Secondary Schizophrenia (152 page)

for example, the cerebellum – reticular-activating
For the second group, vulnerability exists but is not a
system – thalamus, or subcircuits within the pale-sufficient factor and psychological stress is necessary
ostriatum, and so on, and these may contribute to
to induce the acute psychosis – this group includes the
unique aspects of an individual’s psychosis. Further,
most common “reactive psychoses” cases. The third
we now know that higher cortical functions are best
group is the physiologic counterpart of the second
understood as served by “distributed” circuits in the
group with additional burden from marginal physio-brain and the same dysfunction may result from
logic resources, anemia, for example, to combat com-damage to any one of a number of different (and
mon physical stress. The physical stress interacts with
interlinked) circuits
[81].
The best analogy is that of
the inherent vulnerability to induce the acute psy-an interstate roadway system, wherein a destination
chosis. This group would include people who develop
may be reached by numerous permutations and
an acute psychosis after fever, puerperium, or infec-combinations of roads, but a primary expressway
tions common in developing countries such as typhoid
serves as the most direct path. Thus, in the case of
and malaria. Some (probable) cases of “psychosis sec-psychosis, the greater the involvement of the psychosis
ondary to a general medical condition” in the DSM

circuit, the greater the chances that psychosis will
could fall under this group. Group 4 consists of cases
result. This anatomical understanding begins to
likely to be diagnosed as clearly organic in ICD or
inform us that the so-called “functional APDs” may
psychosis secondary to a general medical condition in
be manifestations of neurobiological dysfunction,
DSM. These medical-neurological conditions appear
which may be anatomical, physiological, or chemical
to have direct neurotoxic effects that produce psy-in nature, or some combination thereof. The vas-chosis depending on the severity of the neurotoxic-cular lesions seen in certain strokes are particularly
ity. Group 5 consists of patients who experience acute
informative. Ischemia from any cause in the areas
psychosis in the face of catastrophic stress such as in
supplied by the anterior cerebral artery is particularly
prisoners of war or in victims of earthquakes, floods,
associated with perceptual and cognitive disturbances
tsunamis, and so on, and may truly be a “psychogenic”

[72, 82].

condition. It should be noted that to some extent,
In the case of acute brief psychoses, organic-these five groups are overlapping but they can also
ity may be invoked, because molecular or metabolic
be unique. Das and colleagues
[79]
found empirical
dysfunction is likely. One possible way out of the
384

Chapter 31 – Acute brief psychosis – an organic syndrome?

organic-functional terminology conundrum is to use
rule in APD, and fits the notion that in many APDs,
the term “neurobiological” for all disorders wherein
there are nonspecific medical factors at work on a vul-there is reasonable suspicion of neurological and/or
nerable “neurobiological” system, and supporting the
biological dysfunction as demonstrated by currently
system is as important as the use of antipsychotics.

available technologies. This term better captures cur-The patient and the family need to be reassured about
rent conceptions of pathologies in psychosis and
the brief duration of psychotic symptoms despite their
should be substituted for the older term “organic.”

florid and dramatic nature. Supportive psychother-The term “neurobiological,” then, is a more accu-apy to support the fragile ego functions during and
rate term for APDs than “organicity.” Many of them
immediately after the psychosis is critical. Psychoed-occur under conditions of altered physiology, and
ucation on the illness nature of the condition, stress
in others, the neural circuits implicated in psychosis
reduction, coping skills, and early detection in case
are very likely involved
[83, 84].
However, there
of recurrence, is an important part of management
is indeed not a significant literature on this topic.

[85, 87].

One suspects this is a result of the focus of most
biological investigations on schizophrenia with the
Suggestions for future research

belief, rightly or wrongly, that much of what we find
Whereas the literature on the phenomenology and
in schizophrenia may be extrapolated to the other
course of APD is rich, the research on the epi-psychoses.

demiology, biology, and treatment of these disorders is limited. Much is extrapolated from the litera-

Clinical management of acute

ture on schizophrenia, and treatment practices remain
psychotic disorder

untested. With the availability of technology for functional imaging, chemical spectroscopy, and genomics,
The treatment of APD typically involves the use of
APDs offer a fertile ground for research into the patho-antipsychotic medications. Clinical experience sug-physiology of psychosis. With their well-known cross-gests that APDs respond well to such medications.

cultural differences, APDs offer a unique opportunity
Both typical and atypical antipsychotic medications
for studying the core pathology of psychosis and pos-may be used and there is no literature to suggest that
sibly untangling genetic–environmental risk factors.

any particular class of medications is to be preferred
The role of specific psychological, social, and cultural
over others. It has become the standard, though, to
factors in the risk-protection equation needs to be
use atypical medications as first-line therapy to avoid
studied.

acute neuromuscular side effects. The literature does
suggest that despite the florid nature of the psychosis,
it is not necessary to use large doses of antipsychotics
Conclusions

for the relief of symptoms in APDs
[85, 86]
. This is sim-Acute psychotic disorders are a commonly seen group
ilar to the experience with the traditional organic psy-of psychoses, with acute onset, short course, and full
chosis. Patients with the latter are more prone to extra-resolution of symptoms. They seem to be more preva-pyramidal adverse effects as well as other toxicities of
lent in developing countries and in other vulnerable
these drugs. Sometimes, it may be sufficient to conser-populations, both psychosocially (e.g., immigrants)
vatively treat the associated symptoms such as fever,
and physiologically (e.g., puerperium and fevers).

dehydration, infections, and so on, and to provide sup-They may be best understood as a transient dys-portive psychotherapy for integration and healing of
function in the psychosis circuit of the nervous sys-the break in the ego to avoid the need to aggressively
tem in the face of (i) inherent vulnerability, (ii) psy-prescribe antipsychotics. This is not as much a rec-chosocial stress, (iii) neurotoxic pathology, or some
ommendation as simply an observation. Further, it
combination thereof, particularly in populations with
may be reassuring to patients that they do not need
marginal physiological resources. There is modest evi-

“stronger” antipsychotic medications typically associ-dence of demonstrable neurobiological abnormalities
ated with the more severe illnesses such as schizophre-in these disorders. They may share a common dys-nia or bipolar disorder. This treatment plan would be
function in the “psychosis circuit” with schizophrenia
consistent with the quick recompensation that is the
and psychotic mood disorders and may justifiably be
385

Related Concepts – Section 4

considered as “neurobiological” disorders. Like other
in a proportion of cases, the long-term prognosis is
psychotic disorders, they are best treated with antipsy-good with preserved function at or close to baseline.

chotic medications, supplemented with symptomatic
They offer a very useful and unique window into the
and supportive medical and psychological therapies.

study of the major psychoses and should become the
Although recurrence of the psychosis is to be expected
focus of more studies.

386

Chapter 31 – Acute brief psychosis – an organic syndrome?

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