Experience in the use of olanzapine in an inpatient ward – clinical cases

Treating both schizophrenia and bipolar disorder require chronic drug therapy that must be chosen after careful consideration of the gains and losses associated with it. Hence, the process of the drug selection must take into account both the profile of patient’s symptoms and his coexisting diseases as well as the patient’s tolerance of earlier therapies. Olanzapine reduces positive symptoms of psychosis and enables stabilization in terms of affective episodes via blocking dopaminergic receptors. An important problem related to olanzapine therapy is its negative effect on the metabolism of carbohydrates and lipids. For this reason, appropriate information for the patient and implementation of appropriate prophylaxis, including monitoring of metabolic parameters, are recommended. Despite the risk of metabolic complications in some patients, olanzapine remains at the forefront of antipsychotic drugs, due to the good balance of benefits and losses associated with pharmacotherapy. In this paper, we present two clinical cases of patients who have been treated with olanzapine for schizophrenia and bipolar disorder.

The impact of family environment on self-esteem and symptoms in early psychosis

Expressed emotion (EE) and self-esteem (SE) have been implicated in the onset and development of paranoia and positive symptoms of psychosis. However, the impact of EE on patients’ SE and ultimately on symptoms in the early stages of psychosis is still not fully understood. The main objectives of this study were to examine whether: (1) patients’ SE mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia; (2) patients’ perceived EE mediated the effect of relatives’ EE on patients’ SE; (3) patients’ SE mediated between patients’ perceived EE and patients’ symptomatology; and (4) patients’ perceived EE and patients’ SE serially mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia. Incipient psychosis patients (at-risk mental states and first-episode of psychosis) and their respective relatives completed measures of EE, SE, and symptoms. Findings indicated that: (1) patients’ perceived EE mediated the link between relatives’ EE and patients’ negative, but not positive, SE; (2) patients’ negative SE mediated the effect of patients’ perceived EE on positive symptoms and paranoia; (3) the association of relatives’ EE with positive symptoms and paranoia was serially mediated by an increased level of patients’ perceived EE leading to increases in negative SE; (4) high levels of patients’ distress moderated the effect of relatives’ EE on symptoms through patients’ perceived EE and negative SE. Findings emphasize that patients’ SE is relevant for understanding how microsocial environmental factors impact formation and expression of positive symptoms and paranoia in early psychosis. They suggest that broader interventions for patients and their relatives aiming at improving family dynamics might also improve patients’ negative SE and symptoms.

Cognitive Insight as the Differentiating Feature of Psychosis and Anxiety

Objective: Cognitive theories and research have focused on the relationship between emotions, particularly anxiety, and the positive symptoms of psychosis. The aim of this study, based on Beck’s cognitive theory, was to compare dysfunctional attitudes and cognitive insight between patients with anxiety disorders and those with delusion. Methods: The study sample consisted of 90 participants in 3 groups (anxiety=30, delusion=30, healthy=30). The study subjects were interviewed using Structured Clinical Interview (SCID-I) for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Then, they completed Beck Anxiety Inventory (BDI), Peters et al.’s Delusions Inventory (PDI), General Health Questionnaire-28 (GHQ-28), Dysfunctional Attitudes Scale-26 (DAS-26), and Beck Cognitive Insight Scale (BCIS). Results: The present research results indicated that anxiety and delusion groups presented significantly greater dysfunctional attitudes than the healthy subjects (P<0.001); however, there was no significant difference between the clinical groups. The anxiety group had significantly higher cognitive insight than the delusional (P<0.05) and normal groups (P<0.01); however, there was no significant difference between the last two groups. Conclusion: Dysfunctional attitudes can be considered as a common aspect and cognitive insight as a differentiating aspect of anxiety and psychosis.

The Psychology and Parapsychology of Spiritual Emergency

A defining aspect of Spiritual Emergency (SE) is ‘psychic opening’ which may predict psi performance. This study tested paranormal (psi) performance of individuals who have or have had experiences of spiritual emergency (i.e., ‘SE-Experients’), and compared their performance against controls. The study also assessed psychological aspects of SE to differentiate it from psychosis and other proposed psi-inhibitive symptoms—namely, alogia (i.e., poverty of speech), depression, anxiety, and stress. Two groups of participants were formed: controls (mainly Psychology students) and SE-Experients. Participants either completed the study on computer in the laboratory or online. Questionnaires on spiritual emergency (which includes a subscale on psychic opening), positive symptoms of psychosis, alogia, spiritual identity, paranormal belief, mysticism, depression, anxiety, and stress, were administered to participants, who then completed the Imagery Cultivation (IC) picture-identification psi task, which uses a shamanic-like journeying protocol (Storm & Rock, 2009). The differences between controls and SE-experients on the psi measures, direct hitting (as a percent hit-rate) and mean rank scores, were not significant, but the sum-of-ranks difference was highly significant. Also, SE-experients had a marginally significant mean rank score. Direct hitting did not correlate significantly with any variable, except rank scores, which correlated significantly with psychic opening, spiritual identity, and paranormal belief, and marginally significantly with spiritual emergency. Direct hitting, rank scores, and SE did not correlate significantly with alogia, depression, anxiety, or stress, but the psychosis measure did correlate significantly with alogia, depression, anxiety, stress, and SE. The statistical evidence suggests some proportion of SE-experients experience psychic opening. While SE and psychosis overlap, only SE was predicted by spiritual identity, extrovertive mysticism, and paranormal belief (but not alogia), whereas psychosis was predicted by alogia only.

Identification of clinical phenotypes in schizophrenia: the role of lurasidone

The treatment of schizophrenia includes the control of symptoms, the prevention of relapses, and amelioration of adaptive skills for patient re-integration into society. Antipsychotic drugs are the agents of choice for the treatment of schizophrenia, as they reduce the positive symptoms of psychosis. Lurasidone is a second-generation antipsychotic drug representing a novel and useful clinical tool for the management of schizophrenia. A board consisting of a panel of Italian expert psychiatrists was organized with the following aims: (a) defining the current modalities of use of lurasidone, highlighted through 17 specific questions; (b) defining and agreeing the main features of the drug and the principal reasons to suggest its administration. We established that lurasidone is suggested at any age, with no gender difference, at all stages of the disease. The switch from previous treatments is done primarily because of lack of efficacy as well as poor adherence/tolerability. Lurasidone is among the best-tolerated antipsychotics, and its use is indicated in the presence of different comorbidities. A wide range of dosages is available, allowing safe titration in particular cases, with the highest dose (148 mg) generally used for the treatment of the acute phase. The discontinuation rate due to poor tolerability, low compliance, and interactions with other drugs is very low. Akathisia is the most reported adverse event, but it may be controlled by dose reduction. Lurasidone does not possess a marked sedative action but, in agitated patients, can be associated with sedative drugs, such as benzodiazepines. The most frequent reason for switching to other therapies is the need for long-acting formulations, as in patients at risk of very low adherence or suicide. Lurasidone does not strongly impact metabolism or the cardiovascular system (QT interval), and does not influence the metabolism of other drugs, showing good efficacy and tolerability.

The Cerebellum Links to Positive Symptoms of Psychosis: A Systematic Review and Meta-analysis

Background Positive symptoms of psychosis may be the result of faulty coordination and automatization of motor and higher order cognitive functions, partly due to cerebellar dysfunction. Specifically, auditory verbal hallucinations (AVH) have been related to altered processing of sensory feedback to one’s own action. Such alterations highlight the role of dysfunctional cerebellar circuitry in psychosis. However, how exactly the cerebellum contributes to AVH remains unclear. Methods A systematic search of electronic databases identified a broad range of cerebellar neuroimaging studies in psychotic patients, reporting volume, structural connectivity, or resting-state functional connectivity data. A total of 22 studies were selected for review: 11 focused on the specific effects of AVH and 11 probed the effects of aggregated positive symptom scores. Meta-analysis was used to probe the consistency of cerebellar differences and their relationship with sociodemographic and clinical measures. An exploratory activation likelihood estimation (ALE) analysis tested the regional specificity of cerebellar differences in patients with such symptoms. Results Cerebellar differences were more consistently associated with AVH than with aggregated positive symptom measures, particularly when considering resting-state functional connectivity data. These differences were not moderated by age, sex, medication, or symptom severity. The ALE meta-analysis revealed a spatial convergence of these differences in lobules V–VI and crus I. Conclusions Cerebellar dysconnectivity might indicate a specific liability for AVH, particularly in sensorimotor (lobules V–VI) and cognitive (crus I) cerebellar zones. These abnormalities may contribute to altered sensory feedback processing and, consequently, affect higher level cognitive functions (eg, cognitive control) in AVH.

Evaluation of Antipsychotic Activity of Ethanolic Extract of Dhatryadi Ghrita on Wistar Rats

Objective: Herbal formulations based on plants are effective against psychosis. The effects of Dhatryadi Ghrita on Wistar rats against psychosis were investigated. Background: An increased preference nowadays is obvious towards the use of herbal drugs in the treatment of chronic ailments. Treatment of psychiatric diseases has become easier, but the extrapyramidal motor disorders are the major adverse effect exists with most of the antipsychotic drugs. Methods: For the assessment of neuroleptic activity of the ethanolic extract of Dhatryadi Ghrita, prepared with different antipsychotic animal models, three doses of the extract (100, 200 and 300 mg/kg) were used for the study with different animal models. Result: A significant reduction of amphetamine-induced stereotype and conditioned avoidance response was observed in the extract-treated animals compared to control. Minor signs of catalepsy were visible in the extract-treated group as compared to the control group. Conclusion: The study revealed that the extract may be possessing the property to alleviate the positive symptoms of Psychosis.

Normalizing the Abnormal: Do Antipsychotic Drugs Push the Cortex Into an Unsustainable Metabolic Envelope?

The use of antipsychotic medication to manage psychosis, principally in those with a diagnosis of schizophrenia or bipolar disorder, is well established. Antipsychotics are effective in normalizing positive symptoms of psychosis in the short term (delusions, hallucinations and disordered thought). Their long-term use is, however, associated with side effects, including several types of movement (extrapyramidal syndrome, dyskinesia, akathisia), metabolic and cardiac disorders. Furthermore, higher lifetime antipsychotic dose-years may be associated with poorer cognitive performance and blunted affect, although the mechanisms driving the latter associations are not well understood. In this article, we propose a novel model of the long-term effects of antipsychotic administration focusing on the changes in brain metabolic homeostasis induced by the medication. We propose here that the brain metabolic normalization, that occurs in parallel to the normalization of psychotic symptoms following antipsychotic treatment, may not ultimately be sustainable by the cerebral tissue of some patients; these patients may be characterized by already reduced oxidative metabolic capacity and this may push the brain into an unsustainable metabolic envelope resulting in tissue remodeling. To support this perspective, we will review the existing data on the brain metabolic trajectories of patients with a diagnosis of schizophrenia as indexed using available neuroimaging tools before and after use of medication. We will also consider data from pre-clinical studies to provide mechanistic support for our model.