Acute and transient psychoses
According to ICD-10, these functional psychoses are not classified as schizophrenia because they lack typical progressive course and do not lead to the development of an emotional-volitional defect. They also differ from organic disorders by the absence of a specific substrate and organic-type personality changes.
The development is rapid (within 1–2 weeks), with a potential for complete recovery within 1–2 months. Two main variants are distinguished:
- Schizophrenia-like psychoses [F23.1]: characterized by delusions of persecution and reference, and psychic automatism.
- Polymorphic delusional ideas [F23.0]: occur within the framework of acute polymorphic psychotic disorder with symptoms of schizophrenia.
Acute polymorphic psychotic disorder is manifested by perplexity, anxiety, insomnia, and unsystematized delusions ("confusion in the head"). Patients may experience delusions of reduplicative paramnesia (feeling of a "play") and delusions of reference (searching for hidden meaning in accidental events). Despite the classification, in practice these conditions frequently relapse and can transform into schizophrenia, especially if the psychosis lasts for more than a month or signs of apathy and abulia appear.
Pharmacotherapy of depressions
The choice of an antidepressant is based on the severity of the condition and the presence of comorbid symptoms.
- TCAs (tricyclic antidepressants): amitriptyline, imipramine. Effective, but have pronounced side effects (sedation, anticholinergic action) and are toxic in overdose.
- SSRIs (selective serotonin reuptake inhibitors): fluoxetine, sertraline. Safer, used for mild and moderate depressions.
- Reversible MAO inhibitors: pirlindole. Also indicated for mild and moderate forms.
- Broad-spectrum action drugs: mianserin, venlafaxine. Prescribed for severe depressions, especially in elderly patients and those with somatic comorbidities.
Efficacy assessment is carried out after 2–3 weeks of therapy. Changing the drug earlier than 1.5–2 months, provided good tolerability, is not recommended. True resistance is established only after prolonged administration of maximum doses.
Overcoming resistance and management of other symptoms
If standard therapy is ineffective, the following approaches are used:
- Switching to a different class of antidepressants.
- Intravenous drip administration.
- Abrupt withdrawal of the drug at maximum doses.
- Combination with sleep deprivation, liothyronine, β-blockers, or calcium channel blockers.
- ECT (electroconvulsive therapy): indicated for severe treatment-resistant depression and high suicidal risk.
It is important to remember that at the beginning of antidepressant treatment, the risk of suicide increases, as motor retardation resolves earlier than depressed mood and anguish. In case of phase inversion (transition to mania), antidepressants are discontinued, and antipsychotics are prescribed.
To relieve insomnia and anxiety, tranquilizers (alprazolam, diazepam) and hypnotics are used short-term. For agitation and delusions, antipsychotics without a depressogenic effect (quetiapine, risperidone) are indicated.
Treatment of mania and prophylactic therapy
Lithium preparations and antipsychotics (haloperidol, olanzapine) are used to manage mania.
Prophylactic pharmacotherapy is necessary for all patients with recurrent forms (bipolar disorder, periodic depression):
- In bipolar psychosis (during remission): lithium salts (with blood concentration monitoring) and mood stabilizers (valproates, carbamazepine) are used.
- In monopolar depression: lithium is of low efficacy; continuous administration of antidepressants is required. To reduce side effects, safer drugs (SSRIs) are chosen or doses are reduced, keeping in mind the risk of relapse.
Briefly: answers to topical questions
What are the ICD-10 diagnostic criteria for schizoaffective disorder?
The diagnosis of schizoaffective disorder is established in cases where symptoms of schizophrenia and affective disturbances (mania or depression) are of equal prominence. In the International Classification of Diseases 10th Revision, this pathology is coded under the category F25. In practice, schizoaffective psychosis is diagnosed when a patient exhibits contradictory clinical symptoms. An example of such a condition is the simultaneous development of persecutory delusions, auditory hallucinations, and altered consciousness.
What side effects are characteristic of tricyclic antidepressants?
Tricyclic antidepressants are characterized by pronounced side effects caused by their anticholinergic and sedative action, as well as high toxicity in overdose. The following groups of adverse reactions are distinguished:
- Frequent effects — dry mouth, accommodation disorders, and constipation.
- Dangerous complications — cardiac rhythm disturbances (up to sudden cardiac arrest) and dysuria (up to acute urinary retention).
- Other manifestations — weight gain, blood pressure fluctuations (decrease or increase), as well as mydriasis, which creates a risk of acute glaucoma attack.
Due to these effects, the use of these drugs is limited in patients over 40 years of age.
Class and exam questions
How to distinguish acute transient psychosis from schizophrenia?
Acute psychoses do not exhibit the continuous progression typical of schizophrenia and do not lead to the development of an emotional-volitional defect.
Why does the risk of suicide increase at the beginning of depression treatment?
Motor retardation disappears faster than depressed mood and anguish, which gives the patient the energy to carry out suicidal intentions.
What is the essence of cognitive psychotherapy in depression?
The method aims to discuss the patient's illogical statements ("nobody needs me") in order to abandon emotional evaluations and form a rational view of reality.
What drugs are used for the prevention of bipolar disorder during remission?
Lithium salts and mood stabilizers (valproic acid salts, carbamazepine, lamotrigine) are used.
What else to study on this topic
- Psychological theories of schizophrenia (role of stress, psychoanalytic and behavioral concepts)
- Clinical case of acute polymorphic psychotic disorder development
- Rehabilitation and social adaptation in manic-depressive psychosis
- Indications for disability assignment in affective psychoses
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Other topics in "Chapter 22. Schizophrenia and Related Disorders"
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