link 9 Smith RL, Tveito M, Kyllesø L, Jukic MM, Ingelman-Sundberg M, Andreassen OA et al.. Impact of antipsychotic polypharmacy on nonadherence of oral antipsychotic drugs - A study based on blood sample analyses from 24,239 patients. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology 2020. link 10 Ouanes S, Becetti I, Ghuloum S, Hammoudeh S, Shehata M, Ghabrash H et al.. Patterns of prescription of antipsychotics in Qatar. PloS one 2020. link 11 Ivashchenko D, Buromskaya N, Savchenko L, Shevchenko Y, Sychev D. Global trigger tool in child psychiatry: Treatment safety evaluation in adolescents with an acute psychotic episode. The International journal of risk & safety in medicine 2020. link 12 Iversen TSJ, Steen NE, Dieset I, Hope S, Mørch R, Gardsjord ES et al.. Side effect burden of antipsychotic drugs in real life - Impact of gender and polypharmacy. Progress in neuro-psychopharmacology & biological psychiatry 2018. link 13 Curto M, Girardi N, Lionetto L, Ciavarella GM, Ferracuti S, Baldessarini RJ. Systematic Review of Clozapine Cardiotoxicity. Current psychiatry reports 2016. link 14 Scott CL, Resnick PJ. Clinical assessment of psychotic and mood disorder symptoms for risk of future violence. CNS spectrums 2014. link 15 Toteja N, Gallego JA, Saito E, Gerhard T, Winterstein A, Olfson M et al.. Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment. The international journal of neuropsychopharmacology 2014. link 16 Lochmann van Bennekom MW, Gijsman HJ, Zitman FG. Antipsychotic polypharmacy in psychotic disorders: a critical review of neurobiology, efficacy, tolerability and cost effectiveness. Journal of psychopharmacology (Oxford, England) 2013. link 17 Alphs L, Gopal S, Karcher K, Kent J, Sliwa JK, Kushner S et al.. Are the long-acting intramuscular formulations of risperidone or paliperidone palmitate associated with post-injection delirium/sedation syndrome? An assessment of safety databases. Current drug safety 2011. link 18 Rajkumar AP, Jebaraj P, Tharyan P. Multi-drug overdose risperidone, ziprasidone, valproate, trihexyphenidyl, and clonazepam. The Journal of the Association of Physicians of India 2007. link 19 Marneros A. Beyond the Kraepelinian dichotomy: acute and transient psychotic disorders and the necessity for clinical differentiation. The British journal of psychiatry : the journal of mental science 2006. link 20 Menkes DB. The silent expert. The journal of the American Academy of Psychiatry and the Law 2006. link 21 Flint J, Goodwin G. Psychiatric genetics: a genetic basis for health?. Current biology : CB 1999. link80204-8) 22 Pande NR, Gulabani DM. Folie à deux: a socio-psychiatric study. The British journal of psychiatry : the journal of mental science 1990. link 23 Smith CH. Hallucinations, delusions and things that go bump in the night. Alabama medicine : journal of the Medical Association of the State of Alabama 1989. link 24 Bankier RG. Role reversal in folie à deux. Canadian journal of psychiatry. Revue canadienne de psychiatrie 1988. link 25 Hare E. Schizophrenia before 1800? The case of the Revd George Trosse. Psychological medicine 1988. link 26 de Zulueta FI. The implications of bilingualism in the study and treatment of psychiatric disorders: a review. Psychological medicine 1984. link

Psychotic disorder