Psychotic Disorders

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[edit] Psychotic Disorders

Frank W. Brown

Although often used to describe states of confusion, disorientation, or delirium, psychosis is best viewed as a state of brain dysfunction characterized by delusions, hallucinations, and formal thought disorder (e.g., derailment, thought blocking, thought insertion) (Box 53-1). Psychosis should not be viewed as a disease but as a dynamic state induced by a neurochemical dysfunction that leads to the specific clinical presentation.^[1] Psychosis may be transient, intermittent, or continuous.

[edit] ETIOLOGY

Etiologies of psychosis may be described in terms of neurobiologic, genetic, environmental, and sociocultural factors. Brain structural and neuropathologic factors are thought to increase the risk of psychosis. The greatest risk factor for late-life psychosis appears to be progressive dementia. Three primary neurochemical systems (dopamine, neurotensin, and serine metabolism) are implicated in the development of a psychotic state.^[1]

Stressful life events tend to occur before an episode of psychosis but are not causes of psychosis; rather, they can be viewed as destabilizing factors that exacerbate a preexisting tendency to develop psychosis. People with prolonged psychosis tend to experience social drift; that is, their impairment causes a downward shift in social class. Whether this change in social class is causative or is an effect of a prolonged psychotic state is not always clear. Most current data suggest that lower social class is a consequence of the psychosis.

[edit] EPIDEMIOLOGY AND PATHOPHYSIOLOGY

The 1-year prevalence rate of psychosis in the United States is less than 2.5%. Schizophrenic-related disorders have a 1.1%, severe cognitive impairment with superimposed psychosis approximately a 1%, and other causes (e.g., medical illness, drug/alcohol-induced psychosis) a 0.5% 1-year prevalence.^[2] Psychosis resulting from a schizophrenic disorder has strong genetic influences, as shown from adoption, family, and twin studies. No simple pattern of inheritance has been isolated. Historic data have indicated that the risk of a person developing schizophrenia (1% throughout the population) increases if other relatives have the disorder, up to 10% with a schizophrenic sibling, 12% with a schizophrenic parent, and 40% to 45% if both parents have schizophrenia.

Theories on the neurobiology of psychosis implicate neurochemical, structural, or functional factors.^[3] Most likely, multiple events (e.g., drugs, brain injury, morphologic changes) cause impairment in neurochemical pathways, producing the expression of psychosis. Dopamine modulation through dysfunctional serine metabolism, brain regional neurotensin levels, and increased activity of dopamine or selected dopamine receptors in certain areas of the brain are important in the etiology of psychosis. Trigger events may be different, but the final common pathway involves altered thalamic filtering.

[edit] PATIENT EVALUATION

[edit] Psychiatric History

The description of the current episode of psychosis is crucial in establishing a differential diagnosis. The knowledge that a psychosis is present does little in determining the etiology and appropriate management. Causes of psychosis can be divided into primary (psychoses with psychiatric illness) and secondary (induced psychosis). These categories overlap because a fundamental impairment remains in neurochemical pathways of the brain.

Duration of the psychotic symptoms needs to be established. An acute onset of visual hallucinations indicates a medical illness or drug-induced psychotic process. In contrast, a 2-to 4-week history of increasing auditory and visual hallucinations suggests a schizophrenia-related disorder. Prodromal development of psychosis refers to more subtle manifestations of an early psychotic process. Before the actual psychosis, the patient may have displayed social withdrawal, decreased attention to personal hygiene, or gradual difficulty with school or work performance. These symptoms would support psychosis of gradual onset. Prodromal development is most often seen in schizophrenia-related disorders and rarely in acute psychosis caused by medical illness or medications.

[edit] Hallucinations.

Visual hallucinations can occur in patients with schizophrenia; however, organic causes must be closely evaluated, such as in drug and alcohol intoxication and withdrawal. Olfactory hallucinations, which are less common in schizophrenia, require careful assessment to rule out sella turcica tumors. Auditory hallucinations are often a feature of a schizophrenic type of disorder. Auditory hallucinations should be assessed as to whether the voices command the patient to perform some act (self-harm or violence), how often the hallucinations occur, and whether the patient perceives them as threatening or frightening. When auditory hallucinations and delusions are present, it is important to assess the patient for suicidal risk.

[edit] Prior Episodes.

Previous episodes and treatment history of psychotic symptoms provide invaluable information as to diagnosis and management techniques that will likely benefit the patient. Primary psychiatric disorders with recurrent features of psychosis include schizophrenia-related disorders, major depression with psychosis, bipolar disorder, and dementia with psychosis. If similar psychotic features recur, the physician should explore the previous diagnosis and treatment. The patient with a chronic psychosis may respond well to a prior treatment plan. The patient who has a major depression with psychosis requires treatment directed at the depression as well as the psychosis; attempting to treat only the psychosis without antidepressants or electroconvulsive therapy will likely fail or delay adequate response.

[edit] Family History.

Because of the genetic “loading” of many of the primary psychiatric illnesses, a family history of similar psychotic symptoms or other psychiatric history provides valuable information. Effective management techniques used in the past to treat a family member will often be effective in the patient who has a similar psychotic presentation. This is especially important with a family history of schizophrenia, major depression, or bipolar disorder.

[edit] Substance Abuse.

Substance abuse is known to predispose a person to develop psychosis especially with acute ingestion of substances such as alcohol, lysergic acid diethylamide (LSD), phencyclidine (PCP), and cocaine or with acute withdrawal. Psychotic states from drugs generally have an acute onset and generally can remit with appropriate removal of the substance unless functional brain impairment occurs, as with use of LSD or PCP.

[edit] Examination and Testing

Although a routine physical examination is appropriate for the patient with psychosis, a few areas should be emphasized. Possible sources of infection need to be identified, such as pneumonia or urinary tract infection. Evidence of a low-grade temperature and slight tachycardia in a patient with recent onset of untreated psychosis should prompt evaluation for an induced psychosis. Drug intoxication with illicit or prescription drugs may present with symptoms similar to a schizophrenic disorder.

The office or bedside examination should include a screening mental status examination. Hallucinations may be described as to type, complexity (single voice or image vs. multiple voices or complex visual images), and duration. Other psychotic symptoms should be described as to first onset, when they occur, and whether they ever occurred in the past. The patient's mood and affect (depressed, normal, or elevated) should be noted. Many schizophrenic patients have a flat or blunted affect with limited range of expression. A minimal assessment for violence or suicide is necessary. Prior episodes of violence, current threats of violence, impaired judgment, and drug-seeking behavior are risk factors for recurrence of violence. If patients are hearing commanding voices, they will generally acknowledge this if asked directly but rarely volunteer this information. Suspicion of psychosis should increase if the patient appears distracted or seems to be looking or responding to one part of the room, since this could indicate that the patient is responding to hallucinations. Guardedness and hyperalertness can indicate paranoia. Directed questions (e.g., “Do you feel safe here?” “Are there voices that are bothering you?”) may elicit the patient's acknowledgement of the psychosis.

Most routine laboratory tests ordered are appropriate for the patient with acute-onset or chronic psychosis (Table 53-1). The goal of these evaluations is to uncover secondary causes of psychosis. Urine drug screens are most valuable in evaluating recent illicit drug use or inappropriate prescription drug use. A urine drug screen should be considered especially for acute onset of psychosis or the reemergence of a previously controlled psychosis when visual hallucinations are prominent.

Table 53-1 Laboratory Tests in Evaluating Psychosis

✢Venereal Disease Research Laboratories (fluorescent treponemal antibody absorption).

[edit] Psychologic Testing.

Psychologic tests are often misunderstood and ordered too infrequently. Comprehensive psychologic testing can be useful in evaluating selected psychotic patients who are stable enough to participate in testing. Many acutely psychotic patients simply cannot focus on this task long enough to make these tests worthwhile. The tests may be beneficial in determining degree of paranoia or delusional thinking, especially if the patient does not volunteer information to directed questions.

[edit] Other Studies.

Chest radiographs may identify a pneumonia or congestive heart failure, which could aggravate a psychotic state. An electrocardiogram (ECG) is recommended in at-risk patients to evaluate for recent but silent myocardial infarction and dysrhythmias. A lumbar puncture is not part of a normal evaluation but should be considered if infection or subarachnoid hemorrhage is suspected. An electroencephalogram (EEG) is appropriate if temporal lobe seizures are suspected. Systemic lupus erythematosus (SLE) may first present as psychosis. Neuroimaging in the workup of psychosis should only be ordered when a specific reason exists, that is, signs of trauma or focal neurologic deficits. The acute onset of psychosis in a young person with a negative psychiatric history and negative family psychiatric history or new-onset psychosis in an elderly person should suggest neuroimaging. With microvascular brain disease, neurologic signs and symptoms may not always be elicited. Microvascular insults to deep white matter and the caudate may be predisposing factors in the development of psychosis in elderly persons.

[edit] DIFFERENTIAL DIAGNOSIS

Greater urgency is shown the patient with a relatively recent onset of psychosis, the presence of a clouded sensorium, or onset of a psychotic process later in life. The patient with a recurrence of psychosis associated with a history of a schizophrenic disorder may not need to be as aggressively evaluated. Psychosis occurring with a clouded sensorium, as in delirium, signals a nonschizophrenic process; medical illnesses, metabolic abnormalities, and drug intoxication are major causes. Although onset in later life is often associated with dementia, the absence of memory impairment with psychosis requires close evaluation of medication side effects, vascular disease, and other physical illnesses (e.g., hypothyroidism, visual impairment, hypoxia).

[edit] Primary Causes

The most common presentation of psychosis in psychiatric illness occurs in schizophrenia-related disorders, major depression with psychotic features, bipolar disorder, and dementing disorders (Box 53-2). A detailed description of each is available in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).^[4]

Schizophrenia normally is associated with bizarre delusions, prominent auditory hallucinations, incoherence, inappropriate or flat affect, looseness of association, or catatonia. Associated features include a decrease in social or work performance. The patient may show prominent changes in activities of daily living (e.g., poor grooming), lack of drive, social withdrawal, or unusual behaviors (e.g., talking to oneself while walking down the street).

[edit] Secondary Causes

When psychosis results from a secondary cause, the presentation may vary. Most secondary causes are seen in the context of a delirium or altered mental status. Important secondary causes of psychosis are infections, electrolyte imbalance, and drug/medication use, withdrawal, and toxicity. In susceptible people, hyponatremia can induce a mild psychosis before the occurrence of seizures. This is most often seen during a mild delirium and slowly clears once the hyponatremia is corrected. Infections, especially pneumonia and urinary tract infections in elderly persons, often are associated with patients having visual hallucinations or mild delusions. After the infection has been successfully treated, these psychotic symptoms may linger for days to weeks and may require low-dose neuroleptics.

Substance abuse and drug/medication use, withdrawal, and toxicity are prime causes of delirium (see Box 53-2). Key features include an inability to maintain attention to a task (e.g., conversation), disorganized thought processes, visual hallucinations, labile affect, alteration in sleep-wake cycle, and impaired short-term memory. Effects of drugs and medications are more pronounced on the aging or immature brain and the previously injured brain (e.g., cerebrovascular accident, head trauma). One review noted that 83% of 177 medications had psychosis as a potential side effect.^[5]

[edit] MANAGEMENT

Management of psychotic patients incorporates nonpharmacologic and pharmacologic interventions. Choice of treatment depends on the severity, type, and presumed etiology of the psychosis. Chronic psychotic patients (e.g., with schizophrenia) generally require only minor changes in their neuroleptics unless an acute exacerbation of the psychosis occurs. Then aggressive treatment with psychotropic drugs usually is required, along with nonpharmacologic interventions. Patients with acute onset of psychosis should always have the cause of the psychosis actively treated.

[edit] Nonpharmacologic Treatment

Any factor that could cause or potentiate a psychotic process should be eliminated, including suspected medications, illicit drugs, and potential environmental stressors. A schizophrenic patient who decompensates on entering the workplace may benefit from a more structured work environment (e.g., set work hours, specific work task).^[6]

Most mild forms of psychosis do not require hospitalization if no major medical illness is present. Keeping the mildly psychotic patient at home in familiar surroundings may prevent further psychotic decomposition compared with hospitalization in unfamiliar surroundings. The family should be educated about the illness, associated symptoms, treatment and management options, and prognosis so that they can provide a home environment with minimal change and maximal routine, with fewer behavioral problems. Community programs provide structured activities or employment and are especially important because they assist the family while monitoring psychotic patients for evidence of relapse, medication compliance, or side effects. These programs are generally developed for patients with chronic psychosis but can be beneficial for those recovering from an acute psychotic episode. State associations for mentally ill persons can provide a listing of resources in a specific community.

Behavioral intervention and reality orientation are necessary for some patients. Acutely psychotic patients need to be oriented to reality (e.g., calendars and clocks in room, reassurance from staff or family as to who they are, where they are, and the date, time, and situation). Interactions with psychotic individuals are best done by one individual at a time; psychotic patients do poorly when they must shift attention between two or more people. A better approach is having one physician or staff member talk to and examine the patient while others remain at the side (not back) of the patient. Soft background music (no words) may also decrease the risk of physical agitation. Calm reassurance may be offered to the patient, and the physician or staff can redirect the patient to nonpsychotic themes. Health care professionals must be alert to protect themselves from a patient who strikes out or feels threatened.

Electroconvulsive therapy (ECT) is appropriate in select patients: depression with psychotic features, manic disorder with psychosis, psychosis with catatonia, ECT used with success previously, and psychosis with strong affective component. ECT may also benefit patients with psychosis resulting from hypopituitarism or Parkinson's disease.

[edit] Pharmacologic Treatment

[edit] Neuroleptics.

Neuroleptics are the main treatment for psychosis. They generally have very similar efficacy, and thus the choice of neuroleptic generally depends on the side effect profile best suited for the patient (Table 53-2). Schizophrenic patients not treated with antipsychotic drugs will likely relapse within 3 years, with greater intensity of psychosis and more frequency than patients treated with antipsychotic medication.^[7] Except for some atypical neuroleptics, all these medications can cause extrapyramidal side effects, tardive dyskinesia, and other anticholinergic side effects.^[6] Neuroleptic malignant syndrome (fever, muscle rigidity, altered mental status, autonomic instability) occurs rarely with neuroleptics but must be considered.

Table 53-2 Antipsychotic Medications

✢PO, Oral; IM, intramuscular;IV, intravenous; SC, subcutaneous.

†1, Minimal; 4, greatest. Lower score reflects higher potency and lower anticholinergic side effects.

‡Acute extrapyramidal reactions more common.

§Also available as suppositories.

∥1% to 2% incidence of agranulocytosis. A weekly complete blood count is required. Other side effects include orthostatic blood pressure changes and lowered seizure threshold.

Neuroleptics with lower potency (e.g., chlorpromazine, thioridazine) tend to have greater anticholinergic side effects and thus increase the risk of falls and orthostatic blood pressure changes, especially in elderly patients. These agents are more sedating, which is a benefit in younger agitated patients. Neuroleptics can also lower the seizure threshold. When prescribing a neuroleptic for a psychotic patient, the physician should obtain informed consent from the family or guardian to treat with this class of medication. Two long-acting depot intramuscular neuroleptics, haloperidol decanoate given every 4 to 5 weeks and fluphenazine decanoate every 3 to 4 weeks, are useful for the noncompliant patient or the chronic psychotic patient who will not take or is sporadic in taking oral medications. Other newer atypical neuroleptics (olanzapine, risperidone, and quetiapine) are excellent choices as first-line neuroleptics.

[edit] Other Medications.

Carbamazepine and valproic acid may be effective if an ictal focus is contributing to the psychosis. Benzodiazepines, when combined with a neuroleptic in the severely agitated psychotic patient, are very effective in achieving more rapid control of the agitation and psychosis. For the young to middle-aged psychotic patient, oral or intramuscular haloperidol (3 to 5 mg) and lorazepam (1 to 2 mg) may be given every 30 to 60 minutes until control is achieved. This combination can be more effective than a neuroleptic alone.

[edit] Consultation or Hospitalization

Consultation with a psychiatric colleague for a patient with psychosis usually is recommended if there is any concern about the etiology, diagnosis, or management. Although the primary care physician is able to diagnose accurately the presence of a psychosis, evaluating the etiology of psychosis may be difficult. Psychiatric consultation can assist in determining the optimal pharmacologic and nonpharmacologic interventions.

Actively psychotic patients may present such a risk of harm to themselves and others that hospitalization should be strongly considered. Disadvantages to hospitalization include (1) removing patients from a potentially safe and structured environment and (2) placing them on a rapidly changing hospital ward where they may become more psychotic. Psychosis itself does not require hospitalization, but other features often seen with psychosis may require it; psychotic patients often have impaired judgment and impulse control. Hospitalization is highly recommended, however, for certain patients. If the psychotic patient is suicidal or is hearing voices that command self-harm, or if a delusion is present that mandates self-mutilation, hospitalization with aggressive treatment is advised.

Violence or physical agitation is often a major concern of family or health care providers. Most episodes of physical agitation are nondirected and defensive in nature, except for the delusional person with focused paranoia who may attack a specific person.^[8] These patients are often noncompliant with outpatient management. Hospitalization provides safety as well as a means to gain better control of the psychosis.

Psychosis with other major mental illness (e.g., major depression, mania) is very difficult to manage on an outpatient basis and places the patient at high risk from impaired judgment and impulse control. Outpatient management of these patients should only be considered if trained 24-hour sitters are available.

[edit] SPECIAL PATIENT POPULATIONS

[edit] Suicidal Patients

Approximately 15% of schizophrenic patients end their life by suicide. Most psychotic patients who commit suicide are young unemployed males with a high level of social functioning before the onset of psychosis. The early detection and treatment of psychosis, especially with depressive features, represent a major strategy to prevent suicide. The physician assessing a psychotic patient for suicide risk at a minimum should address the following questions: (1) Is there a history of prior suicide attempts? (2) Is there a plan and means to commit suicide? (3) Does the patient have feelings of hopelessness or that life is not worth living? and (4) Are there thoughts of death? The presence of command hallucinations needs to be determined because the commands are often for self-injury. A psychotic patient who fears mental disintegration or has not been compliant with treatment is at higher risk for completed suicide.

When a psychotic patient is identified at moderate to high suicide risk (a subjective decision), hospitalization and psychiatric consultation are indicated. A patient with only occasional transient suicidal ideations may be managed as an outpatient; however, the clinician must be knowledgeable about the treatment of psychosis as well as affective disorders, while realizing that a psychotic patient's judgment is generally impaired. Outpatients should be provided community services that combine treatment with recreational and occupational activities.

[edit] Adolescents

When psychosis occurs in the adolescent, the physician must evaluate for primary vs. secondary psychosis. Brief reactive psychosis generally is time limited and may only require supportive care and a structured environment. The use of neuroleptics in this age group requires careful consideration of whether the benefits outweigh the risks for development of tardive dyskinesia. If the psychosis necessitates a medication because of auditory or visual hallucinations, commanding voices, or delusions, one of the atypical antipsychotics may be useful.

Adolescents require special concern regarding suicide potential. An acutely psychotic adolescent is at increased risk of self-harm because of impaired impulse control, impaired judgment, and commanding voices. This patient should be hospitalized; unless experienced in managing young psychotic patients, the physician should consult with a trusted psychiatrist.

[edit] Pregnant and Postpartum Patients

Psychosis during pregnancy places mother and fetus at risk from its sequelae. The physician must consider the risks and benefits of any treatment. Potential causes of the psychosis must be excluded and environmental control maximized. If the pregnant patient is taking a neuroleptic, the dosage should be kept as low as possible to control the psychosis. Any use of a neuroleptic requires the patient's informed consent. Although the risk for an increased rate of physical malformation from neuroleptic use is minimal, even during the first trimester, the potential effects of neuroleptics on the developing fetal brain for future behavior are not known. If a psychosis must be treated during pregnancy and other treatable causes of the psychosis have been excluded, the physician should consider a low-dose neuroleptic therapy (e.g., haloperidol, 2 mg daily increased by 1 to 2 mg every other day, up to a maximum of 10 mg). A chronic psychotic process may best be treated with a low-dose maintenance neuroleptic. Because of the potential teratogenic effect of pharmacotherapy, ECT should be considered, especially if affective or catatonic symptoms are present.

A small subset (less than 1%) of postpartum women will develop a psychosis within the first weeks after delivery. These psychotic episodes may occur during a postpartum depression. Aggressive treatment to control the primary illnesses (antidepressants for the depression, neuroleptics for the psychosis) should be undertaken to maintain maternal-infant bonding and to reduce the overall disruption from the psychosis. If the mother is taking neuroleptics, she must be cautioned against breast-feeding because the newborn would be exposed to potentially significant levels of the neuroleptic. Low doses of a neuroleptic (e.g., haloperidol, 2 to 5 mg/day) should be used until the psychosis is controlled. After the psychosis is under control for 4 to 8 weeks, the neuroleptic can be decreased by 1 mg each week until discontinued, with careful attention to psychotic recurrence. ECT is useful in postpartum psychosis with an affective component.

[edit] Elderly Patients

Geriatric patients with psychosis fall into four broad diagnostic groups: (1) delirium related or drug/illness induced, (2) continuation of lifelong or chronic psychotic illness, (3) affective disorders with psychosis, and (4) dementia-related syndromes with psychosis. The first group, although likely requiring neuroleptics, should have aggressive intervention to correct the underlying deficits (e.g., hypoxia, infection, decreased cerebral blood flow) causing the delirium. Neuroleptics in elderly patients should be started at low doses and slowly titrated (e.g., risperidone, 0.25 to 0.50 mg increased by 0.25 to 0.50 mg every 1 to 2 days). Faster titration may be needed but requires greater attention to orthostatic blood pressure monitoring. Acute episodes of psychosis with agitation may require higher initial doses (e.g., 1.0 to 1.5 mg of risperidone). Elderly patients show the greatest sensitivity to neuroleptic side effects, especially orthostasis, increased risk of falls, and extrapyramidal symptoms, and therefore require lower doses and slower titration. The newer atypical agents (risperidone, olanzapine, quetiapine) are ideally suited for this age group. Cumulative effects of neuroleptics may require that the dose be decreased after about 3 to 4 weeks, since some patients become more sedated as the psychosis is controlled.

[edit] Perioperative Patients

Psychotic patients awaiting surgery must have individualized treatment recommendations. An actively psychotic patient may receive a high-potency oral or intramuscular neuroleptic 2 hours before anesthesia as long as the anesthesiologist notes potential side effects. Stable patients with a chronic psychotic illness may safely have their neuroleptics stopped 12 to 24 hours before surgery; psychosis generally does not reemerge immediately, usually taking weeks to reappear. Neuroleptics can then be safely restarted 24 to 48 hours postoperatively.

[edit] Hospitalized Medical Patients

Hospitalized patients are more at risk to develop a psychotic reaction than the general population. The stress of the medical illness, a different environment, and the interaction of medications (e.g., Sinemet and Parlodel) can precipitate a psychosis. The medical patient with a history of psychosis and reemergence of psychotic symptoms can generally be treated with the same neuroleptic regimen effective in the past. Medical patients with no previous psychotic symptoms require careful evaluation so that the causative agent(s) may be removed or reduced, if possible. Short-term use of high-potency neuroleptics (e.g., haloperidol, 1 to 8 mg/day) is appropriate for control of hallucinations, delusions, and agitation. Besides neuroleptics, management should incorporate a structured environment with a reduction in external disrupting noise. Potential for suicide must be assessed, and the patient at risk should receive one-to-one care until consultation is obtained.

[edit] Stable Compensated Patients

Stable compensated patients with a prior history of psychosis should be maintained with a similar treatment plan that has kept them stable in the past. The primary care physician should realize that neuroleptics are generally only one part of this treatment approach. The patient may have been in a structured home setting or group home environment, and maintaining these nonpharmacologic interventions should not be overlooked.

Neuroleptic-induced side effects (e.g., akathisia, stiffness, cogwheel rigidity) are a major reason for medication noncompliance. For patients with evidence of cogwheel rigidity or extrapyramidal symptoms, benztropine (1 to 2 mg orally twice a day for 2 to 4 weeks) is generally effective. Decreasing the neuroleptic can reduce these side effects and is especially helpful in decreasing or eliminating akathisia. Tapering an antipsychotic in a patient with a history of chronic psychosis to the lowest effective dosage should be attempted slowly and in small increments over several months. Recent hallucinations, delusions, bizarre behaviors, and decreased attention to grooming are concerns for the reemergence of psychosis. If these symptoms emerge, the physician should consider increasing the neuroleptic dose by 10% to 20%. If the patient is still stable at 6 months, the neuroleptic can be decreased by 10% to 20%, with close follow-up to ensure that psychosis does not recur.

[edit] SUMMARY

Psychosis is a state of brain dysfunction characterized by delusions, hallucinations, and formal thought disorder. It can often be managed very effectively, and in many patients with secondary induction, sustained remission can be achieved. Neuroleptic treatment remains the cornerstone of care for the psychotic patient. Neuroleptics have similar efficacy, and thus the choice of neuroleptic should be based on the most desired side effect profile. Pharmacologic developments will pursue the reduction of troublesome side effects, resulting in more effective treatment and better compliance.

[edit] EVIDENCE-BASED MEDICINE

Primary sources for the revision of this chapter were MEDLINE. Electronic searches dating back to 1995 were conducted. Areas of focus included psychosis and psychotic disorders.

[edit] REFERENCES