ADD psychosis: treatment with antipsychotics and methylphenidate?

Two patients with a psychotic disorder who also met the diagnostic criteria for attention deficit hyperactivity disorder ADHD were treated with antipsychotics and methylphenidate. The first patient remained stable for many years with this combination treatment, whereas the second became psychotic several months after he had increased the dose of methylphenidate and had started to use cocaine. In the light of these two case studies, we have reviewed the literature on ADD psychosis, and we formulate recommendations regarding the specialised treatment needed for this uncommon disorder.     

Why psychosis is frequently associated with Parkinson's disease?

Psychosis is a common non-motor symptom of Parkinson’s disease whose pathogenesis remains poorly understood.Parkinson’s disease in conjunction with psychosis has been shown to induce injury to extracorticospinal tracts as well as within some cortical areas.In this study,Parkinson’s disease patients with psychosis who did not receive antipsychotic treatment and those without psychosis underwent diffusion tensor imaging.Results revealed that in Parkinson’s disease patients with psychosis,damage to the left frontal lobe,bilateral occipital lobe,left cingulated gyrus,and left hippocampal white-matter fibers were greater than damage to the substantia nigra or the globus pallidus.Damage to white-matter fibers in the right frontal lobe and right cingulate gyrus were also more severe than in the globus pallidus,but not the substantia nigra.Damage to frontal lobe and cingulate gyrus white-matter fibers was more apparent than that to occipital or hippocampal fiber damage.Compared with Parkinson’s disease patients without psychosis,those with psychosis had significantly lower fractional anisotropy ratios of left frontal lobe,bilateral occipital lobe,left cingulated gyrus,and left hippocampus to ipsilateral substantia nigra or globus pallidus,indicating more severe damage to white-matter fibers.These results suggest that psychosis associated with Parkinson’s disease is probably associated with an imbalance in the ratio of white-matter fibers between brain regions associated with psychiatric symptoms(frontal lobe,occipital lobe,cingulate gyrus,and hippocampus) and those associated with the motor symptoms of Parkinson’s disease(the substantia nigra and globus pallidus).The relatively greater damage to white-matter fibers in psychiatric symptom-related brain regions than in extracorticospinal tracts might explain why psychosis often occurs in Parkinson’s disease patients.     

Are personality traits associated with cognitive disturbance in psychosis?

OBJECTIVE: Personality and cognition are often considered as disparate constructs, both in normal individuals and in those with a psychosis. The goal of the present study was to analyze the relationship between dimensions of personality and cognitive performance in individuals with psychosis. METHODS: Sixty-one consecutively admitted patients with an acute psychotic episode were recruited for this study. Personality was assessed through a semistructured interview with a close relative using the Personality Assessment Schedule. A wide neuropsychological battery was applied, including attentional, executive, memory tasks and global cognition. Assessments took place when symptomatology was in remission. RESULTS: Higher scores on a passive-dependent dimension were significantly associated with poorer memory performance. Similarly, higher levels for a schizoid dimension were significantly associated with poorer executive performance. The results remained significant after partialling out the effect of gender, psychopathological dimensions and drug status. CONCLUSION: It is hypothesized that personality traits and cognitive performance are interrelated domains in psychosis.     

Clinicians’ attitudes to the employment of people with psychosis

Background  Negative staff attitudes have been cited as a factor in explaining the low rates of employment in people with psychosis. We aimed to conduct the first systematic survey of staff attitudes in UK community mental health teams. Methods  A questionnaire survey of clinicians working in community mental health teams in North London, UK. Results  Clinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients. Conclusions  In this London catchment area, clinicians believed the majority of people with psychosis to be capable of some kind of work, albeit not always open market, but they had few resources available to them to facilitate this. They give priority to the development of place and support vocational services.     

Unusual ‘Spike-wave stupor’ in a patient with manic-depressive psychosis treated with amitriptyline

Summary Spike-wave stupor was observed in a 58-year-old male patient with manic-depressive psychosis. Almost continuous atypical spike-wave activity was seen in conjunction with a stuporous episode with stereotyped automatism. Intravenous diazepam ended both the electroencephalographic epileptiform discharges and the clinical stupor. Before and during this episode the patient was treated with an average-dose amitriptyline monotherapy. There was no family history of epileptic seizures. The patient had had electroconvulsive therapy. The history suggests that the analeptic property of amitriptyline induced the spike-wave stupor in this patient.

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Zusammenfassung Während eines Stupors mit stereotypen Bewegungsabläufen und Reihensprechen, der im Rahmen einer depressiven Phase eines an einer manisch-depressiven Psychose erkrankten 58jährigen Patienten auftrat, wurde eine nahezu kontinuierliche unregelmäßige spike-wave- und sharp-wave-Aktivität im EEG abgeleitet. Der spike-wave-Stupor konnte durch eine intravenöse Applikation von Diazepam in seiner klinischen und elektroenzephalographischen Ausprägung rasch unterbrochen werden. Vor und während der stuporösen Attacke wurde der Patient mit Amitriptylin als Monotherapie in üblicher Dosierung behandelt. Die Eigen- und Familienanamnese ergab keinen Hinweis auf das Vorliegen einer Epilepsie. Epileptische Anfälle hatte der Patient nur aus therapeutischen Gründen im Rahmen einer Elektroschocktherapie. Die Analyse des Falles läßt in der analeptischen Wirkung von Amitriptylin die Ursache für das Auftreten des spike-wave-Stupors erkennen.

     

Khat-induced psychosis?

Khat is a drug endemic in East Africa, whose active ingredient has amphetamine-like effects. Khat might induce psychosis, but there is no consensus about this in the literature. Two cases of suspected khat-induced psychosis are presented. Treatment of choice appears to be discontinuation of khat use, possibly combined with treatment with an antipsychotic.     

Does socioeconomic status predict course and outcome in patients with psychosis?

Background We examined the relationship between socioeconomic status (SES) and course and outcome of patients with psychosis. Two hypotheses were examined: a) patients with higher best-ever SES will have better course and outcome than those with lower best-ever SES, and b) patients with greater downward drift in SES will have poorer course and outcome than those with less downward drift. Method Data were drawn from the baseline and 2-year follow-up assessments of the UK700 Case Management Trial of 708 patients with severe psychosis. The indicators of SES used were occupational status and educational achievement. Drift in SES was defined as change from best-ever occupation to occupation at baseline. Results For the baseline data highly significant differences were found between best-ever groups and negative symptoms (non-manual vs. unemployed – coef −10.5, p=0.000, 95 % CIs 5.1–15.8), functioning (non-manual vs. unemployed – coef −0.6, p=0.000, 95 % CIs 0.3 to −0.8) and unmet needs (manual vs. unemployed – coef 0.5, p=0.004, 95 % CIs 0.2–0.9). No significant differences between best-ever groups were found for days in hospital, symptoms, perceived quality of life and dissatisfaction with services. Significant differences for clinical and social variables were found between drift and non-drift SES groups. There were no significant findings between educational groups and clinical and social variables. Conclusions Best-ever occupation, but not educational qualifications, appeared to predict prognosis in patients with severe psychosis. Downward drift in occupational status did not result in poorer illness course and outcome. Accepted: 3 August 2001     

Vulnerability of an epileptic case to psychosis: Sodium valproate with lamotrigine, forced normalization, postictal psychosis or all?

Patients with epilepsy can be considered to be at high risk for developing psychotic disorders. Furthermore, there is association between seizure freedom or the disappearance of the interictal epileptiform events from the EEG record and the occurrence of psychotic symptoms. Also, several newer antiepileptic drugs have been reported to induce psychotic symptoms. We present a patient with epilepsy who developed psychotic symptoms under the treatment of valproic acid (VPA) and lamotrigine (LTG) combination. The mechanism underlying the association between LTG, seizure control and development of psychosis are discussed in the light of the literature.     

Prolactin concentrations in newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis

Background

Previous studies have found increased prolactin concentrations in antipsychotic-naïve patients with schizophrenia. However, the roles of other hormones, and of potentially confounding variables such as gender and smoking, have not been considered.

Methods

Blood from newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis (13 women and 20 men) and matched controls (12 women and 21 men) was assayed for prolactin, as well as three other hormones that impact prolactin concentrations: thyrotropin-stimulating hormone (TSH), ghrelin, and cortisol.

Results

Patients had significantly higher prolactin concentrations: female patients had a mean [SD] of 37.1 ng/mL [24.9] vs. 13.5 ng/mL [7.2] for female control subjects (p = .001), while male patients had a mean of 15.3 ng/mL [9.5] vs. 7.6 ng/mL [2.2] for male control subjects (p = .006). Patients and control subjects did not differ on concentrations of TSH, ghrelin, or cortisol. The group differences could not be attributed to differences in age, gender, smoking, body mass index, ethnicity, or the socioeconomic status of the family of origin.

Conclusions

Increased prolactin concentrations in antipsychotic-naïve patients do not appear to be due to important confounding variables, or to the effects of elevated TSH, ghrelin, or cortisol.     

Persistent interferon-ß-1b-induced psychosis in a patient with multiple sclerosis

Interferon‐β is used in patients with multiple sclerosis to reduce autoimmunity; although other psychiatric side‐effects are common, in contrast to interferon‐alpha, psychosis has been reported only once. A patient with multiple sclerosis developed auditory hallucinations, paranoid delusions, and increased aggressiveness after 16 months of treatment with interferon‐β‐1b, 250 µg every other day. He responded after about one month to antipsychotic treatment, but tended to relapse upon dose reduction, and after 2 years still needs antipsychotics to control his symptoms. Because there was no change in his magnetic resonance imaging between pre‐ and post‐treatment with interferon, we concluded that psychosis was more related to interferon treatment than to the underlying disease.     

Do people with a first episode of psychosis differ in personality profiles?

Studies on personality profiles in psychosis typically report certain personality traits as linked to the disorder. OBJECTIVES: To determine if individuals with a first episode of psychosis: 1) differ from a non-clinical group on the five factor model of personality; 2) all present with similar personality profiles; 3) hold stable personality traits over time. METHOD: 79 individuals with a first episode of psychosis were recruited. RESULTS: The first episodes significantly differed from the control group on all five personality dimensions. Results also revealed three personality profiles, one linked to psychotic symptoms. Moreover, personality traits of the first episodes showed stability over time.     

Reactive psychosis. II. Does DSM-III-R define a third psychosis?

The DSM-III and DSM-III-R criteria for "brief reactive psychosis" change the original concept of this disorder in a manner so restrictive as to virtually eliminate the diagnosis. In a companion paper to this one, we have reviewed the original concept and data supporting further study of this classification. We now argue that the operational criteria of the DSM-IIIs do not enhance the study of this putative disease entity, but rather thwart this goal by restricting the diagnosis so severely that too few cases will be found to test the third psychosis hypothesis. We suggest revised criteria that will retain the essential features of the traditional concept while defining explicit criteria in the style of the DSM-IIIs.