Treatment for delusional schizophrenia

The efforts of a psychiatrist are aimed at achieving stable remission, i.e. 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 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 him.

Early treatment of schizophrenia is more successful, i.e. high-quality therapy of the first episode allows achieving rapid elimination of psychopathological productive symptoms - delusions and hallucinations and long-term remission. If the start of therapy is delayed, then stopping subsequent episodes of delusional-hallucinatory psychosis is very difficult. It requires higher doses of neuroleptics, 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 his rapid disability increases.

Currently, there is no specific protocol for treating schizophrenia. Drugs and their doses are selected individually, and different approaches to treatment are used depending on the stage of the disease.

Each subsequent relapse reduces the chances of a favorable prognosis and increases the likelihood of developing resistance to drug therapy. Therefore, prevention of relapses is the main goal of treatment. [ 1 ]

The relief of an exacerbation must begin immediately upon the appearance of the first signs of delirium. Usually, the same drug that was effective in the previous episode is prescribed, only in larger doses.

The prognosis is especially good when treating the disease when it is recognized in the prodromal stage. Drug therapy is usually not prescribed, but the patient is observed by a psychiatrist, cooperates with him, which ensures timely prescription of medication during the period of manifestation of the first symptoms. In our case, these are delirium and hallucinations, the so-called productive symptoms, which are currently called upon to cope with neuroleptics.

And although recently many psychiatrists have expressed the opinion that treatment at 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 prelude to the disease, so treatment started during the manifestation of the first symptoms is very important, since it determines the prognosis of the further course of the disease. How to remove delusional hallucinations in a patient with schizophrenia? Only with medication.

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

Most psychiatrists worldwide consider atypical antipsychotics to be the drugs of choice for initial treatment. They are easier to tolerate, have a broad spectrum of action, and neutralize the development of deficit symptoms. Classical antipsychotics are also used, although mainly as second-line drugs. The simultaneous administration of two or more drugs of this class is not recommended, and most specialists consider polytherapy dangerous. The risk of cardiovascular complications increases, and the combined sedative effect, platelet dysfunction, and other side effects are also undesirable.

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

The so-called atypical neuroleptics, compared to classical ones, do not have such a powerful effect on the patient's motor functions. It is because of the absence of pronounced extrapyramidal disorders that their action is called atypical, but they also have a whole list of side effects. Their use leads to disorders of the cardiovascular system, blood picture disorders, obesity, and other metabolic disorders. Even the development of motor disorders is not excluded. Nevertheless, treatment usually begins with second-generation neuroleptics.

Such atypical neuroleptics as olanzapine, risperidone, amisulpiride have shown in studies to be even more effective than classical ones in stopping positive symptoms, in particular delusional-hallucinatory syndrome. They also reduce negative symptoms and even contribute to some restoration of cognitive abilities and emotionality.

Olanzapine may be prescribed for severe delusional-hallucinatory syndrome, especially in cases where it is accompanied by affect disorder, since the drug has a strong sedative effect. Against the background of 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. Typical side effects of this drug, however, developing infrequently, are called a decrease in the number of neutrophils in the blood (kamikaze cells that absorb bacteria), short-term changes in the activity of liver 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 long-term use are hyperprolactinemia and seizures. Immediately after the start of treatment, hyperexcitation, insomnia, headache may occur, which eventually pass. [ 3 ]

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

Typical antipsychotics are also used in the treatment of schizophrenia, especially paranoid, since they reduce delusional-hallucinatory manifestations well. 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 specific patient and are well tolerated, they are also used at the stage of maintenance therapy. It is not recommended to change the drug without sufficient grounds for this.

Typical neuroleptics prevent the relapse of delusional-hallucinatory syndrome, but practically do not reduce deficit changes, however, in 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 neuroleptics, flupentixol, zuclopenthixol and haloperidol are considered the safest - the most effective in stopping delirium and hallucinations, but also causing many side effects, in particular, extrapyramidal, especially in high doses.

There are no absolute contraindications to prescribing neuroleptics for schizophrenia, except for severe fulminant allergy. Relative contraindications include pregnancy, decompensated cardiovascular diseases, severe liver and kidney failure, hypotension, prolactin-dependent neoplasms, glaucoma, leukopenia, prostate adenoma, leukopenia, acute drug intoxication with centrally acting drugs, and malignant neuroleptic syndrome.

The development of side effects is individual and depends on the patient’s age, genetic predisposition to the development of certain conditions, the presence of concomitant pathologies, and the pharmacodynamic characteristics of a particular patient.

Neuroleptics can cause many side effects and almost a third of patients experience them quite severely. [ 4 ]

The most common neurological complication resulting from taking neuroleptics 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, and are also the reason for refusing therapy. They can manifest themselves in any symptoms of this spectrum of disorders: tremors in the limbs and throughout the body; muscle spasms and twitching; the occurrence of internal and external motor restlessness, chaotic, jerky movements that fit into the symptoms of akathisia, tics, athetosis, chorea; stereotypies; sometimes a full range of neurological symptoms develops - drug-induced parkinsonism. The most severe manifestation of this side effect is malignant neuroleptic syndrome. The emerging complex of motor disorders is associated with a change in the dopaminergic activity of the brain, taking first-generation neuroleptics, especially haloperidol, often ends in the development of extrapyramidal complications. However, taking newer drugs also does not guarantee the absence of this effect. An even greater risk of its development arises when combining a neuroleptic with antidepressants, cholinomimetics, anticonvulsants, antiarrhythmic agents and other centrally acting drugs necessary to relieve the manifestations of symptoms accompanying delirium and hallucinations, since they themselves can also lead to the appearance of motor disorders. [ 5 ]

The main side effects of later generation drugs are negative effects on the cardiovascular system, more pronounced effects on metabolic processes and hormonal metabolism, which results in obesity, hyperprolactinemia, sexual dysfunction, and the development of diabetes.

Surveys of patients show that they have difficulty tolerating such effects as excessive sedation, loss of strength, lethargy, drowsiness, forgetfulness, and difficulty concentrating.

Anticholinergic effects do not brighten up life either - dry mouth, problems with vision and emptying the bladder up to dysuria. Neuroleptics are capable of changing the blood picture, especially clozapine, causing other pathological changes in somatic health - a long list of possible complications is given in the instructions for the drug. Sometimes somatic pathologies developing during the treatment of schizophrenia are very serious, and yet patients (according to surveys) are more concerned about side effects in the field of mental disorders. Agitation, insomnia, anxiety are relieved by short courses of benzodiazepines (phenazepam, diazepam).

Considering the side effects of treatment and the fact that therapy should be continuous and long-term, the prescription of the drug and its dosage is the most important 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 therapeutic effect. In case of frequent exacerbations of psychosis, lifelong use of an effective neuroleptic may be recommended.

In the observations of researchers it is noted that sudden spontaneous cessation of taking the drug (and this happens often - painful side effects, unwillingness to change the way of life and give up bad habits, etc.), exacerbation, in most cases, does not take long to come and occurs within the next few weeks. Therefore, the formation of motivation for long-term treatment and compliance with medical recommendations is considered very important in the treatment of schizophrenia.

Various 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 personnel, who must try with all their might to maintain or restore the patient’s social and labor status.

It has been noted that people diagnosed with schizophrenia who have comprehensive support from all possible sides need neuroleptics less, especially in high-dose administration, than patients whose assistance is limited to pharmacotherapy alone. At the same time, an inverse relationship can also be observed - those who receive adequate drug therapy are more inclined to cooperate and comply with the restrictions, agree to visit a psychotherapist and do not refuse various forms of assistance, and, accordingly, their treatment results are higher.

Psychotherapy is of great importance in establishing compliance, treatment, rehabilitation and prevention of exacerbations of schizophrenia. It is carried out in different forms - individual, family and group. It is started as early as possible, the main task is to overcome the stigmatization or label of a schizophrenic. The style of work with a patient with schizophrenia is usually directive, but the doctor should try to avoid obvious pressure on the patient, so as not to cause a reaction of rejection, anxiety and fear. It is undesirable to change a psychotherapist with whom a trusting relationship has been established. [ 6 ]

Various methods of working with the patient are used: psychoanalytically oriented, existential, client-centered, cognitive-behavioral therapy, hypnotherapy, occupational therapy, zootherapy, and their combinations. Together with social support (assistance in education, employment, improvement of housing conditions), such a comprehensive approach ensures fairly high treatment results.