Medical Treatment on Schizophrenia

Psychopharmacology: An Introduction 4th Edition, Rene Spiegel

1.1 Definition and Classification

Psychopharmacology is the branch of pharmaceutical sciences that deals with medications that affect
the behaviour or perception of a person under the medications' influence. These effects are called
psychotropic.
Examples include legal substances like alcohol and nicotine, and illegal recreational drugs such
as cocaine and heroin.
Classification of psychopharmaceuticals according to clinical criteria:
Antipsychotics
o Treats schizophrenia and "states of agitation occurring in other psychiatric syndromes"
(1)
o Occasionally called neuroleptics or major tranquillizers (1)
Antidepressants
o Treats depression
Mood stabilizers
o Treats mania/hypomania
Anxiolytics
o Treats states of anxiety and tension
o Aka minor tranquillizers
Psychostimulants
Nootropics
o Treats dementia

1.2 Antipsychotics
"Antipsychotics are calming medications used to counteract marked inner unrest, psychomotor
agitation and severe insomnia." (3)
Mainly used for schizophrenic psychoses, esp. catatonic and paranoid forms
Mania
"psychotic syndromes as sequelae of organic brain disorders (e.g. old age paranoia")
Depressions, esp. w/ anxious and agitated symptoms

Antipsychotic drugs have a calming effect on patients that differ from other sedatives in two ways:
1. "most antipsychotics are not myorelaxant", that is, most antipsychotics do not relax the muscles
which affects muscle function and muscle tone.
2. act against psychotic symptoms (hence, "antipsychotics")
o The effects of these drugs usually occur after several days or weeks of treatment. At first
delusions recede and the ideas of persecution are at least partially if not entirely
removed as a psychotic symptom. Auditory hallucinations diminish; "demanding voices
become quieter or are totally silenced." The patient seems to be able to recognize the
real environment and cope with their surroundings more comprehensibly. All in all, they
become "less `psychotic'" (4).

One can distinguish three phases of the effects of antipsychotic drugs:
1. "First phase (duration about one week):"

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"the patient tends to doze and sleep, even during daytime" and their motives are
reduced. The patient loses initiative, appears lethargic, and indifferent towards their
surroundings.
They are detached from sources of anxiety,
and symptoms of psychosis like delusions and "paranoid-hallucinatory" (4) experiences
become less apparent
2. "Second phase (duration about one week):"
Around the second week of the treatment, the "sedative effect recedes while the
`antipsychotic' effect is retained;" this means the patient is no longer lethargic and
shows drive towards their daily activities while having suppressed their psychotic
symptoms.
There is still a chance that an emotional outbreak may occur spontaneously or with
cause.
3. "Third phase:"
In the third phase, the patient still has minor loss of motivation alongside reduced
emotional responsiveness. "The antipsychotic drug effect is retained" as the patient's
insight to their schizophrenic disorder increases.

1.2.3 Difference between different products
There are more than thirty antipsychotics on the market, and the difference between products are
determined by their
Pharmacokinetics - "study of the movements of a medication"
o This includes the differences in how each drug show differences in "absorption,
distribution, metabolism, and excretion as a result of their different chemical structures
and pharmaceutical preparations (capsule, tablet, injectable" for example).
o "The binding to specific brain structures and thus its actions depend on the
physicochemical properties of the molecules."
o All this affects the drugs' onset and duration, and are important in choosing which
medication a patient may respond to and its effectiveness. The differences in
pharmacokinetics may be why patients react differently to each medication.
Pharmacodynamics - "their pharmacological and clinical profiles of action. A rough distinction is
made between highly sedative, hypnotic antipsychotics... and other products with weaker initial
sedative action" (6).
o The differences in drugs' pharmacodynamics make their uses tailored to the severity of
psychotic outbursts. Sedative antipsychotics are given during "states of major unrest",
whereas the less sedative antipsychotics are given for symptoms such as hallucinations
and delusions that may be given in the daytime when the patient should be awake.

Psychopharmacology 1 Part 2, Clinical Psychopharmacology, H. Hippius & G. Winokur

Dopamine
Looking at which systems are affected by antipsychotic medications, the drug action of
antipsychotic drugs on the "dopaminergic system" suggests the system is related to the
generation of psychotic symptoms
This drug action forms the basis for the dopamine hypothesis of schizophrenia, which suggests
that schizophrenia results from the "functional overactivity of some dopamine (DA) system in
the central nervous system". This suggests that antipsychotics block certain dopamine

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receptors.

Psychiatric Drugs Explained 3rd Edition, David Healy

Serotonin and the atypical antipsychotics (12)
With the dopamine hypothesis suggesting all antipsychotics affect the dopamine system, most
antipsychotics act on the serotonin (5HT) system as well, binding to particular serotonin
receptors.
The effects of serotonin binding by antipsychotics, serotonin antagonists, can block the
hallucinogenic effects brought on by recreational drugs like LSD, which suggest it may treat
some psychotic symptoms of schizophrenia.



1.2.4 Side Effects (`Adverse Effects') of Antipsychotics

In general, especially in large doses, antipsychotics can induce vegetative side effects like orthostatic
hypotension, "sweating, dry mouth, and sometimes impaired sexual function".
In contrast, some strong antipsychotic action often leads to extrapyramidal motor symptoms," like
dyskinesias, which is disturbed movements, iatrogenic (treatment-induced) Parkinsonian states and,
after prolonged use, tardive dyskinesias.
With all the possibilities for adverse effects, the benefits and risks of antipsychotic treatment have to be
weighed against one another in each patient.

Psychiatric Drugs Explained 3rd Edition, David Healy

Dopamine System Side Effects (28)
We have mentioned that antipsychotics reduce the amount of dopamine activity in the brain.
"Parkinson's disease involves reduced dopamine levels" which may be a side effect of the
antipsychotic medication; the patients sometimes show a state of Parkinson's. Fortunately once
the medication is stopped, so do the Parkinson-like symptoms, and do not cause Parkinson's
disease.

Stiffness/Lack of Movement: Akinesia (29)
"This is the central feature of parkinson's disease." One may show a milder form caused by
antipsychotics and their movements feel slowed, and in more severe forms, the patient may feel
restricted, "even strait-jacketed".
They may be wide awake but sit motionless because the medication slows down all movements,
"and all extra or unnecessary movements are reduced in frequency", even their facial
expressions, causing them to sit still and stare blankly.
This slowed movement may cause slowed reactions as well, causing a lapse of time between
answering questions, drooling, and find it difficult to stop walking once they start.

Abnormal Movements: Dyskinesias (29-30)
Tremors most common in the hands, arms, and legs. Sometimes the whole body may writhe and
shake, most noticeable symptom.

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Tardive Dyskinesia (30-31)
Tardive refers to late onset, which means the tremors occur several months after the treatment
has started and can last months to years after the drug has been discontinued.

Abnormal Muscle Tone: Dystonia (30)
Dystonia means that some muscle "has gone into spasm". Usually these spasms are abrupt and
will subside within the hour. The most commonly affected muscles are the eyes, mouth, and
jaws, but can happen to any muscle.
This includes the eyes rolling to the back of their heads showing only the whites, called an
oculogyric crisis.
When the mouth is affected, there can be difficulty speaking, eating, or drinking. When the
larynx is affected their voices can change as well.

Other side effects:
Akathisia (restlessness, nervousness, agitation, turmoil), lack of interest (demotivation),
hormonal changes (most antipsychotics increase the level of the hormone prolactin - affects
breast size and lactation), weight gain, sedation/arousal, sexual side effects (inability to sustain
erections in men, decrease in libido), skin rashes, aggression and impatience, epilepsy (rare)

Shean, G. D. (2004). Understanding and treating schizophrenia: Contemporary research, theory, and
practice. Binghamton, NY: The Haworth Press, Inc.

Betsy

Well, an old man put his hands on my neck and I shot him. He kept trying to sneak around and
peek in the windows and I shot him right through the butt [laughs]. And then I shot him again. I had to
have my breast operated on. There was blood in them, and I had to nurse my babies. Then he knocked
me in the head with a stick and tried to kill me. My father wrote and told him that I couldn't hold food in
my stomach and I was throwing up all the time. And I was taking care of my mother because my sister
was mistreating her, so I bet the hell out of her.

First time I came here was twenty-eight years ago, and I been home a bunch of times.

I make bombs here out of dynamite. I have a big machine set up, and I use the energy from the
sun to run it. It is a hard job, and I don't ever take ay vacations. I had a boyfriend, but the Japanese came
around and my baby was killed. They had my baby murdered. They did that in here She was murdered,
and they proved that from the blood-type analysis.

All my children are doctors. I been trying to get my daddy out from China. My daddy was an
American man, but he was in China. But the Chinese tried to rape me one night, and I pushed him so he
fell and broke his neck. I bombed the hell out of China.

Sources:

Shean, G. D. (2004). Understanding and treating schizophrenia: Contemporary research, theory,
and practice. Binghamton, NY: The Haworth Press, Inc.

Winokur, G., & Hippius, H. (1983). Clinical psychopharmacology. Amsterdam: Excerpta Medica.

Spiegel, R. (2004). Psychopharmacology, an introduction. (4 ed.). West Sussex, England: Wiley.

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Healy, D. (2002). Psychiatric drugs explained. (3 ed.). London: Churchill Livingstone.

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