Antipsychotics: Predicting Response/Maximizing Efficacy
Mark S. Gold, R. Bruce Lydiard, John S. Carman in Advances in Psychopharmacology: Predicting and Improving Treatment Response, 2018
Predicting and monitoring a response to medication requires specifying what the expected response will be. The literature contains studies measuring “response” to treatment which range from reduction of specific symptoms (e.g., hallucinations or assaultiveness) to reestablishment of social and occupational competence. The extent to which improvement can be expected, then, is quite dependent on the variable in question. This is particularly important for the treatment of schizophrenic patients. “Positive” symptoms of psychosis such as hallucinations or delusions, which are often reduced by antipsychotic medication, occur in schizophrenic, affective, and other psychoses. These nonspecific symptoms may be associated with the “active” (possibly hyperdopaminergic) states in many psychotic patients. Other symptoms which may be related to the core process of schizophrenia are called “negative” symptoms, such as blunted affect and withdrawal. These have been observed most often in those patients with poor premorbid adjustment and early and insidious onset of illness; these symptoms are sometimes accompanied by early neuroanatomic changes. The “negative” symptoms tend to be less affected by antipsychotic medication and are postulated by Crow to be possibly unrelated to dopaminergic transmission. Accordingly, these “DA insensitive” symptoms are less responsive to antidopamine drugs. It is important, then, to define the particular target symptoms and to have a reasonable expectation of outcome for that symptom. While “active” symptoms of psychosis in a chronic schizophrenic patient may respond to treatment, the chronic course and ultimately poor prognosis will likely not be altered significantly by medication treatment. In general, patients who have responded to medication in the past are likely to respond favorably again. There is also good evidence that most patients will respond to medication, although, as noted above, there will be a broad range in the degree of the response. Finally, there are patients who actually do as well or better without medication or respond at a much lower dosage than is usually required for most patients. The following sections in this chapter will explore possible ways to facilitate prediction of response, optimize treatment in drug-responders, and identify patients for whom medication is less likely to be helpful.
Posttraumatic Personality Disorders
Rolland S. Parker in Concussive Brain Trauma, 2016
Apathy refers to indifference to the environment. It has the characteristics of diminished motivation not attributable to decreased level of consciousness, cognitive impairment, or emotional distress. It is different from depression, which is the experience of sadness and related feelings. Apathy has been observed in patients with impaired neural pathways, for example, neurodegenerative disorders (Levy et al., 1998). Stroke patients, with and without poststroke depression, may show similar impairments in emotional prosody, comprehension aprosody (sensory), and poststroke depression (Starkstein et al., 1994). While aprosodic patients may be apathetic (lost motivation, activity level), apathy is a different symptom. Blunt or flattened affect is found as a deficit system in chronic schizophrenia, some organic mental syndromes, and severe depression (Yager & Gitlin, 2000).
Questions and Answers
David Browne, Brenda Wright, Guy Molyneux, Mohamed Ahmed, Ijaz Hussain, Bangaru Raju, Michael Reilly in MRCPsych Paper I One-Best-Item MCQs, 2017
Thought blocking.Answer: C. The relationship with the therapist is of lesser importance in CBT. [www.trickcyclists.co.uk/OSCEs/]Answer: C. Historically, the following types of family dysfunctions were at various times believed to be a cause of schizophrenia: schizophrenogenic mother, double bind, martial skew and marital schism and abnormal family communication. These theories are now out of favour, but there is evidence for the more recent theory relating to the effect of expressed emotion with respect to relapse in schizophrenia. [R. pp. 137–8]Answer: E. Paraphrenia was first described by Kraepelin. It is characterised by delusions and hallucinations while other symptoms like blunted affect, formal thought disorder or change in personality are not prominent. [AB. p. 480]Answer: E. This is a component of alogia, a negative symptom. The other groups of negative symptoms are: affective flattening/blunting, avolition-apathy, anhedonia-asociality, and attentional difficulties. [T. p. 247]A 55-year-old patient with a history of depression tells you that she is planning to go out for a meal to celebrate her birthday. She is currently taking phenelzine. Which of the following foods is safest for this woman to order? Brie cheese.Caviar.Guacamole.Pheasant.Sausages.A 40-year-old female patient with schizophrenia, recently admitted to the acute psychiatric unit where you work, describes to you looking in the mirror and not seeing her own image.
Sexual Abuse and Posttraumatic Stress Disorder in Adult Women with Severe Mental Illness: A Pilot Study
Published in Issues in Mental Health Nursing, 2010
Rebecca Bonugli, Margaret H. Brackley, Gail B. Williams, Janna Lesser
Research indicates that women with serious mental illness (SMI) are vulnerable to sexual abuse, resulting in adverse health outcomes such as posttraumatic stress disorder (PTSD). The purpose of this pilot study was to examine the prevalence of undiagnosed PTSD among a cohort of 20 women with SMI and reporting past sexual abuse. Furthermore, the researcher sought to identify specific symptom manifestations of PTSD among women with SMI and sexual abuse histories. Finally, the feasibility of using specific data collection tools was examined. Results indicated that PTSD was not previously diagnosed or recognized in the study sample, in spite of the presence of a sexual trauma history. The screening tools were effective in identifying depression, guilt, emotional withdrawal, blunted affect, decreased psychomotor activity, suicidal ideations, sexual dysfunction, and substance abuse. Additionally, the data collection tools provided a framework for discussing sensitive issues related to sexual abuse. Implications of this pilot study suggest the need to evaluate all women with SMI and history of sexual abuse for PTSD.
Symptoms versus neurocognitive skills as correlates of everyday functioning in severe mental illness
Published in Expert Review of Neurotherapeutics, 2006
A critical review of cross-sectional and longitudinal studies conducted from 2001–2005 investigating the relationship of symptoms and neurocognitive skills to everyday functioning in patients with severe mental illness was completed. Literature and bibliographic searches identified seven studies, which were grouped according to the methodology of measurement of everyday function selected: clinician-rated scales of psychosocial function based on patient and proxy report; performance-based measures of functional capacity; or competitive vocational success. Results of the review revealed that negative symptoms, such as social withdrawal, psychomotor slowing and blunted affect, and neurocognitive measures of attention, executive function, working memory, verbal memory and psychomotor speed, were most commonly linked to all three domains of everyday function. With the exception of one study, there was no evidence of a relationship between positive symptoms, such as delusions and hallucinations, and everyday function. The implications of these findings for guiding future research are discussed.
Traumatic brain injury results in altered physiologic, but not subjective responses to emotional stimuli
Published in Brain Injury, 2018
Prin X. Amorapanth, Viswanath Aluru, Jennifer Stone, Arash Yousefi, Alvin Tang, Sarah Cox, Seda Bilaloglu, Ying Lu, Joseph Rath, Coralynn Long, Brian Im, Preeti Raghavan
Background: While the cognitive sequelae of traumatic brain injury (TBI) are well known, emotional impairments after TBI are suboptimally characterized. Lack of awareness of emotional difficulties can make self-report unreliable. However, individuals with TBI demonstrate involuntary changes in heart rate variability which may enable objective quantification of emotional dysfunction. Methods: Sixteen subjects with chronic TBI and 10 age-matched controls were tested on an emotional function battery during which they watched a series of film clips normed to elicit specific positively and negatively valenced emotions: amusement, sexual amusement, sadness, fear and disgust. Subjective responses to the emotional stimuli were also obtained. Additionally, surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity, the respiratory frequency area (RFA) and sympathetic activity, the low frequency area (LFA), of the HRV frequency spectrum were derived. The Neurobehavioral Rating Scale-Revised (NRS-R) and the King-Devick (KD) test were administered to assess neurobehavioral dysfunction. Results: The two groups showed no differences in subjective ratings of emotional intensity. Subjects with TBI showed significantly decreased sympathetic activity when viewing amusing stimuli and significantly increased sympathetic activity when viewing sad stimuli compared to controls. Most of the subjects did not show agitation, anxiety, depression, blunted affect, emotional withdrawal, decreased motivation or mental fatiguability on the NRS-R. However, 13/16 subjects with TBI demonstrated attention difficulty on the NRS-R which was positively correlated with the increased sympathetic activity during sad stimuli. Both attention difficulty and abnormal autonomic responses to sad stimuli were correlated with the timing on the KD test, which reflected difficulty with visual attention shifting. Conclusions: The HRV spectrum may be useful to identify subclinical emotional dysfunction in individuals with TBI. Attention difficulites, specifically impairment in visual attention shifting, may contribute to abnormal reactivity to sad stimuli that may be detected and potentially treated to improve emotional function.
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