Schizophreniform Disorder Treatment & Management

Treatment may involve psychotherapy, family and social-educational therapies, and pharmacotherapy. The general aims of treatment are as follows:

• To protect and stabilize the patient

• To minimize the psychosocial consequences

• To resolve the target symptoms with minimal adverse effects

Patients who may be likely to harm themselves or others should be hospitalized. This will allow a complete diagnostic evaluation and help ensure the safety of both patients and others. A supportive environment with minimal stimulation is most helpful.

As improvement progresses, help with coping skills, problem-solving techniques, and psychoeducational approaches may be offered to patients and their families. Patients may benefit from a structured intermediate environment (eg, a day hospital) during the initial phases of their return to the community.

According to Stromgren, electroconvulsive therapy (ECT) has been helpful in treating brief reactive psychoses, but in the setting of schizophreniform disorder, it is generally reserved for medication-resistant cases. ^[13]

Compton described barriers to treatment after the first psychotic episode, including inadequate remission of paranoia, impaired insight, and involvement with the criminal justice system between discharge from the hospital and the first outpatient appointment. ^[14] Strong family support appeared to be an important facilitator of treatment engagement during the first several months of outpatient treatment. Various other potential barriers to treatment, such as involuntary status at the time of hospital discharge, must also be considered.

Virtually all psychotherapeutic treatment modalities used in the treatment of patients with schizophrenia may be helpful in treating patients with schizophreniform disorder. Insight-oriented therapy is not indicated in patients with schizophreniform disorder, because these patients have limited ability to explore and may also be in denial.

Patients may experience a high degree of distress related to the onset of symptoms. Both supportive and educational approaches may help patients manage feelings of turmoil or distress. Group psychotherapy may be helpful; however, patients with schizophreniform disorder who are concerned about their prognosis may become frightened in groups where they are mixed with patients who have chronic schizophrenia. Thus, care must be taken in the formation of therapy groups.

Treatment of patients with schizophreniform disorder frequently involves working with family members and significant others. The family therapy strategies used in working with the families of patients with schizophrenia are highly appropriate for patients with schizophreniform disorder and their families.

In view of the variable course of schizophreniform disorder, brief treatments with clear goals may be helpful initially, though therapeutic strategies must remain flexible to allow for the transition to longer-term treatments for patients who progress to schizophrenia. Similarly, social-vocational function may be preserved in patients with schizophreniform disorder. However, in patients exhibiting impairments in these areas, rehabilitative strategies similar to those described for patients with schizophrenia are appropriate.

Pharmacotherapy for schizophreniform disorder is similar to that for schizophrenia. ^[15] At present, atypical antipsychotics (eg, risperidone, olanzapine, quetiapine, and ziprasidone) are commonly used. Dosing strategies appear to be similar to recent approaches to treating patients with schizophrenia, which emphasize the use of minimal but effective doses.

Adequate treatment or prophylaxis of adverse extrapyramidal effects is critical to patient tolerance of neuroleptic treatment and to medication therapy compliance. Neuroleptic-resistant psychosis in patients with schizophreniform disorder may be managed through approaches similar to those used in patients with schizophrenia, including adjustment of the neuroleptic dose, addition of lithium, or addition of anticonvulsant agents and older typical antipsychotics.

Antidepressants may be helpful for mood disturbances associated with schizophreniform disorder, but care must be taken to monitor for possible exacerbations of psychotic symptoms.

Additional antipsychotic agents that have been used to treat schizophreniform disorder include the following:

• Aripiprazole - Unlike its predecessors, this agent is a partial agonist at the dopamine receptors

• Paliperidone - This agent is a major active metabolite of risperidone and the first oral agent that can be given once daily

• Asenapine - Starting and recommended dose is 5 mg sublingually twice daily, not to exceed 10 mg sublingually twice a day

• Iloperidone -– The initial dosage is 1 mg orally twice daily; this is titrated upward daily to reach the target dosage of 12-24 mg/day by day 7 (orthostatic hypotension is the dose-limiting adverse effect)

• Lurasidone - Starting dose of 40 mg daily with at least 350 calorie of nonliquid food is an effective dose, not to exceed 160 mg daily maximum

Ziprasidone is available in injection form to help control acute psychosis; aripiprazole is also now available as an injection. These injections are less likely to cause acute extrapyramidal side effects.

Sajatovic et al concluded in one study that both risperidone and quetiapine improved scores on the Hamilton Depression Rating Scale (HAMD), though quetiapine yielded greater improvement than risperidone did in all patients. ^[16]

Emsley, in an international, multicenter, double-blind study conducted on 183 patients who had a first psychotic episode and were treated with flexible doses of risperidone or haloperidol for 6 weeks, found that 63% of patients treated with risperidone and 56% of those treated with haloperidol were clinically improved (350% reduction in Positive and Negative Syndrome Scale [PANSS] total scores). ^[17] Risperidone was tolerated better than haloperidol was.

Post hoc analysis indicated that low dosages of these antipsychotics were efficacious in some patients. ^[17] Other study findings also suggested that low antipsychotic dosages may be required for patients with a first psychotic episode. To optimize therapy for these patients will require trials that are specifically designed to compare low antipsychotic dosages with high dosages.

In a study examining patients with first-episode psychosis to determine the efficacy and safety of olanzapine and haloperidol treatment, Sanger et al found olanzapine to have a better risk-benefit profile than haloperidol in this population. ^[18] They concluded that because of advantages in safety and efficacy, atypical antipsychotic agents (eg, olanzapine) should be considered a preferred option for managing first-episode psychosis.

The clinical trial carried out by Sanger et al involved a subpopulation of first-episode patients selected from a pool of patients who were diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder. ^[18] The duration of the patients’ current psychotic episodes had to be 5 years or less, and the patients had to be aged 45 years or younger at the onset of their first psychotic symptoms.