Treatment of delusional schizophrenia

The efforts of a psychiatrist are aimed at achieving sustainable remission, that is, eliminating painful manifestations that limit the degree of personal freedom of a person, for which a necessary condition is the establishment of trusting relationships with the patient and his relatives, cooperation with them (the so-called compliance). This contributes to a more effective therapy, since the patient independently and conscientiously adheres to the recommended regimen of taking medications and the necessary restrictions in lifestyle and behavior, and close people support and control it.

The early treatment of schizophrenia is more successful, that is, high-quality therapy of the first episode allows you to quickly eliminate psychopathological productive symptoms - delirium and hallucinations and prolonged remission. If the start of therapy is delayed, then stopping subsequent episodes of delusional-hallucinatory psychosis is very difficult. It requires higher doses of antipsychotics, the symptoms become resistant to treatment, the increase in deficit changes is more noticeable, and also - the need for hospitalization of the patient increases and the risk of rapid disability increases.

There is currently no specific treatment protocol for schizophrenia. Drugs and their doses are selected individually, depending on the stage of the disease, a different approach to treatment is used.

Each recurrence reduces the chances of a favorable prognosis and increases the likelihood of resistance to pharmacotherapy. Therefore, the prevention of relapse is the main objective of treatment. [1]

Relief of exacerbation must begin immediately when the first signs of delirium appear. Usually prescribe the same drug that was effective in the previous episode, only in large doses.

Especially good prognosis for treatment when the disease is recognized in the prodromal stage. Drug therapy is usually not prescribed, but the patient is observed by a psychiatrist, collaborates with him, which ensures timely prescription of the drug during the onset of the first symptoms. In our case, this is nonsense and hallucinations, the so-called productive symptoms that antipsychotics are currently designed to cope with.

And although recently many psychiatrists have expressed the opinion that treatment in the early stages should begin at least a year before the development of the first episode of psychosis, in reality there are still no clear criteria for recognizing the threshold of the disease, so the treatment started during the manifestation of the first symptoms is very important because it determines the prognosis of the further course of the disease. How to remove delusional hallucinations in a patient with schizophrenia ? Only medication.

Modern views on the treatment of schizophrenia suggest monotherapy, that is, treatment with one drug. This approach minimizes side effects, which are very impressive in psychotropic drugs and, when used together, can lead to undesirable interactions. An additional argument for the use of one drug is the lack of the need for regular monitoring of the function of the cardiovascular system. [2]

Most psychiatrists around the world consider atypical antipsychotics to be the preferred drug for starting treatment. They are easier to tolerate, have a wide spectrum of action and level the development of deficient symptoms. Classical antipsychotics are also still used, although mainly as second-line drugs. The simultaneous administration of two or more drugs of this class is not recommended, and most experts consider polytherapy to be dangerous. The risk of complications from the cardiovascular system increases, and the total sedative effect, platelet dysfunction, and other side effects are also undesirable.

In each case, the choice of the drug is at the discretion of the doctor. As part of compliance, it is currently recommended that the patient and his relatives, as well as related specialists, be involved in the drug selection process, of course, not at the time of relief of acute psychosis, but when it comes to long-term prophylactic administration. The drug is prescribed depending on the stage of therapy (relief of acute psychosis, stage of stabilization, supportive or prophylactic), severity, structure and severity of the leading syndrome, the presence of concomitant diseases, contraindications. If the patient takes other drugs, in order to exclude undesirable effects from the interaction of drugs, the features of their action are analyzed.

The so-called atypical antipsychotics, in comparison with the classical ones, do not have such a powerful effect on the motor functions of the patient. It is because of the absence of pronounced extrapyramidal disorders that their action was called atypical, but they also have a list of side effects. Their use leads to disorders of the cardiovascular system, disturbances in the blood picture, obesity, and other metabolic disorders. Even the development of motor impairment is not ruled out. However, treatment is usually started with second-generation antipsychotics.

Atypical antipsychotics such as olanzapine, risperidone, amisulpiride in studies showed, when stopping the manifestations of positive symptoms, in particular, delusional hallucinatory syndrome, even higher efficacy than classical ones. They also reduce the manifestations of negative symptoms and even contribute to some restoration of cognitive abilities and emotionality.

Olanzapine can be prescribed for severe delusional hallucinatory syndrome, especially in cases where it is accompanied by impaired affect, since the drug has a strong sedative effect. While taking olanzapine, patients develop an increase in appetite, which is accompanied by rapid weight gain and is fraught with corresponding complications, for example, in the form of diabetes mellitus. Typical side effects of this drug, though not often developing, are called a decrease in the number of neutrophils in the blood (kamikaze cells that absorb bacteria), short-term changes in the activity of hepatic transaminases and tardive dyskinesia.

Risperidone in comparison with the previous drug has moderate antipsychotic activity, which is still higher than that of classical drugs. It is often used to prevent exacerbations. The most common side effects with prolonged use are hyperprolactinemia and convulsions. Immediately after the start of the intake, hyper-excitation, insomnia, headache, which have passed since time, may occur. [3]

Amisulpiride for the reduction of productive symptoms is used in high doses (0.6-1g). The drug copes well with traditionally pharmacoresistant conditions - chronic systematized delirium, obsessions. Statistically significant treatment efficacy is noted by the end of the first week, the relevance of delusional experiences is markedly reduced by the end of the second or third week. The antipsychotic effect of amisulpiride is combined with antidepressant and antideficiency, and side effects are minimal, since it has high selectivity, selectively blocking dopaminergic (D2 and D3) limbic system receptors and leveling the balance of dopamine, in contrast to the two drugs mentioned above, which have high affinity for serotonergic receptors. It also has no affinity for cholinergic receptors, so cholinolytic effects: dry mouth, blurred vision, constipation, difficulty swallowing and others are also not typical for this drug. Basically, when it is taken, sleep is disturbed, too good an appetite appears, paradoxical effects may occur - anxiety, hyper-excitement. Amisulpiride, like other antipsychotics, can increase prolactin levels, which provokes the development of sexual dysfunction.

Typical antipsychotics are also used in the treatment of schizophrenia, especially paranoid, as delusional-hallucinatory manifestations are well reduced. They are often prescribed in cases where the disease manifests itself with psychomotor agitation and its genesis is not yet clear. If they are effective for a particular patient and well tolerated, they are used at the stage of maintenance therapy. Changing the drug without sufficient grounds for this is not recommended.

Typical antipsychotics prevent relapse of delusional-hallucinatory syndrome, but practically do not reduce deficit changes, however, with the paranoid form of the disease, they are almost not noticeable, especially in the initial stages. Also, classic drugs do not have an antidepressant effect and can even provoke increased anxiety, depressed mood and the manifestation of negative symptoms. Of the typical antipsychotics, flupentixol, zuclopentixol and haloperidol are considered the safest, most effectively stopping delusions and hallucinations, but also causing many side effects, in particular extrapyramidal, especially in high doses.

There are no absolute contraindications to the appointment of antipsychotics for schizophrenia, except for severe fulminant allergies. Relative are pregnancy, decompensated diseases of the cardiovascular system, severe hepatic and renal failure, hypotension, prolactin-dependent neoplasms, glaucoma, leukopenia, prostate adenoma, leukopenia, acute drug intoxication with centrally acting drugs, malignant antipsychotic syndrome.

The development of side effects is individual in nature and depends on the age of the patient, a genetic predisposition to the development of certain conditions, the presence of concomitant pathologies, and pharmacodynamics in a particular patient.

Antipsychotics can cause many side effects, and in almost a third of patients they manifest themselves quite strongly. [4]

The most common neurological complication resulting from the use of antipsychotics are extrapyramidal disorders. They are the reason for the constant search for new drugs, since they seriously complicate the course of this already serious disease and reduce the patient’s quality of life, as well as the reason for refusing therapy. They can occur by any symptoms of this spectrum of disorders: trembling in the limbs and throughout the body; muscle cramps and twitches; the occurrence of internal and external motor anxiety, erratic, jerky movements that fit into the symptoms of akathisia, tics, athetosis, chorea; stereotypes; sometimes a full range of neurological symptoms develops - drug parkinsonism. The most severe manifestation of this side effect is malignant antipsychotic syndrome. The resulting complex of motor disorders is associated with a change in the dopaminergic activity of the brain, the intake of first-generation antipsychotics, especially haloperidol, often ends with the development of extrapyramidal complications. However, taking newer drugs also does not guarantee the absence of this particular effect. An even greater risk of its development occurs with the combination of an antipsychotic with antidepressants, anticholinergics, anticonvulsants, antiarrhythmic drugs and other centrally acting drugs necessary to relieve symptoms associated with delirium and hallucinations, since they themselves can also lead to the appearance of motor disorders. [5]

The leading side effects of drugs of later generations are a negative effect on the work of the cardiovascular system, a more pronounced effect on the processes of metabolism and hormonal metabolism, which translates into obesity, hyperprolactinemia, sexual disorders, and development of diabetes mellitus.

Surveys of patients show that they are difficult to tolerate effects such as excessive sedation, loss of strength, lethargy, drowsiness, forgetfulness, difficulty concentrating.

Cholinolytic effects, such as dry mouth, problems with vision and emptying of the bladder up to dysuria, do not decorate life. Antipsychotics can change the blood picture, especially clozapine, cause other pathological changes in somatic health - a long list of possible complications is given in the instructions for the drug. Sometimes somatic pathologies developing in the treatment of schizophrenia are very serious, and yet patients (according to surveys) are more concerned with side effects from the field of mental disorders. Excitement, insomnia, anxiety are stopped by short courses of benzodiazepines (phenazepam, diazepam).

Given the side effects of treatment and the fact that therapy should be continuous and lengthy, prescribing and dosing is the most responsible task and requires an individual approach to each patient. At present, schizophrenia cannot be completely cured, the main task of treatment is to achieve and maintain a long-term state of the therapeutic effect. With frequent exacerbations of psychosis, a lifelong intake of an effective antipsychotic can be recommended.

In the observations of researchers, it is noted that a sudden independent cessation of medication (and this often happens - painful side effects, unwillingness to change lifestyle and abandon bad habits, etc.), exacerbation, in most cases, does not keep itself waiting and occurs within the next few weeks. Therefore, the formation of motivation for long-term treatment and the implementation of medical recommendations is considered very important in the treatment of schizophrenia.

Different methods of influencing the patient’s consciousness are used - various methods of psychotherapy, constant support of the patient from family members, social services and medical primary, who must do their best to maintain or restore their social and labor status.

It was noted that people with a diagnosis of schizophrenia, who have comprehensive support from all possible sides, are less in need of antipsychotics, especially in high dosage, than patients whose help is limited only by pharmacotherapy. At the same time, an inverse relationship is also traced - those who receive adequate drug therapy are more likely to cooperate and observe the regime of restrictions, agree to visit a psychotherapist and do not refuse various forms of assistance, respectively, and their treatment results are higher.

Psychotherapy is of great importance in creating compliance, treatment, rehabilitation and prevention of exacerbations of schizophrenia. It is carried out in various forms - individual, family and group. They start it as early as possible, the main task is to overcome the stigma or stigma of schizophrenic. The style of work with a patient with schizophrenia is usually prescriptive, however, the doctor should try to avoid obvious pressure on the patient so as not to cause him reactions of rejection, anxiety and fear. Changing a psychotherapist with whom a trusting relationship has been established is undesirable. [6]

Various methods of working with the patient are used: psycho-analytically oriented, existential, client-centered, cognitive-behavioral therapy, hypnotherapy, ergotherapy, zootherapy, and combinations thereof. Together with social support (assistance in the field of education, employment, housing improvement), such an integrated approach provides sufficiently high treatment results.