Primary Psychotic Illness Research Articles

Substance-Induced Psychotic Disorder

A clinical dilemma is how to clearly differentiate a substance-induced psychotic disorder (SIPD) from a primary psychotic illness or a psychotic illness with comorbid substance use. Symptoms of SIPD include but are not limited to paranoia and hallucinations, negative symptoms, disinhibition or dreaminess, and/or sensations of heightened awareness. In cocaine use, there also exist paranoid delusions and hallucinations. While there is no definitive standard of treatment to address SIPD, management of such disorders tends to vary depending on substances used, clinical symptomatology, dosage, frequency, and chronicity, among other variables. Given that the relationship between SIPD and the development of several mental illnesses is well established, a long-term follow-up period is needed to identify, prevent, and effectively treat further relapses. [ Psychiatr Ann . 2023;53(4):166–170.]

Drug-Induced Psychosis: Causes, Symptoms, and Treatment

IntroductionA relationship between drug abuse and the onset of psychotic symptoms is strongly supported. A struggling clinical dilemma is how to clearly identify a substance-induced psychosis from a primary psychotic illness or a psychotic illness with comorbid substance use.ObjectivesIn this review, the presence of associated psychotic symptoms and the differences in clinical presentation will be analyzed for each substance.MethodsΑ bibliographical review was performed using the PubMED platform. All relevant articles were found using the keywords: substance-Induced Psychoses, symptoms, treatmentResultsPresent review shows a picture of the complex relationship between psychotic symptoms and the use and abuse of illicit drugs. Furthermore, in most cases, chronological criteria are not sufficient to prove a direct causal effect between the substance and psychosis. The subjects who presented psychotic symptoms after substance abuse seemed to have a higher risk of the development of a primary psychotic illness.ConclusionsPsychosis due to substance abuse is a common issue in clinical practice and the propensity to develop psychosis seems to be associated with the severity of use and dependence.Disclosure of InterestNone Declared

Approach to acute psychosis in older adults.

Approach to acute psychosis in older adults.

Understanding the Impact of COVID-19 on People with Severe and Persistent Mental Illness within Rehabilitation Services: A Thematic Analysis

The COVID 19 pandemic has required major changes in healthcare delivery. This study sought to understand the impact of the mental healthcare changes associated with COVID-19 on people living with severe and persisting mental illness (SPMI) and staff working in rehabilitation teams in Queensland in Australia. Telephone interviews were completed with participants diagnosed with SPMI who were supported by the rehabilitation teams of a public mental health service (n = 18). Additionally, an anonymous survey was completed with staff from these teams (n = 20, 17.5% of staff). Both datasets were analysed separately using thematic analysis. Four themes were identified through the analysis of the patient interviews: wishing the whole thing would go away; [COVID-19 has] delayed my recovery; being more socially aware; and (you've) got to be clean (which is a) good thing. Four themes emerged through the analysis of the staff survey data: needing to change the model of care; impact on patients, the impact on staff, positive impact. The perceived impact on participant’s mental health was like that which was reported in the general population. Participants’ emphasised anxiety, loneliness, boredom, and depression rather than a relapse of their primary psychotic illness. Participants noted the pandemic slowed the pace of personal recovery and limited the delivery of specialised rehabilitation programs.

Visual phenomenology in schizophrenia and post-traumatic stress disorder: an exploratory study.

Visual experiences such as hallucinations are commonly reported by people with psychosis, psychological trauma and dissociative states, although questions remain about their similarities and differences. For diagnostic and therapeutic purposes, clinical research must better delineate and compare the characteristics of these experiences in post-traumatic stress disorder (PTSD) and in schizophrenia. To compare visual phenomena and dissociation in participants with a primary psychotic illness and those with a trauma diagnosis. A quantitative group design study comparing visual phenomena in three participant groups who also have a history of hearing voices: schizophrenia and no trauma history (n = 19), PTSD with dissociation (n = 17) and comorbid schizophrenia and PTSD (n = 20). Validated clinical measures included the North-East Visual Hallucination Interview, PTSD Symptoms Scale Interview, Clinician Administered Dissociative States Scale, Psychotic Symptoms Rating Scales and Positive and Negative Syndrome Scale. There was a remarkable similarity in visual experiences, including rates of complex visual hallucinations, between the three diagnostic groups. There were no significant differences in the severity or components of distress surrounding the visual experiences. Dissociation predicted visual hallucination severity for the comorbid schizophrenia and PTSD group, but not for PTSD or schizophrenia alone. Visual experiences in PTSD can include visual hallucinations that are indistinguishable from those experienced in schizophrenia. Multimodal hallucinations are frequently observed in both schizophrenia and PTSD. A model for visual hallucinations in PTSD is suggested, following two separate neurobiological pathways based on distinct responses to trauma.

Clinical correlation but no elevation of striatal dopamine synthesis capacity in two independent cohorts of medication-free individuals with schizophrenia.

Dysregulation of dopamine systems has been considered a foundational driver of pathophysiological processes in schizophrenia, an illness characterized by diverse domains of symptomatology. Prior work observing elevated presynaptic dopamine synthesis capacity in some patient groups has not always identified consistent symptom correlates, and studies of affected individuals in medication-free states have been challenging to obtain. Here we report on two separate cohorts of individuals with schizophrenia spectrum illness who underwent blinded medication withdrawal and medication-free neuroimaging with [18F]-FDOPA PET to assess striatal dopamine synthesis capacity. Consistently in both cohorts, we found no significant differences between patient and matched, healthy comparison groups; however, we did identify and replicate robust inverse relationships between negative symptom severity and tracer-specific uptake widely throughout the striatum: [18F]-FDOPA specific uptake was lower in patients with a greater preponderance of negative symptoms. Complementary voxel-wise and region of interest analyses, both with and without partial volume correction, yielded consistent results. These data suggest that for some individuals, striatal hyperdopaminergia may not be a defining or enduring feature of primary psychotic illness. However, clinical differences across individuals may be significantly linked to variability in striatal dopaminergic tone. These findings call for further experimentation aimed at parsing the heterogeneity of dopaminergic systems function in schizophrenia.

Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880.

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin's chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin's mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860-1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study

ObjectivesDespite limited efficacy and significant safety concerns, antipsychotic medications are frequently used to treat behavioral and psychological symptoms of dementia (BPSD) in long-term residential care. This study evaluates the sustained reduction of antipsychotic use for BPSD through a deprescribing intervention and education of health care professionals. DesignRepeated-measures, longitudinal, single-arm study. SettingLong-term residential care of older adults. ParticipantsNursing staff from 23 nursing homes recruited 139 residents taking regular antipsychotic medication for ≥3 months, without primary psychotic illness, such as schizophrenia or bipolar disorder, or severe BPSD. InterventionAn antipsychotic deprescribing protocol was established. Education of general practitioners, pharmacists, and residential care nurses focused on nonpharmacological prevention and management of BPSD. MeasurementsThe primary outcome was antipsychotic use over 12-month follow-up; secondary outcomes were BPSD (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, and social withdrawal) and adverse outcomes (falls, hospitalizations, and cognitive decline). ResultsThe number of older adults on regular antipsychotics over 12 months reduced by 81.7% (95% confidence interval: 72.4-89.0). Withdrawal was not accompanied by drug substitution or a significant increase in pro-re-nata antipsychotic or benzodiazepine administration. There was no change in BPSD or in adverse outcomes. ConclusionIn a selected sample of older adults living in long-term residential care, sustained reduction in regular antipsychotic use is feasible without an increase of BPSD.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia.

Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

The co-occurrence of eating disorders and psychosis

IntroductionSeveral reviews have reported the incidence of schizophrenia in patients with eating disorders (ED) to be between 3–10% and the incidence of transient psychotic episodes to be 10–15%. On the other hand, anorexia nervosa appears to affect 1 to 4% of schizophrenia patients. Reports of psychosis and ED occurring in the same patient have led to various views as to the nature of the relationship between the two.ObjectiveAnalysis of the literature illustrated by different clinical cases in which appears to be a relationship between ED and psychosis.AimsCritical reflection about the hypothesis that could underlie the comorbidity of psychotic illness and ED.MethodsNon-systematic review of a literature search using the keywords: eating disorders; psychosis; comorbidity.ResultsThere is no consistent sequence in the co-occurrence of the two conditions – ED sometimes precede and sometimes follows the onset of psychosis. ED patients can develop psychotic symptoms, most frequently transient in the course of the disorder, while others are subsequently diagnosed with a chronic psychotic disorder. On the other hand, patients with a primary psychotic illness can develop an eating disorder. The connection between the two, however, remains speculative, considering the hypothesis that ED and psychosis can be entirely separate disorders that can, by chance, occur in the same person.ConclusionsThe area of comorbidity and overlapping symptoms in psychiatry requires more deep research. Despite evidence from case series, the comorbidity between ED and psychosis is poorly understood, and firm conclusions cannot be drawn from this analysis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Secondary psychoses: an update

Psychotic disorders due to a known medical illness or substance use are collectively termed secondary psychoses. In this paper, we first review the historic evolution of the concept of secondary versus primary psychosis and how this distinction supplanted the earlier misleading classification of psychoses into organic and functional. We then outline the clinical features and approach to the diagnosis of secondary psychotic disorders. Features such as atypical presentation, temporal relation to detectable medical cause, evidence of direct physiological causal relationship to the etiological agent, and the absence of evidence of a primary psychotic illness that may better explain the presentation suggest consideration of a secondary psychosis. Finally, we discuss how careful studies of secondary psychotic disorders can help elucidate the pathophysiology of primary, or idiopathic, psychotic disorders such as schizophrenia. We illustrate this issue through a discussion of three secondary psychotic disorders - psychoses associated with temporal lobe epilepsy, velocardiofacial syndrome, and N-methyl D-aspartate (NMDA) receptor encephalitis - that can, respectively, provide neuroanatomical, genetic, and neurochemical models of schizophrenia pathogenesis.

Is It Medication-Induced Psychosis or Prodromal Psychosis Unmasked by Medication?

Is It Medication-Induced Psychosis or Prodromal Psychosis Unmasked by Medication?

Frontotemporal Dementia—A Chameleon?

To the Editor: Frontotemporal dementia (FTD) is a pathologically heterogeneous illness characterized by progressive atrophy of the frontal and anterior temporal cortex. Some cases are familial, but the etiology is more often idiopathic.1 There is no known treatment, and the illness progresses inexorably to death, with a mean survival of about 8 years.1 FTD is often misdiagnosed because of its confusing initial presentation.2–4 A variety of psychiatric symptoms may be seen during the course of illness. We describe a patient with FTD who presented initially with mood and psychotic symptoms. Case report. Ms A, a 45-year-old woman, was in good health until May 2008. Her initial symptoms were depressed mood, crying spells, decreased energy, anhedonia, and poor appetite and sleep and were attributed to her father's death. She also reported that the police were keeping her under surveillance and that a neighbor was “messing with my head” and trying to harm her children, leading to homicidal threats. After accosting the neighbor, she was admitted with a diagnosis of bipolar disorder, mixed, with psychotic features (DSM-IV criteria). Results of routine laboratory work, urine drug screen, and computed tomography scan were unremarkable. After 3 weeks of inpatient treatment, she was discharged with improvement of symptoms and resolution of the homicidal ideation. Within 1 month, a change in her behavior was noticed; she became loud and aggressive, started making obscene calls to her mother, and developed pressured speech. She quickly deteriorated, becoming dependent in activities of daily living. She was readmitted in December 2008; this admission lasted for about 3 months. Results from full medical and neurologic evaluation, including magnetic resonance imaging scan, electroencephalogram, and lumbar puncture, were unrevealing. Neuropsychological testing revealed prominent executive dysfunction, and positron emission tomography scan revealed severe frontal and temporal hypometabolism. The DSM-IV criteria for dementia were used and, furthermore, were also correlated with the Consensus Clinical Diagnostic Criteria for frontotemporal dementia.5 On presentation to our Memory Disorder Clinic in November 2009, she was mute, minimally interactive, and markedly apathetic; there was also some evidence of dysphagia. The family reported trials of numerous psychotropic medications, all with minimal effect. She had an unsteady gait, swaying from side to side and magnetic in nature. She was restless, repeatedly rising from her seat, but was easily redirected. Her mood could not be assessed, but her affect was flat. It did not appear that she was responding to internal stimuli. She died in January 2010. Frontotemporal dementia is the second most common dementia in younger individuals.6 A young person presenting with psychotic and mood symptoms may suggest a primary psychiatric diagnosis, but the clinician must consider a neuropsychiatric syndrome such as FTD. Often, the clinical picture will evolve over time. Importantly, the consensus criteria for diagnosis of FTD do not emphasize psychiatric features.3 For our patient, the onset of what appeared to be a typical depressive illness after her father's death proved to be a “red herring.” While she clearly presented with symptoms of a delusional depression, the clinical picture quickly evolved with increasing dependence in activities of daily living and mutism, and death soon followed. A review of the literature reveals cases in which the initial presentation of FTD was suggestive of a primary psychotic illness or a mood disorder.4,7 A greater index of suspicion for FTD in younger patients with new-onset psychiatric symptoms, and a longitudinal view as the disease progresses, will lead to better clinical diagnosis.

Tactile, Olfactory, and Gustatory Hallucinations in Psychotic Disorders: A Descriptive Study

Hallucinations are a common feature of psychotic illness and occur across diagnoses. While auditory and visual hallucinations are known to represent common features of psychosis, tactile, olfactory, and gustatory hallucinations (TOGHs) are often believed to be rare in primary psychotic illness. The present study examined hallucinations across sensory modalities in patients with primary psychotic disorders by diagnosis and in association with mood and psychotic symptoms. In this descriptive study we examined diagnostic and symptom data from a large cohort of patients with schizophrenia (n = 133), schizoaffective disorder (n = 101), or bipolar I disorder (n = 186). TOGHs were common (20% of the total sample), and occurred across all diagnostic categories, although at different rates by diagnosis. TOGHs were correlated with each other and with other hallucinations, and were associated with specific clinical features such as somatic delusions, delusions of control, thought broadcasting, earlier age at onset, and a lifetime history of depressive episodes. In the present sample, hallucinations in all modalities occurred in patients across diagnoses suggesting that no one type of hallucinatory experience is pathognomonic to any given diagnosis. Additionally, TOGHs were present in patients across diagnostic groups are were associated with specific symptoms and earlier age of onset. Implications for clinical practice and clinical and neurobiological research are discussed.

Visual hallucinations in consultation-liaison neuropsychiatry.

In consultation-liaison settings, neuropsychiatrists are commonly asked to assess patients with hallucinatory syndromes and to differentiate 'functional' from 'organic' psychotic presentations. The occurrence and management of visual hallucinations (VH) in healthy individuals, lesion states, neurodegenerative disorders, intoxication/withdrawal states and delirium are reviewed. The presence of VH has been shown to predict a secondary rather than primary psychotic illness and an understanding of the neurobiology of the visual system - including how and where underlying neurotransmitter systems interact in visual processing and how perturbations can result in VH - allows for appropriate clinical assessment and management.

Acute Neuroleptic Treatment in Elderly Patients Without Dementia

Low doses of neuroleptics are the standard for treating psychosis in elderly patients because of concern about inducing adverse effects. The authors found that fixed, low-dose neuroleptic treatment (0.15 mg/kg/day) for 10 days resulted in low perphenazine levels and low rates of acute response (25%) in elderly patients with primary psychotic illness (without dementia). Increase in initial dose did not speed acute response and induced adverse effects that were absent or minimal with low-dose treatment. With higher-dose treatment, drug blood levels rose disproportionately, and level-to-dose ratios were higher than those observed in non-elderly adults. Naturalistic follow-up suggested that response may take longer to develop than in non-elderly adults and that low doses for a longer duration may provide effective treatment.

Antidepressant treatment of posttraumatic stress disorder and major depression in veterans.

Many patients with chronic posttraumatic stress disorder (PTSD) suffer from comorbid major depression. The present study examines the responsiveness of such dual-diagnosis patients to antidepressant medication. Subjects were enrolled in the PTSD medication clinic at the San Diego Veterans Affairs Medical Center. Inclusion criteria were current diagnoses of PTSD and major depression, at least 6 months of regular participation in the clinic, and treatment with antidepressant medication at therapeutic levels and durations. Exclusion criteria were current drug or alcohol abuse, primary psychotic illness, and poor compliance or frequent missed appointments. Among 72 patients meeting inclusion and exclusion criteria, 50% were estimated to be substantially improved, on the basis of Clinical Global Evaluation (CGE) scores of 2 or 1, after remaining on the same antidepressant treatment regimen at therapeutic doses for at least 1 month. Antidepressant medications affecting predominantly serotonin reuptake (sertraline, fluoxetine) were associated with better outcomes than antidepressants affecting predominantly norepinephrine reuptake (nortriptyline, desipramine).

Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study

Psychiatric illness is a potent risk factor for suicide, rates of which differ markedly with age. The purpose of this study was to examine whether the psychiatric diagnoses of suicide victims vary predictably with age. DSM-III-R axis I diagnoses of 141 persons aged 21 to 92 years who had completed suicide were established by the psychological autopsy method. Multiple logistic regression analyses were used to determine whether age, gender, or their interaction predicted the presence of specific disorders. One or more axis I conditions were diagnosable in 90.1% of the suicide victims. Substance use disorders were most frequent, followed by mood disorders and primary psychotic illness. Younger age at death was a significant predictor of substance abuse or dependence and primary psychoses, while older age predicted major mood disorders. Comorbidity of substance use and mood disorders was common. Among victims with substance abuse or dependence, older age at death predicted major depression; among victims with mood disorders, younger age at death predicted comorbid substance abuse or dependence. The distribution of psychiatric illnesses in suicide victims differs across the life course. Age-related patterns of addictive and psychotic disorders echo their prevalence in the general population. In contrast, the relationship between age and mood disorders among suicide victims is distinctly different from that of the general population. These findings suggest that risk for suicide increases with age in individuals with major affective illness. Depressed elderly men are particular targets for suicide prevention strategies.