Overview: Psychopharmacological
Strategies in Non-responsive Psychosis
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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