Psychosis should be avoided if possible. If it does occur, early diagnosis and treatment are important for a better prognosis. Antipsychotics of the latest generation should be selected and dosed in such a way that they are also suitable for the patient in the long term. In exceptional cases, sedation may be necessary. However, this should only be done in the short term.
Schizophrenia is caused by an imbalance of chemical messengers, so that signal transmission in the CNS is disturbed. Consequences are fundamental and characteristic disturbances of thinking and perception as well as inadequate or flattened affects. Approximately 3-4% of the population will develop a psychotic episode during their lifetime [1]. Schizophrenic psychoses often have an unfavorable course with long-term cognitive and functional decline, even with remission of positive symptoms (delusions, hallucinations, formal thought disorders) [2].
The onset of psychosis is preceded by a “prodromal phase” lasting several years [3]. After the onset of psychotic symptoms that define the disorder, it usually takes another one to two years to be diagnosed and treated. However, even in the unrecognized early stages, the developing psychoses often have serious medical and psychosocial consequences. Early diagnosis at this stage is difficult. However, it is possible to assess the risk of developing psychosis and take appropriate action.
The European Psychiatric Association (EPO) has issued recommendations for the early detection of psychosis (box) [4]. In it, she distinguishes three clinical risk criteria to be used alternatively after ruling out current or previous psychosis and a physical cause of symptomatology:
- At least one attenuated psychotic symptom (APS),
- Unusual thinking or delusional ideas that are not held with complete conviction
- Perceptual abnormalities or hallucinations with still present insight into their abnormal nature
- disorganized communication or language that is still understandable in terms of content and responsive to structuring aids.
- at least two of nine basic cognitive symptoms (COGDIS) that are not familiar to the patient from his or her “healthy time,” have occurred at least intermittently on a weekly basis or more frequently within the past three months, and are not attributable to the effects of a substance,
- Thought Interference
- Thought Blocks
- Thought crowding
- Expressive language disorder
- Disorder of receptive languages
- Symbol capture malfunction
- Self-relationship tendency
- Inability to split attention
- Attention distraction
- At least one transient spontaneously remitting psychotic symptom (BIPS):
- Delusion
- Hallucinations
- Formal thinking disorders
Early detection in the prodromal phase with appropriate monitoring can help prevent the transition to psychosis.
| EPA recommendations for early detection of psychosis [4]. |
| Recommendation 1: Risk criteria EPA recommends that the following three clinical risk criteria be used alternatively for screening for psychosis – after ruling out current or previous psychosis and a physical cause of the symptomatology at risk: 1. at least one attenuated psychotic symptom (APS) that meets the additional requirements of the Structured Interview for Psychosis-Risk Syndromes (SIPS) or the Comprehensive Assessment of At-Risk Mental States (CAARMS): – Unusual thought patterns or delusional ideas of which the individual is not fully convinced – Perceptual abnormalities or hallucinations with existing insight into their abnormal nature – disorganized communication or language that is understandable in content and responsive to structuring aids. 2. at least two self-perceived and reported baseline cognitive symptoms (COGDIS) that are not known to the patient from his or her “healthy time” and are evaluated independently of the clinical impression according to the patient’s statements, occurred at least intermittently weekly or more frequently within the last 3 months, and are not attributable to the effect of a substance: – Thought interference with shooting in of completely irrelevant contents of consciousness – Thought blocks that cannot be explained by concentration or attention deficits – Thought chasing, -rushing of thematically unrelated thoughts – Receptive language disorder with use of native language in everyday life – Disturbance of expressive speech in the use of the mother tongue in everyday life – Symbol acquisition disorder in the sense of impaired or delayed acquisition and comprehension of abstract, metaphorical, or symbolic content. – Self-relation tendency, which is immediately recognized as erroneous – Inability to split attention between tasks that do not in themselves require full attention and primarily involve different senses – e.g., making a sandwich and having a conversation – Captivation of attention by irrelevant stimuli, which interferes with the voluntary directing of attention to more relevant stimuli. 3. at least one transient spontaneously remitting psychotic symptom (BIPS) that meets the additional requirements of SIPS or CAARMS: – Delusion – Hallucination – formal thinking disorders. Recommendation 2: Role of genetic risk A genetically increased risk of psychosis from a positive family history of psychosis in a first-degree biological relative should not be used by itself as a clinical risk criterion, even if accompanied by functional impairment and mental health problems. Rather, it should be perceived as a general risk factor indicating an increased pretest risk for psychosis that already existed prior to risk elevation. As such, it should be considered in patients at clinically increased risk according to one of the three criteria. Patients who do not meet any of the three risk criteria but who have genetic risk and psychological symptoms should be encouraged to revisit if they notice the onset of risk symptom-like symptoms. Recommendation 3: Role of psychosocial functional deficits. EPA’s general recommendations for the prevention of mental disorders aim, among other things, to prevent the onset of illness and losses in economic productivity and social functioning. On this basis, it is recommended that a significant dip in educational-occupational and/or social functioning levels should not be a mandatory additional requirement for clinical psychosis risk according to the three criteria mentioned above because of the lack of evidence that this addition increases risk. However, a marked decline in functioning should be taken as an indication of an imminent risk of transition to psychosis. Therefore, patients with clinical risk and significant functional decline should be considered high risk for treatment. Recommendation 4: Target population EPA recommends that the clinical risk criteria mentioned at the beginning of this document only be applied: – to people who are already suffering from mental health problems and are seeking help for them – to individuals who desire clarification of their current clinical risk status because of a known higher risk, such as a positive family history for psychosis. Any clinical screening in other individuals does not currently appear to be justified by the scientific evidence base. Recommendation 5: Children and adolescents EPA recommends that the clinical risk criteria mentioned at the outset should be used and communicated only with extreme caution in children and younger adolescents. Nevertheless, they should be raised with them and observed in the further course. In later adolescence, however, clinical risk criteria appear to be similarly applicable in adolescents as in adults. Recommendation 6: Expertise needed (expert consensus). EPA recommends that a trained professional (psychiatrist, clinical psychologist, or other mental health professional) with sufficient experience in clinical elevated risk status for psychosis conduct the survey. If referral to an appropriate specialist is not possible, the responsible practitioner should consult a specialist in an advisory capacity about the case. Specialized psychosis screening facilities should facilitate such consultations, e.g., during telephone consultation hours. Case discussions with an expert in screening for psychosis are also advised for mental health professionals without additional expertise in this area. |
The earlier diagnosis and therapy, the better the prognosis
If acute psychosis develops nevertheless, the prognosis improves the sooner the diagnosis is made and effective treatment can be initiated. The wide range of available antipsychotics should be used for this purpose. Preferably preparations of the latest generation, which must be individually selected and dosed. The selection should also be made with a view to the future. In the inpatient setting, therefore, care must be taken to determine which preparation is also suitable for the patient in the long term.
Ideally, preparations such as aripiprazole, brexpiprazole, or cariprazine should be chosen that have as few sedating properties as possible [5]. But this is not always possible, for example, when patients are aggressive or highly agitated. In these cases, consideration should be given to resorting to sedative effects of other drugs, at least intermittently. Some sedating medications also have anxiolytic effects, so their use may be appropriate in sufferers with anxiety. There are patients who can be dangerous because of their fears. In these cases, drugs with a low sedative effect are often not sufficient.
Substances such as benzodiazepines, zuclopenthixol, quetiapine, olanzapine can be used for short-term sedation, anxiolysis and sleep promotion (table 1). Sedation should be achieved as modularly as possible, i.e., by combining, for example, partial agonists with a sedating antipsychotic in low dosage or a benzodiazepine. Care must also be taken to quickly reduce sedating medication as soon as it is no longer absolutely necessary. The goal should always be to avoid sedating patients, if possible, so as not to impair cognitive functions. The sleep-inducing effect is a little different, which can be quite intentional, especially at night. Patients with sleep disorders then benefit from olanzapine or quetiapine at a low dosage, for example. In our clinical experience, a combination of, for example, olanzapine with one of the “ABC” psychotics (aripiprazole, brexpiprazole, or cariprazine) – with some sedation toward evening but activating effects during the day – has proven helpful here. Here, too, the individual adjustment of the medication is essential.
Between psychotic episodes, patients should not be limited in their cognitive and functional abilities by sedative effects, if possible. This is exactly why it is important to think about long-term medication already at the beginning of treatment and to design any necessary sedation in a modular way.
Core symptomatology in focus
If fatigue occurs in a patient, attention should always be paid to whether it is due to a drug effect or is part of the disease. Especially in the transition from an inpatient to an outpatient setting, medication should be adjusted so that it can be continued. In the event of unwanted sedative effects from the medication, for example, a dose reduction or a switch to a different preparation is then available.
Whether a patient perceives sedative effects of medication as a relief or a relief depends very much on the stage of the disease. In the acute situation, patients do find sedation relaxing, especially when anxiety is the primary concern. As soon as the acute symptoms subside, the affected person feels the sedation more strongly, which can then turn into a burden. For example, if the patient’s participation is slowed down by the medication. At the latest then, treatment management should be adjusted. Care should also be taken to avoid further limiting affected individuals with severe negative symptomatology. The patient’s quality of life with opportunities for activity should always be a priority.
Detect unwanted sedation
Especially young patients in the first episodes often express on their own when unintended sedating effects occur. This is not always the case with older patients. However, since one usually accompanies the affected person for a long time, such unintentional symptoms can be taken from the clinical impression. Sometimes the environment also expresses itself to the unusually tired condition of the patients. In addition, sedation also has effects on cognition. This e.g. perceived driving in conversation is not easy to distinguish with a re-emerging psychotic symptomatology. Here, it should be considered whether these symptoms were already present before the medication. Then they are to be considered as a component of the disease.
If a drive disorder is present as part of the symptomatology, the preparations with a sedative effect discussed so far should not be used under any circumstances in the medication. In this case, use should be made of agents without a sedative effect, such as the “ABC” psychotics (overview 1) . The same applies to patients whose professional or family situation places a certain demand on their ability to function. According to experience to date, partial agonists can have a concentration-promoting and drive-increasing effect here. Also, possible use of potentially sedating substances, such as cannabis or alcohol, must not be disregarded. In addition, patients with schizophrenia are at increased risk for somatic disorders. Especially in an acute situation, these should be excluded. Here, a detailed laboratory and, if necessary, electroencephalogram and magnetic resonance imaging are indicated.
Optimized treatment management
In principle, it can be said that ideally, especially in young people, psychosis should be prevented as far as possible already in the prodomal phase. If these efforts failed, the first step was to use “ABC” agents, i.e. partial agonists. Here, it is important to dose as low as possible, but as high as necessary to achieve an optimal effect. You should take the time to make an individual adjustment and monitor closely. Treatment with antipsychotics should be maintained for a period of one to two years, with previous relapses extending the treatment period. Also, in the inpatient setting, treatment should always be given with an eye toward the future, so that a change in therapy is not necessary in the outpatient setting. In this way, it can be ensured that sedation is only used in acute cases for a limited period of time and that those affected can go about their daily lives as actively as possible. The wide range of available antipsychotics should be used to provide individualized treatment management.
Sedation should be considered only in exceptional cases, such as anxiety or aggressive behavior in the acute phase, for a short period of time. As a rule, this is more likely to be an undesirable side effect of medication that should be avoided – especially in patients who are cognitively impaired and exhibit negative symptomatology. In order to avoid long-term sedation and to ensure an optimal transition from hospital to everyday life, a close exchange between inpatient and outpatient practitioners must also be ensured.
Take-Home Messages
- Early detection in the prodromal phase as well as appropriate monitoring of young risk patients help to avoid the transition into psychosis as far as possible.
- In psychosis, early diagnosis and treatment are very important for a better prognosis.
- The latest generation antipsychotics should be used, individually selected and dosed.
- If possible, the preparation that is suitable for the patient in the long term should already be selected in the hospital.
- Sedation should only be used in exceptional cases in the acute phase for a short time.
take place. Combinations of partial agonists are possible, primarily with an appropriately approved benzodiazepine or, later, with a low-dose sedating antipsychotic.
Literature:
- Perälä J, Suvisaari J, Saarni SI, et al: Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007; 64(1): 19-28.
- Remberk B, Bażyńska AK, Bronowska Z, et al: Which aspects of long-term outcome are predicted by positive and negative symptoms in early-onset psychosis? An exploratory eight-year follow-up study. Psychopathology 2015; 48(1): 47-55.
- Schaffner N, Schimmelmann BG, Niedersteberg A, Schultze-Lutter F: Pathways-to-Care for First-Episode psychotic patients – an overview of international studies. Fortschr Neurol Psychiatr 2012; 80(2): 72-78.
- Schultze-Lutter F, Michel C, Schmidt SJ, et al: EPA guidance on the early detection of clinical high risk states of psychoses. Eur Psychiatry J Assoc Eur Psychiatr 2015; 30(3): 405-416.
- Citrome L: Activating and Sedating Adverse Effects of Second-Generation Antipsychotics in the Treatment of Schizophrenia and Major Depressive Disorder: Absolute Risk Increase and Number Needed to Harm. J Clin Psychopharmacol 2017 Apr; 37(2): 138-147. doi: 10.1097/JCP.0000000000000665. PMID: 28141623.
InFo NEUROLOGY & PSYCHIATRY 2023; 21(4): 6-10.
