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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by ed_uk on November 16, 2004, at 9:50:24
In 1989, Keck performed a review of several earlier studies examining the efficacy of neuroleptics in the treatment of psychosis, he stated... 'in studies comparing neuroleptics with sedatives, similar improvement was observed with both treatments.'
One psychiatrist (Turns, 1990) responded to these revelations with anguished questions: "Has our clinical judgement about the efficacy of antipsychotics been a fixed, encapsulated, delusional perception . . . Are we back to square one in antipsychotic psychopharmacology?".
I have been interested for some time in the activity of APs against hallucinations and delusions. The question is: Do APs truly have the power to eliminate hallucinations (and delusions) or do they simply allow people to ignore their hallucinations more easily? ie. the 'voices' are quieter and cause less distress.
Put simply, would it be more truthful if APs were once again referred to as being the 'major tranquillisers'? Personally, I prefer the name neuroleptic because of their ability to cause restlessness and distress....subjectively very different from the calm associated with the benzodiazepines, the so-called 'minor tranquillisers'.
What I am suggesting is that the neuroleptics are no more a specific treatment for hallucinations and delusions than the SSRIs are a specific treatment for depression. After all, the SSRIs are so often prescribed as general purpose 'psycho-analgesics'- effective in relieving the symptoms of many conditons but specific for none.
In many ways I'm probably posting this on the wrong board. Unsurprisingly, psycho-babble has always been more popular among anxiety/depression sufferers like myself rather than people with schizophrenia and other psychoses. Most people on psycho-babble use APs to relieve anxiety, insomnia, agitation, hypomania etc.
I would like to hear people's opinions on what I have said.
If anyone on p-babble has suffered from prominent hallucinations, I'd like to ask: what was the effect of the AP? (Unfortunately, it's always impossible to know what would have happened without the medication........ in many cases, equal improvement but a great deal less weight gain!)
Regards,
Ed
Posted by alexandra_k on November 16, 2004, at 23:52:48
In reply to Specificity of Anti-psychotics, posted by ed_uk on November 16, 2004, at 9:50:24
I get what are called 'pseudo-hallucinations'. Basically I hear voices, but I understand that they are my brain processes and don't attribute them to an external agency. In times of great stress I also get visual hallucinations, but not very often whereas I get the voices pretty much on a daily basis.
I have been on a variety of anti-psychotics and none have had any effect with respect to reducing the intensity and / or frequency of the voices. What they do do for me, however, is make that experience less distressing for me and I am more able to keep a focus on what is going on in the real world rather than being caught up in them.
I have met people who have claimed that voices have gone away with anti-psychotics. Others say that they are just better able to cope with them, and others say that they reduce a bit in intensity and / or frequency. I guess that is a bit individual.
I agree with what you say about non-specific effects, though. I find the anti-psychotic useful with respect to my generalised anxiety and also with respect to getting off to sleep (because of the sedating side-affect). I personally think that anti-psychotics should be used over benzo's for anxiety and sleep because they aren't addictive.
Posted by SLS on November 17, 2004, at 7:29:53
In reply to Specificity of Anti-psychotics, posted by ed_uk on November 16, 2004, at 9:50:24
Hi Ed.
I am convinced that neuroleptics provide the sort of specifity you talk about. I have seen someone with schizoaffective disorder suffer from both auditory and visual hallucinations in addition to delusional thinking. In short, Risperdal completely extinguishes all of these things and leaves her in a state where she doesn't feel at all sedated.
- Scott
Posted by ed_uk on November 17, 2004, at 7:37:21
In reply to Re: Specificity of Anti-psychotics, posted by SLS on November 17, 2004, at 7:29:53
Hi,
Most psychiatrists believe that anti-psychotics are highly active against hallucinations and delusions. At the moment, my opinion is that they are effective in extinguishing these symptoms in only a small proportion of psychotic patients. I certainly believe that their efficacy has been overstated, as is the case with most psychiatric drugs.
Ed
Posted by ed_uk on November 17, 2004, at 11:57:32
In reply to Re: Specificity of Anti-psychotics, posted by ed_uk on November 17, 2004, at 7:37:21
Hello, I just wanted to expand a little bit on what I said earlier...
In order to perform a clinical trial to determine the efficacy of a psychiatric drug, a valid measure of symptom severity is needed. It is very difficult, however, perhaps even impossible to design a rating scale which accurately reflects the severity of symptoms in a large number of people. A scale which appears to be a valid measure of symptom severity in one individual may turn out to be a highly insensitive measure of symptom severity in someone else.
Here is the Brief Psychiatric Rating Scale (BPRS)...... It is one of the most popular scales which is used to measure symptom severity in patients suffering from schizophrenia. It has been widely used in clinical trials of anti-psychotic drugs.
This form consists of 24 symptom constructs, each to be rated in a 7-point scale of severity ranging from 'not present' to 'extremely severe' If a specific symptom is not rated, mark 'NA' (not assessed). Circle the number headed by the term that best describes the patient's present condition. The overall score is then calculated.
1.not present 2.very mild 3.mild 4.moderate 5.moderately severe 6.severe 7.extremely severe
1 Somatic concern NA 1 2 3 4 5 6 7
2 Anxiety NA 1 2 3 4 5 6 7
3 Depression NA 1 2 3 4 5 6 7
4 Suicidality NA 1 2 3 4 5 6 7
5 Guilt NA 1 2 3 4 5 6 7
6 Hostility NA 1 2 3 4 5 6 7
7 Elated Mood NA 1 2 3 4 5 6 7
8 Grandiosity NA 1 2 3 4 5 6 7
9 Suspiciousness NA 1 2 3 4 5 6 7
10 Hallucinations NA 1 2 3 4 5 6 7
11 Unusual thought content NA 1 2 3 4 5 6 7
12 Bizarre behaviour NA 1 2 3 4 5 6 7
13 Self-neglect NA 1 2 3 4 5 6 7
14 Disorientation NA 1 2 3 4 5 6 7
15 Conceptual disorganisation NA 1 2 3 4 5 6 7
16 Blunted affect NA 1 2 3 4 5 6 7
17 Emotional withdrawal NA 1 2 3 4 5 6 7
18 Motor retardation NA 1 2 3 4 5 6 7
19 Tension NA 1 2 3 4 5 6 7
20 Uncooperativeness NA 1 2 3 4 5 6 7
21 Excitement NA 1 2 3 4 5 6 7
22 Distractibility NA 1 2 3 4 5 6 7
23 Motor hyperactivity NA 1 2 3 4 5 6 7
24 Mannerisms and posturing NA 1 2 3 4 5 6 7
In schizophrenia, treatment with an antipsychotic is sometimes effective in reducing the BPRS score. It is quite possible, however, for the score to be reduced without any change whatsoever in the patients 'core' psychotic symptoms. To give an example..... anxiety, hostility, excitement, motor hyperactivity, tension and elation may be reduced without any change in more specific symptoms such as hallucinations and delusions. A (possibly) small proportion of psychotic individuals may obtain a 'true' antipsychotic effect from their medication ie. elimination of hallucination and delusions etc.... many others might be expected to do as well on diazepam!What do you think???
Regards,
Ed
Posted by alexandra_k on November 17, 2004, at 15:20:20
In reply to Re: Specificity of Anti-psychotics, posted by ed_uk on November 17, 2004, at 11:57:32
I don't know all that much about medication. But I think there are a couple of different kinds of anti-psychotics, the older ones (the tranquilisers) such as chlorpromazine, and the newer ones. The older ones do have more of a pronounced sedating effect than the newer ones.
The newer ones also seem to be better with respect to improving levels of functioning. Some people say that they also assist with negative symptoms, though I am not sure that there is evidence for that.
I used to live in supported accomodation (part of the spirit of deinstitutionalisation). Most of the people there were schizophrenic. People relapsed when they didn't take their anti-psychotics. I saw that happen a lot. I also saw a major improvement in people on Clozapine. They improved on that even when the other anti-psychotics were of limited effectiveness.
I am not sure about whether anti-psychotics actually produce a reduction in hallucinations, but what I think that they do do is allow one to interpret them in a positive or at least neutral light instead of being caught in a 'revelation' that one hears the voice of god etc. It seems to be the interpretation of such hallucinations that just is delusions, and so one is also able to consider a delusional hypothesis as a hypothesis rather than as a fact.
I think that instead of using benzo's for positive symptoms of schizophrenia (as you suggest) one would be better prescribing anti-psychotics for anxiety (as there is a risk of physical and psychological addiction to benzo's). Rather than being a 'bad' thing that there are non-specific effects, we should embrace those and use that to our advantage. Of course, ongoing research may be able to pinpoint the mechanisms that produce the effect and we may be able to develop more specific drugs to target those mechanisms exclusively. Until then, anti-psychotics seem to be the best we have got: for psychotic symptoms, and also (in my opinion) for anxiety.
But this is all my opinion, and I have this nagging concern that I don't really know what I am talking about...
Posted by ed_uk on November 18, 2004, at 7:11:33
In reply to Re: Specificity of Anti-psychotics » ed_uk, posted by alexandra_k on November 17, 2004, at 15:20:20
Hello Alexandra, thank you for answering my post...
Some of the older APs are quite sedating esp. chlorpromazine, methotrimeprazine etc, but some of the older APs are much less sedating eg. trifluoperazine. Similarly, some of the newer APs are usually sedating eg. clozapine and quetiapine, whereas some are much less likely to cause drowsiness eg. amisulpride.There is some evidence that the newer APs are more effective in treating the negative symptoms of schizophrenia. At least the newer drugs are less likely to worsen the negative symptoms than the old ones!!
Unfortunately, all APs can cause withdrawal symptoms, including a severe exacerbation of the underlying psychosis. Clozapine is particularly problematic in this regard- causing severe withdrawal symptoms in many. Many psychiatrists may not be aware of this and are most likely to assume that the patient has relapsed.
I'm certainly not suggesting that benzodiazepines should be used to treat psychosis in place of APs! But in patients who don't respond well to APs, benzos may be a useful way of relieving severe anxiety. Also, benzos do have the advantage of being much less toxic than APs.
I do think APs have a useful role in schizophrenia. But I strongly believe that their efficacy and impact is often profoundly overexagerated.
Regards,
Ed.
Posted by anxiety_free on November 18, 2004, at 19:43:28
In reply to Re: Specificity of Anti-psychotics, posted by ed_uk on November 18, 2004, at 7:11:33
hey! I take abilify myself, and I must say that it has improved my life INCREDIBLY. That said, I do think the case for neuroleptics is sometimes overstated. Thorazine, for instance, wasn't discovered or designed for psychosis; it was a pre-op sedative a French doc tried out on schizophrenics and found that it "worked". Really, it did reduce positive symptoms, but more important to officials at the time, it made the patients manageable. Now, new APs are based on the old idea that dopamine needs to be altered, but they go about it differently; instead of the old-school dopamine BLOCKING effect, you have more of a MODULATING effect with the newer ones. Its not perfect- TD, akathisia, etc. still happen- but its better. Some studies suggest patients treated with newer drugs have lower rates of relapse, violence, and (I think) suicide than those treated with the old drugs, so we may be moving in a good direction here. The way schizophrenia is managed has, thank god, changed too. There's more likely to be a whole cocktail of drugs involved to perfect chemical balance than in the past, when they Rx'd some Haldol, maybe some Cogentin, and forgot about it. Ohhh...and let's not forget the lobotomy. Fun stuff. So, basically I think the new drugs are a big step forward, and we should be thankful for that while pushing for better, cheaper, gentler treatment. Phew. I'm done.
Posted by ed_uk on November 19, 2004, at 8:23:49
In reply to anti-psychotics, posted by anxiety_free on November 18, 2004, at 19:43:28
Hi!
What do you take aripiprazole for?
Ed.
PS. I'm not saying APs don't have a place, I'm just saying that their impact on patients suffering from schizophrenia is often overstated.
Posted by anxiety_free on November 19, 2004, at 15:05:49
In reply to Re: anti-psychotics, posted by ed_uk on November 19, 2004, at 8:23:49
Hey! I have schizophrenia/may be schizoaffective (the Diagnosis isn't completely clear yet), so that's why I take Abilify @ 20 mgs daily. I dig what you're saying about the efffects of neuroleptics, especially the early ones, being overstated; the "broken brain theory" of mental illness has been oversold by the drug industry and others...it needs to be balanced out by other theories, but isn't. That said, the newer generation of APs represent a huge step forward for the pharmacological management of a number of disorders.
Posted by ed_uk on November 20, 2004, at 14:46:33
In reply to Re:Re:anti-psychotics, posted by anxiety_free on November 19, 2004, at 15:05:49
Hi!
I agree that the atypical APs represent a step forward. They do have side effects of their own though eg. obesity from Zyprexa. How do you find Abilify, are you doing well at the moment?
Regards,
Ed
Posted by anxiety_free on November 20, 2004, at 17:54:18
In reply to Re:Re:anti-psychotics » anxiety_free, posted by ed_uk on November 20, 2004, at 14:46:33
I like abilify. You're right about side effects, though...I remember getting weight gain and anxiety from zyprexa and hyper-sedation from seroquel. Sucks. But, I read about abilify and asked my shrink if we could try it, it was OK'd, and I've been pretty much OK since then. I also take ADs and a stimulant, so that really helps even things out. Abilify suits me best b/c it has anti-anxiety and anti-depressant properties that I need (I'm negative-symptom heavy).
Posted by CraigD on November 22, 2004, at 23:22:23
In reply to anti-psychotics, posted by anxiety_free on November 20, 2004, at 17:54:18
> I like abilify. You're right about side effects, though...I remember getting weight gain and anxiety from zyprexa and hyper-sedation from seroquel. Sucks. But, I read about abilify and asked my shrink if we could try it, it was OK'd, and I've been pretty much OK since then. I also take ADs and a stimulant, so that really helps even things out. Abilify suits me best b/c it has anti-anxiety and anti-depressant properties that I need (I'm negative-symptom heavy).
Did you find Abilify to be agitating at all? I am neither schizophrenic nor solid Bipolar, but both are prevelant in my family.
Doc gave me a script for abilify to boost the anti-anxiety/obsessional qualities of Celexa. I've come down to 20 mgs but refuse to go back up even though the depression/social anxiety/obsessiveness/anger is returning.
One poster said abilify was very agitating and was surprised the doc would use it as a PRN for anxiety.
Also, does it work right away or is there a build-up period?
Thanks,
Craig
Posted by anxiety_free on November 23, 2004, at 3:46:04
In reply to Re: anti-psychotics » anxiety_free, posted by CraigD on November 22, 2004, at 23:22:23
Abilify didn't cause any agitation for me whatsoever. I find it soothing. BUT you shouldn't be taking 20mgs of it if you're not bipolar or schizophrenic or so anxious that even benzos don't help. I'm not a doc, but Abilify is for SERIOUS conditions and can have SERIOUS side effects. Instead of abilify, ask your doc (who, I take it, dislikes benzos? or not?) about buspar or a different anti-depressant or adding another anti-depressant to the celexa (my vote goes to a tricyclic). I would also look for another doc, b/c APs need to handled with care and are an absolute last resort in anxiety management. As for the time frame...my hallucinations went away within one-two doses; the soothing effect was immediate, and sustained improvement took place over a month or so...then I was good to go, and it kind of plateued; I am now functioning, happy, and productive. But again, not all meds do the same for all people, and I think your doc is a bit free with heavy meds...try to get something else. Klonopin rocks, if you can get that out of him/her. Xanax XR is a newer, increasingly popular choice...I prefer Klonopin, though. Good luck!
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