Pharmacological Management of Psychoses

Welcome to Winston-Salem State University Pharmacology Project. This page was created by the students in the Doctor of Physical Therapy department at Winston Salem State University in Winston Salem, NC. to provide pharmacological resources for management of Psychoses in Physical Therapy practice.

Pharmacological Management of Psychoses

Background

The term psychosis is used to describe a person who experiences loss of contact with the world around them and disturbances with thoughts and perceptions of reality. [1] In the United States, approximately 8.6% (0.9%) of Americans have reported having a psychotic experience. [2] One cross-national study determined approximately 5.8% (0.2%) of people experience a psychotic episode in their lifetime.[2]

There are a wide variety of conditions associated with psychotic episodes including schizophrenia, bipolar mania, hallucinations, and delusional disorder, with schizophrenia being most prevalent.[1] Schizophrenia has positive symptoms such as hallucinations and delusions, and negative symptoms such as social and emotional withdrawal.[1] Regardless, most psychotic disorders include some form of positive symptoms.[1]

Pathophysiology

The pathophysiology of psychosis is not fully determined. Currently, the most prevalent theory of the mechanisms behind psychotic episodes is a dysregulation of the central dopaminergic pathways leading to increased dopamine. [3] This theory is based upon the mechanism of action of antipsychotic drugs, which aim to reduce the positive symptoms of schizophrenia. Positive symptoms are associated with an increase of dopamine neurotransmission while negative symptoms result from decreased dopaminergic activity.[4] Newer research has shown medications targeting serotonin and other neurotransmitters have been equally effective to older medications targeting solely dopamine receptors.[4]

Relevance

Medications used to manage psychotic episodes have extensive adverse effects and generally regulate the central nervous system (CNS). Because of this, scheduling and treatment sessions may be altered. It is important for physical therapists to monitor these patients and their symptoms for optimal care.

Introduction to Types of Drug Therapy Used in the Treatment of Psychosis

Typical Antipsychotics

1950 marked the birth of the psychopharmacological era with the introduction of typical (first generation) antipsychotic drugs. Prior to their introduction, psychiatric patients were treated with electrotherapy, insulin comas, and frontal lobotomies.[5] Their discovery introduced extensive research for the treatment of psychosis and increased the number of new pharmaceutical options.

The side effect profile for typical antipsychotics includes sedation, hypotension, anticholinergic effects, and extrapyramidal symptoms.

Atypical Antipsychotics

In 1990, the approval and implementation of clozapine for treatment-resistant schizophrenia gave birth to the atypical (second generation) antipsychotics.[5]  The reduced extrapyramidal effects of these proved beneficial for psychoses, decreasing the prevalence of conditions like tardive dyskinesia.

The side effect profile for atypical antipsychotics includes sedation, dizziness, weight gain, menstrual and sexual dysfunction, myocarditis, and extrapyramidal side effects.[6]

Classes of Drugs

Typical Antipsychotics

Atypical Antipsychotics

Patient Implications

Patients taking antipsychotic medications should be aware of the side effects commonly experienced. These include dizziness with changing positions or standing, weight gain, and drowsiness. As antipsychotics are sedatives, caution should be taken with driving and operating machinery. Regular doctor visits should be performed to monitor neurological and cardiac functioning and prevent potential blood disorders. The patient should consult a doctor before mixing medication with alcohol or other sedatives. Regardless of severity or intensity, side effects should be reported. If serious side effects are experienced a doctor should be contacted immediately.

Summary/Conclusion

Typical and atypical antipsychotic medications are used when a person experiences loss of contact with the world around them and disturbances with their thoughts and perceptions of reality. It is imperative that physical therapists understand the potential adverse effects of these drugs and that they might interfere with the physical therapy itself. Keeping a vigilant watch for serious side effects, maintaining patient safety, and staying up to date on popular medications are all requirements of a great physical therapist.

  1. 1.0 1.1 1.2 1.3 What is Psychosis? National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml. Accessed November 13, 2018.
  2. 2.0 2.1 McGrath JJ, Saha S, Al-Hamzawi A, et al. Psychotic Experiences in the General Population: A Cross-National Analysis Based on 31,261 Respondents From 18 Countries. Current neurology and neuroscience reports. https://www.ncbi.nlm.nih.gov/pubmed/26018466. Published July 2015. Accessed November 17, 2018.
  3. Roth, B. (2003). Biologic Mechanisms of Psychosis and Antipsychotic Drug Actions: from Dopamine Excess to Dopamine Stabilization. [online] Semantic Scholar. Available at: https://pdfs.semanticscholar.org/edae/9576f425138f82ee61dae4cc8ee211bfc6ad.pdf [Accessed 17 Nov. 2018].
  4. 4.0 4.1 Li, P., L. Snyder, G. and E. Vanover, K. (2018). Dopamine Targeting Drugs for the Treatment of Schizophrenia: Past, Present and Future. [online] NCBI. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112764/ [Accessed 17 Nov. 2018].
  5. 5.0 5.1 Ramachandraiah CT, Subramaniam N, Tancer M. The story of antipsychotics: Past and present. Indian J Psychiatry. 2009;51(4):324-6.
  6. Uçok A, Gaebel W. Side effects of atypical antipsychotics: a brief overview. World Psychiatry. 2008;7(1):58-62.