Second edition

20.qxd 3/10/08 9:58 AM Page 614
614 Idiopathic psychotic, mood, and anxiety disorders
overall initial response is only partial, but otherwise promising,
one may elect to observe the patient for another 4
weeks and, if the response is good, then move to maintenance
treatment, as described below. If the response to the
first agent is poor, or the side-effects are unacceptable, then
a trial with a different agent should be considered. Should
patients fail to get a good response to adequate trials of two
agents, one may be dealing with a treatment-resistant case.
In such cases several options are available, including a trial
of clozapine, trials of other agents, or simply ‘living with’ a
less than optimal treatment regimen. As regards effectiveness,
clozapine is clearly head and shoulders above all other
antipsychotics in treatment-resistant cases, and indeed may
yield some of the most gratifying treatment responses in all
of medical practice; however, its side-effect profile gives
pause to many patients and physicians. If clozapine is not
an option, some clinicians will try trial after trial of different
agents, hoping to find one that ‘works’; provided that
patients have the fortitude, this is not an unreasonable
strategy, as in some cases patients will simply have idiosyncratic
and unpredictable ‘good’ responses to one agent but
not others. In some cases, however, patients will opt to stay
with a regimen that, although perhaps providing less relief
than is hoped for, is at least tolerable.
Maintenance treatment is appropriate in almost all
cases. Initially, patients should be maintained on a dose that
is similar to, if not identical to, that utilized during initial
treatment. Once patients are stable, cautious dose adjustments
may be considered every 3–4 months. As noted earlier,
in many cases the course of schizophrenia is
characterized by gradually occurring exacerbations and
partial remissions, and in such cases it is appropriate to try
to ‘titrate’ the dose to the underlying severity of the disease,
always seeking the lowest possible dose consistent with
acceptable symptomatic control. This serves not only to
reduce cost and side-effect burden but also reduces the risk
of tardive dyskinesia (this dreaded complication of longterm
treatment with antipsychotics, primarily first-generation
agents, is discussed further in Section 22.2). In a
minority of cases, the underlying course is so favorable, and
the partial spontaneous remissions so profound, that it may
be possible to taper the dose to almost nothing, at which
point some patients and physicians may consider stopping
treatment. This is a difficult decision. Schizophrenia is a
chronic disease and, although far-reaching spontaneous
partial remissions do occur, exacerbations may be expected
at some point in the future. Consequently, it is necessary to
continue seeing patients in regular follow-up visits and to
discuss with them, and with family, the importance of calling
immediately should symptoms recur.
In both initial and maintenance treatment phases there
are two side-effects that must always be kept in mind,
namely akinesia and akathisia. Akinesia, as noted in Section
3.9, may leave patients psychomotorically retarded and, in
the unwary clinician, may prompt a misdiagnosis of depression
(King et al. 1995; Van Putten and May 1978). Akathisia,
described in Section 3.10, classically renders patients restless
but at times may manifest only with an exacerbation of psychotic
symptoms (Van Putten 1975; Van Putten et al. 1974);
unless this is properly diagnosed, a ‘vicious cycle’ may occur,
in which the exacerbation is mistakenly attributed to the
underlying schizophrenia, prompting an increased dose of
the antipsychotic with a consequent worsening of the psychosis.
Although these side-effects are classically seen with
first-generation agents, they may also, albeit rarely, occur
with second-generation ones.
Post-psychotic depression may occur after psychotic
symptoms have partially remitted, either spontaneously or
by virtue of antipsychotic treatment. These sustained
depressions must be treated as they carry a significant risk
of suicide. Treatment may be accomplished with an antidepressant
(Siris et al. 1987), such as a selective serotonin
reuptake inhibitor (SSRI), or, in severe cases, with electroconvulsive
therapy (ECT). Of interest, ECT may also be
effective in the acute treatment of catatonic schizophrenia.
In addition to treatment with antipsychotics and routine
supportive care, many patients will also require extensive
assistance in gaining housing and sheltered employment;
social skills training and cognitive–behavioral treatment
may also be beneficial. Insight-oriented or psychodynamically
oriented psychotherapy is generally contraindicated,
as it may make patients worse.
Hospitalization is required for most patients at some
point in their illness and, in many cases, repeated admissions
occur. In some cases involuntary hospitalization is
required and may be life-saving. Partial hospitalization or
‘day hospitals’ may enable some severely ill patients to be
maintained in the community.
20.2 SCHIZOAFFECTIVE DISORDER
The term ‘schizoaffective’ has had many definitions since it
was first coined by Kasanin in 1933. As conceived of here,
schizoaffective disorder is characterized by chronic,
unremitting psychotic symptoms, similar to those seen in
schizophrenia, upon which are superimposed full episodes
of either depression or mania, during which the pre-existing
psychotic symptoms undergo an exacerbation. Although the
prevalence of schizoaffective disorder is not known with certainty,
it is probably far less common than schizophrenia.
Clinical features
The onset is typically in the late teens or early twenties, and,
viewed over time, this disorder, as suggested above, appears
to represent a superimposition of a mood disorder, such as
major depressive disorder or bipolar disorder, upon schizophrenia.
Thus, these patients typically present with a psychosis
similar to that described in the preceding section for
schizophrenia, and the symptoms (e.g., hallucinations, delusions,
disorganized speech, etc.) persist in a chronic, generally
lifelong fashion. Periodically, however, these chronic