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Overview: Psychopharmacological Strategies in Non-responsive Psychosis

From Innovative Psychopharmacotherapy

Vernon M. Neppe

The term non-responsive psychosis operationally involves a chronic non-neuroleptic responsive psychosis. The concept of ``non-responsive psychosis'' thus encompasses far more than typical deteriorating schizophrenia as many non-responsive psychotics are not schizophrenic. For example, chronic residual schizophrenia is linked theoretically, empirically and neuropsychologically with ostensible organic change. The effects of chronic institutionalization in those patients adds a dynamic complication to interpretations of their non-responsiveness. In contrast, the object of this chapter is to seek out and manage ``non-responsive'' psychotics who do not exhibit the special organicity or chronicity of the typical chronic schizophrenic. This paper applies three pharmacological principles to an approach to the non-responsive psychotic, namely toleration, responsiveness and pharmacologic tracing. Non-toleration of neuroleptics implies that a ``functional psychosis'' cannot be present - organic pathology invariably is. Toleration without response may imply non-compliance. If the patient is complying, certain fundamental symptoms should be sought and adjunctive treatment to neuroleptics considered. Pharmacologic tracing is reflected by responsiveness to target symptoms. Thus, anxiety can be treated with propranolol; affective features may mean the addition of lithium or for depression an antidepressant; extra-pyramidal symptoms and signs require anticholinergics; and limbic kindling-like phenomena could hypothetically improve with carbamazepine. Dosage of neuroleptic is critical: while the continued presence of florid symptoms without side-effects implies increasing doses, neuroleptic overdosage is a common error. Choice of neuroleptic is very important: their different receptor profiles allow specific guidelines for management. Two special options unavailable in the USA are the use of sulpiride in the presence of refractory positive psychotic features, and of pipothiazine palmitate when deficit features predominate, are often worth considering. The use of dopamine agonists is discussed in extreme cases. Finally, the role of drug interactions, diet, cigarette smoking, coffee, and alcohol in preventing pharmacological response should not be ignored.

Keywords

Alcohol, Anticholinergics, Antidepressant, Benzodiazepines, Caffeine, Carbamazepine, Chronic deficit syndrome, Cigarette smoking, Crow-Type 2 schizophrenia, Diet, Dopamine agonists, Drug interactions, Electro-convulsive therapy Fronto-temporal pathology, Institutionalization, Lithium, Neuroleptic compliance, Neuroleptic dosage and choice, Neuroleptic non-toleration, Neuroleptic receptor profiles, Non-responsive psychosis, Pharmacologic tracing, Pimozide, Pipothiazine palmitate, Positive and negative, schizophrenic symptoms, Propranolol, Responsiveness to neuroleptics, Sulpiride, Target symptoms, Toleration of neuroleptics

 

 

 


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