Secondary Schizophrenia (159 page)

Pharmacological management of

without dementia. Mov Disord,

associated with complex partial

Huntington’s disease: an

2002.
17
:676–81.

seizure disorder. Ann Clin

evidence-based review. Curr

95. Fernandez H. H., Friedman J. H.,

Psychiatry, 1997.
9
:31–51.

Pharm Des, 2006.
12
:2701–20.

Jacques C.,
et al.
Quetiapine for

77. Sibbitt W. L. Jr., Brandt J. R.,

86. Factor S. A., Friedman J. H. The

the treatment of drug-induced

Johnson C. R.,
et al.
The incidence

emerging role of clozapine in the

psychosis in Parkinson’s disease.

and prevalence of

treatment of movement disorders.

Mov Disord, 1999.
14
:484–7.

neuropsychiatric syndromes in

Mov Disord, 1997.
12
:483–96.

96. Molho E. S., Factor S. A.

pediatric onset systemic lupus

87. Akil M., Brewer G. J. Psychiatric

Worsening of motor features of

erythematosus. J Rheumatol,

and behavioral abnormalities in

parkinsonism with olanzapine.

2002.
29
:1536–42.

Wilson’s disease. Adv Neurol,

Mov Disord, 1999.
14
:1014–16.

78. Bodani M., Kopelman M. D. A

1995.
65
:171–8.

97. Schindehutte J., Trenkwalder C.

psychiatric perspective on the

88. Leweke F. M., Gerth C. W.,

Treatment of drug-induced

therapy of psychosis in systemic

Klosterkotter J.

psychosis in Parkinson’s disease

lupus erythematosus. Lupus, 2003.

Cannabis-associated psychosis:

with ziprasidone can induce

12
:947–9.

current status of research. CNS

severe dose-dependent

79. Tincani A., Brey R., Balestrieri G.,

Drugs, 2004.
18
:895–910.

off-periods and pathological

et al.
International survey on the

89. Pollak P., Tison F., Rascol O.,

laughing. Clin Neurol Neurosurg,

management of patients with SLE.

et al.
Clozapine in drug induced

2007.
109
:188–91.

II. The results of a questionnaire

psychosis in Parkinson’s disease: a

98. Wolkowitz O. M., Reus V. I.,

regarding neuropsychiatric

randomised, placebo controlled

Canick J.,
et al.
Glucocorticoid

manifestations. Clin Exp

study with open follow up.

medication, memory and steroid

Rheumatol, 1996.
14
(Suppl
J Neurol Neurosurg Psychiatry,

psychosis in medical illness. Ann

16):S23–9.

2004.
75
:689–95.

N Y Acad Sci, 1997.
823
:81–
80. Sanna G., Bertolaccini M. L.,

90. Trosch R. M., Friedman J. H.,

96.

Khamashta M. A.

Lannon M. C.,
et al.
Clozapine use

99. Herguner S., Bilge I., Yavuz Y. A.,

Neuropsychiatric involvement in

in Parkinson’s disease: a

et al.
Steroid-induced psychosis in

systemic lupus erythematosus:

retrospective analysis of a large

an adolescent: treatment and

current therapeutic approach.

multicentered clinical experience.

prophylaxis with risperidone.

Curr Pharm Des, 2008.
14
:
Mov Disord, 1998.
13
:377–82.

Turk J Pediatr, 2006.
48
:244–7.

1261–9.

91. Widman L. P., Burke W. J., Pfeiffer

100. DeSilva C. C., Nurse M. C., Vokey

81. Sewell D. D., Jeste D. V.,

R. F.,
et al.
Use of clozapine to

K. Steroid-induced psychosis

McAdams L. A.,
et al.
Neuroleptic

treat levodopa-induced psychosis

treated with risperidone. Can J

treatment of HIV-associated

in Parkinson’s disease:

Psychiatry, 2002.
47
:388–9.

404

Chapter 32 – Drug treatment of secondary schizophrenia

101. Kramer T. M., Cottingham E. M.

steroid-induced psychosis in a

pulmonary disease. Am J Emerg

Risperidone in the treatment of

child. Ann Pharmacother, 2003.

Med, 1999.
17
:735.

steroid-induced psychosis. J Child

37
:1036–9.

104. Abbas A., Styra R. Valproate

Adolesc Psychopharmacol, 1999.

103. Ahmad M., Rasul F. M.

prophylaxis against steroid

9
:315–16.

Steroid-induced psychosis treated

induced psychosis. Can J

102. Ingram D. G., Hagemann T. M.

with haloperidol in a patient with

Psychiatry, 1994.
39
:188–
Promethazine treatment of

active chronic obstructive

9.

405

Section 5

Treatment

secondary schizophrenia

David J. Kavanagh, Jennifer M. Connolly, and Kim T. Mueser
Facts box

outcomes. Up to now, little research has focused solely
r

on psychological treatment for unequivocally sec-Irrespective of etiology, there is significant
ondary psychosis. As a consequence, we must rely on
room for psychological treatments to target

extrapolations from work on psychoses in general, on
cognitive or behavioral triggers for psychotic
schizophrenia or affective psychosis, or even on the
symptoms and for strategies to improve

management of the behavioral risk in nonpsychotic
outcomes.

populations. Although the treatments and methods
r
There is a substantial body of literature

discussed here have an evidence base in primary psy-targeting the treatment of substance use in
chosis, the evidence supporting their application to
schizophrenia because of its important

secondary psychosis is yet to be established. Much of
association with this disorder.

this chapter must therefore be speculative.

r
Insomnia may complicate the management

Because of the importance of substance use as a
of psychosis or be its trigger, and

risk for psychotic symptoms, this chapter emphasizes
nonpharmacological strategies for its

research on that topic. However, that is not the only
management may have an important clinical

potential target of psychological intervention. Among
role.

potential determinants, insomnia has been addressed
r
Strategies to manage residual psychotic

in its own right within the general population. Fea-symptoms include cognitive behavior
tures and sequelae of psychosis – positive symptoms,
therapy, social skills training, cognitive

cognitive deficits, and functional skills-have also had
remediation, and family intervention – and

research attention, as have factors that may improve
these could possibly be applied to both

outcomes, such as adherence, family interventions,
primary and secondary schizophrenia.

and early detection of relapse. Although this work has
r

not been specific to secondary psychosis, aspects may
There have not as yet been controlled trials

be applicable to it.

on averting potential psychosis using either a
substance use or insomnia intervention,

although substance use is addressed in

Substance use

multicomponent studies on early episodes of

psychosis.

As previously discussed in this volume (Chapters 14–
22), use of some psychoactive substances can not only
trigger a temporary psychotic reaction
[1, 2]
but can

initiate a potentially lifelong disorder in vulnerable
Because the primary focus of this book is on psychoses
individuals
[3, 4].
Because substance use is very com-arising from specific organic syndromes, it may at first
mon in patients with psychosis
[5, 6],
and because it
seem odd that a chapter on psychological interven-is often hard to know whether it has a primary role in
tions for these problems should be included, as there
the psychosis at early stages of the disorder, substance
is no psychological treatment that directly targets their
use needs to be routinely assessed and addressed in
organic basis.

patients with psychosis.

However, there is significant room for psychologi-Treatment of substance misuse in people with
cal treatments to target cognitive or behavioral triggers
psychotic disorders has often relied on a parallel
406

for psychotic symptoms and for strategies to improve
or sequential approach. In parallel treatments, the
Chapter 33 – Nonpharmacological interventions in secondary schizophrenia

mental illness and substance misuse are treated by dif-chotic episode, provided the person can maintain
ferent clinicians, usually from different agencies. In
attention on a single subject for a few minutes. In
sequential treatments, efforts initially focus on treat-fact, engagement during an inpatient stay has some
ing or stabilizing one disorder and then addressing the
advantages – high availability for brief discussions
second. Problems arise with each of these strategies
[7,

and salience of negative consequences (e.g., unpleas-

8].
Parallel or sequential treatments by different agen-ant symptoms, being on a psychiatric ward, receiving
cies are subject to differing policies and procedures in
a psychiatric diagnosis, receipt of medication, medica-each agency and to problems with communication and
tion side effects, involuntary treatment). Motivation to
coordination
[9]
. At worst, this can result in the patient
maintain session attendance and remain symptom free
missing treatment for one or more of their problems
may be augmented by contingent reinforcement
[22,

(e.g., because they do not fulfill priority criteria for ser-

23, 24, 25]
, although care needs to be taken to ensure
vice or do not receive assertive follow-up) or receiving
that this reinforcement is not so great as to undermine
inconsistent advice.

intrinsic motivation
[26].

There is another, potentially critical problem with
Most current approaches also incorporate harm
the separation of treatments: unless both treating clin-reduction as well as abstinence goals. Any ongoing
icians have the knowledge and skills to treat both
use of psychoactive substances heightens the risk of
types of problem, the treatment may not be sufficiently
a return to problematic substance use
[27],
and in
modified to suit this population. Furthermore, except
some cases, the risk of psychotic relapse
[10].
How-where psychotic symptoms remain secondary to the
ever, many patients are initially unwilling or unable
substance misuse, each problem is likely to exacer-to adopt an abstinence goal. Commitment to address-bate the other
[10].
Accordingly, current treatments
ing potential risks, to partial reductions, or to stopping
for substance misuse and psychotic symptoms typi-use of one drug is often easier to elicit, and has the
cally have a single clinician or clinical team assuming
advantages of consolidating collaborative engagement,
responsibility for management of both problem areas
building confidence, and addressing urgent threats
[11].
Based on the theme of integration, a number of
to the patient’s life and welfare. Those who choose
treatment programs have been developed for comor-to adopt intermediate goals are encouraged to evalu-bidity
[12, 13, 14, 15, 16].
These programs have consid-ate whether achieving these goals effectively addresses
erable differences, but they typically share emphases
their substance-related problems. As a result, many do
on engagement and motivation enhancement, harm
then adopt an abstinence goal. In this way, therapists
reduction, assertive outreach, and comprehensiveness.

provide support for patient-identified goals, without
Some of the engagement and motivational chal-