The Treatment of Hallucinations in Schizophrenia Spectrum Disorders

This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350-450 mu g/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated

Comorbid Diagnosis of Psychotic Disorders in Borderline Personality Disorder:Prevalence and influence on Outcome

Background: A diagnosis of psychotic disorder is traditionally considered incompatible with borderline personality disorder (BPD), even though patients sometimes fulfill the diagnostic criteria for both disorders. How often this happens is barely known, as is the influence of comorbid psychotic disorders on the outcome of BPD. Since studies on isolated auditory verbal hallucinations in patients with BPD indicate that these perceptual symptoms have severe consequences and are associated with suicidal behavior and hospitalization, patients with comorbid psychotic disorders are unlikely to fare better. Objective: To examine the point prevalence of psychotic disorders in patients with BPD, their association with the outcome of BPD, and their predictive value for outcome. Methods: In a cross-sectional design, 84 female outpatients diagnosed with BPD were interviewed with the aid of the MINI-International Neuropsychiatric Interview to establish the point prevalence of comorbid psychotic and other comorbid disorders. After termination of their treatment at a specialized outpatient clinic, the type of referral was considered to be a "good" outcome when they were referred to their general practitioner or to basic psychiatric care for noncomplex patients, and a "poor" outcome when referred to a specialized psychiatric department or to a psychiatric district team for patients with severe psychiatric disorders. Results: Psychotic disorders were present in 38% of the patients with BPD. With a prevalence of 20%, psychotic disorder not otherwise specified (NOS) was the most common subtype; the least common types were schizophrenia (2%), substance-induced psychotic disorder (2%), and brief psychotic disorder (1%). Among six types of comorbid disorders, only psychotic disorders were associated with a poor outcome; they were also predictors for a poor outcome, along with comorbid mood disorders, eating disorders, and somatoform disorders, as well as the severity of BPD, and, counterintuitively, more years of education. Conclusion: Psychotic disorders, notably of the psychotic disorder NOS subtype, are common among patients with BPD, and their presence is associated with a poor outcome. This implies that adequate diagnosis and treatment of both disorders is warranted in this subgroup with a dual diagnosis

Sensory processing deficiencies in patients with borderline personality disorder who experience auditory verbal hallucinations

Auditory verbal hallucinations (AVH) are common in patients with borderline personality disorder (BPD). We examined two candidate mechanisms of AVH in patients with BPD, suggested to underlie sensory processing systems that contribute to psychotic symptoms in patients with schizophrenia; sensory gating (P50 ratio and P50 difference) and change detection (mismatch negativity; MMN). Via electroencephalographic recordings P50 amplitude, P50 ratio, P50 difference and MMN amplitude were compared between 23 borderline patients with and 25 without AVH, and 26 healthy controls. Borderline patients with AVH had a significantly lower P50 difference compared with healthy controls, whereas no difference was found between borderline patients without AVH and healthy controls. The groups did not differ on MMN amplitude. The impaired sensory gating in patients with borderline personality disorder who experience AVH implies that P50 sensory gating deficiencies may underlie psychotic vulnerability in this specific patient group. Patients with borderline personality disorder with or without AVH did not have problems with auditory change detection. This may explain why they are spared from the poor outcome associated with negative symptoms and symptoms of disorganization in patients with chronic schizophrenia

Long-Stay Psychiatric Patients: A Prospective Study Revealing Persistent Antipsychotic-Induced Movement Disorder

OBJECTIVE: The purpose of this study was to assess the frequency of persistent drug-induced movement disorders namely, tardive dyskinesia (TD), parkinsonism, akathisia and tardive dystonia in a representative sample of long-stay patients with chronic severe mental illness. METHOD: Naturalistic study of 209, mainly white, antipsychotic-treated patients, mostly diagnosed with psychotic disorder. Of this group, the same rater examined 194 patients at least two times over a 4-year period, with a mean follow-up time of 1.1 years, with validated scales for TD, parkinsonism, akathisia, and tardive dystonia. RESULTS: The frequencies of persistent movement disorders in the sample were 28.4% for TD, 56.2% for parkinsonism, 4.6% for akathisia and 5.7% for tardive dystonia. Two-thirds of the participants displayed at least one type of persistent movement disorder. CONCLUSIONS: Persistent movement disorder continues to be the norm for long-stay patients with chronic mental illness and long-term antipsychotic treatment. Measures are required to remedy this situation

Does transcranial direct current stimulation to prefrontal cortex affect mood and emotional memory retrieval in healthy individuals?

Studies using transcranial direct current stimulation (tDCS) of prefrontal cortex to improve symptoms of depression have had mixed results. We examined whether using tDCS to change the balance of activity between left and right dorsolateral prefrontal cortex (DLPFC) can alter mood and memory retrieval of emotional material in healthy volunteers. Participants memorised emotional images, then tDCS was applied bilaterally to DLPFC while they performed a stimulus-response compatibility task. Participants were then presented with a set of images for memory retrieval. Questionnaires to examine mood and motivational state were administered at the beginning and end of each session. Exploratory data analyses showed that the polarity of tDCS to DLPFC influenced performance on a stimulus-response compatibility task and this effect was dependent on participants' prior motivational state. However, tDCS polarity had no effect on the speed or accuracy of memory retrieval of emotional images and did not influence positive or negative affect. These findings suggest that the balance of activity between left and right DLPFC does not play a critical role in the mood state of healthy individuals. We suggest that the efficacy of prefrontal tDCS depends on the initial activation state of neurons and future work should take this into account. © 2014 Morgan et al

Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)? A Meta-Analysis of the Efficacy of rTMS in Psychiatric Disorders

Objective: Repetitive transcranial magnetic stimulation (rTMS) is a safe treatment method with few side effects However, efficacy for various psychiatric disorders is currently not clear Data sources: A literature search was performed from 1966 through October 2008 using PubMed, Ovid Medline, Embase Psychiatry, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and PsycINFO The following search terms were used transcranial magnetic stimulation, TMS, repetitive TMS, psychiatry, mental disorder, psychiatric disorder, anxiety disorder, attention-deficit hyperactivity disorder, bipolar disorder, catatonia, mama, depression, obsessive-compulsive disorder, psychosis, posttraumatic stress disorder, schizophrenia, Tourette's syndrome, bulimia nervosa, and addiction. Study selection: Data were obtained from randomized, sham-controlled studies of rTMS treatment for depression (34 studies), auditory verbal hallucinations (AVH, 7 studies), negative symptoms in schizophrenia (7 studies), and obsessive-compulsive disorder (OCD, 3 studies) Studies of rTMS versus electroconvulsive treatment (ECT, 6 studies) for depression were meta-analyzed. Data extraction: Standardized mean effect sizes of rTMS versus sham were computed based on pretreatment-posttreatment comparisons Data synthesis: The mean weighted effect size of rTMS versus sham for depression was 0.55 (P <001). Monotherapy with rTMS was more effective than rTMS as adjunctive to antidepressant medication. ECT was superior to rTMS in the treatment of depression (mean weighted effect size -0 47, P = 004) In the treatment of AVH, rTMS was superior to sham treatment, with a mean weighted effect size of 0.54 (P <001) The mean weighted effect size for rTMS versus sham in the treatment of negative symptoms in schizophrenia was 0.39 (P = 11) and for OCD, 0 15 (P = .52) Side effects were mild, yet more prevalent with high-frequency rTMS at frontal locations Conclusions: It is time to provide rTMS as a clinical treatment method for depression, for auditory verbal hallucinations, and possibly for negative symptoms We do not recommend rTMS for the treatment of OCD J Clin Psychiatry 2010,71(7).873-884 (C) Copyright 2010 Physicians Postgraduate Press, In

Review of the Efficacy of Transcranial Magnetic Stimulation for Auditory Verbal Hallucinations

With an increase of the number of studies exploring repetitive transcranial magnetic stimulation (rTMS) for the treatment of auditory verbal hallucinations (AVH), an update is provided on the efficacy of different paradigms. A literature search was performed from 1966 through April 2013. Twenty-five randomized controlled trials using the severity of AVH or psychosis as outcome measures were included. Standardized mean weighted effect sizes were computed; a qualitative review of the literature was performed to assess the effects of various rTMS paradigms. rTMS versus sham treatment for AVH yielded a mean weighted effect size of .44. No significant mean weighted effect size was found for the severity of psychosis (i.e., .21). For patients with medication-resistant AVH, the mean weighted effect size was .45. rTMS applied at the left temporoparietal area with a frequency of 1 Hz yielded a moderate mean weighted effect size of .63, indicating superiority of this paradigm. Various other paradigms failed to show superior effects. rTMS applied at the right temporoparietal area was not superior to sham treatment. rTMS, especially when applied at the left temporoparietal area with a frequency of 1 Hz, is effective for the treatment of AVH, including in patients with medication-resistant AVH. The results for other rTMS paradigms are disappointing thus far. A next step should be to explore the effects of rTMS in medication-free individuals, for example, during the initial phases of psychosis, and in patients with diagnoses other than schizophrenia who do not have comorbid psychotic symptoms

Auditory verbal hallucinations in patients with borderline personality disorder are similar to those in schizophrenia

Background. Auditory verbal hallucinations (AVH) in patients with borderline personality disorder (BPD) are frequently claimed to be brief, less severe and qualitatively different from those in schizophrenia, hence the term 'pseudohallucinations'. AVH in BPD may be more similar to those experienced by healthy individuals, who experience AVH in a lower frequency and with a more positive content than AVH in schizophrenia. In this study the phenomenology of AVH in BPD patients was compared to that in schizophrenia and to AVH experienced by non-patients. Method. In a cross-sectional setting, the phenomenological characteristics of AVH in 38 BPD patients were compared to those in 51 patients with schizophrenia/schizoaffective disorder and to AVH of 66 non-patients, using the Psychotic Symptom Rating Scales (PSYRATS). Results. BPD patients experienced AVH for a mean duration of 18 years, with a mean frequency of at least daily lasting several minutes or more. The ensuing distress was high. No differences in the phenomenological characteristics of AVH were revealed among patients diagnosed with BPD and those with schizophrenia/schizoaffective disorder, except for 'disruption of life', which was higher in the latter group. Compared to non-patients experiencing AVH, BPD patients had higher scores on almost all items. Conclusions. AVH in BPD patients are phenomenologically similar to those in schizophrenia, and different from those in healthy individuals. As AVH in patients with BPD fulfil the criteria of hallucinations proper, we prefer the term AVH over 'pseudohallucinations', so as to prevent trivialization and to promote adequate diagnosis and treatment