RESUMO
BACKGROUND: Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken. METHODS: In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks. RESULTS: For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression. CONCLUSION: Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.
Assuntos
Transtornos de Ansiedade/tratamento farmacológico , Transtorno Depressivo/tratamento farmacológico , Flufenazina/análogos & derivados , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Adolescente , Adulto , Assistência Ambulatorial , Antipsicóticos/efeitos adversos , Transtornos de Ansiedade/induzido quimicamente , Transtornos de Ansiedade/diagnóstico , Doenças dos Gânglios da Base/diagnóstico , Doenças dos Gânglios da Base/etiologia , Doenças dos Gânglios da Base/prevenção & controle , Benzotropina/análogos & derivados , Benzotropina/uso terapêutico , Transtorno Depressivo/induzido quimicamente , Transtorno Depressivo/diagnóstico , Desipramina/uso terapêutico , Diagnóstico Diferencial , Relação Dose-Resposta a Droga , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Flufenazina/uso terapêutico , Glicopirrolato/uso terapêutico , Humanos , Carbonato de Lítio/uso terapêutico , Masculino , Pessoa de Meia-Idade , Placebos , Escalas de Graduação Psiquiátrica , Fatores SexuaisRESUMO
The relationship between insight and acute psychopathology was explored in a group of 52 acutely psychotic, schizophrenic patients. A measure of insight, reflecting patients' recognition of their illness and need for care, was validated against ratings from a semi-structured interview and against assessments of patients' compliance with medication. Contrary to expectations, degree of insight was not consistently related to the severity of acute psychopathology, as measured on two structured scales. Nor did changes in insight during hospitalization vary consistently with changes in acute psychopathology. These data suggest that very little of the deficiency in insight seen in schizophrenic patients is explainable on the basis of acute psychopathological features. The mechanism that accounts for impairment in insight in schizophrenia may be relatively resistant to treatment with neuroleptic medication.