ones. I don't understand exactly what the delineation is but from
personal experience of life and psychosis I guess the positive symptoms
cause the negative ones based upon the psychology of the individual and
the society/culture they're brought up in and live in.
These thoughts are based on a paper I read recently on the heterogeneity
of the diagnosis of schizophrenia. It went on specifically about
prognosis but admitted that the heterogeneity can mean many things with sz.
But people experience these symptoms to varying degrees. Someone may
have lots of positive symptoms and fewer negative ones and vice versa.
Antipsychotics research seems to lump all these together in a way I just
can't stomach. The symptoms were spilt for a reason.
If I was a clinician rather than going, "right....lets just try some of
these drugs and see what happens" I'd want to have the capability to
make the choice to pick the best medication first time. I guess that
practising psychiatrists have many methods they use outside empirical
research and clinical guidelines to make these decisions. That's call
being a good doctor, or a bad one depending on how these non-scientific
methods apply in practice (e.g. 9 times overdiagnosis rate of black men
with sz in the UK).
This is guess work by me. It's a guess based on knowledge that different
psychiatrists have different prescribing practices. They'll make guesses
basded on personal experience as to which antipsychotic works better in,
say, patients with progressive onset rather than acute onset. Or they
might recognise a certain combiantion of drugs works better with
patients with more positive symptoms while another might work best for
those with more negative symptoms in general.
The paper I was reading was from a while back. I don't know where to
look to find papers where modern psychiatrists can make their choice of
drug based on empirical evidence and an operational definition to select
within a drug class.
All NICE have advised doctors in 2009 was try two standard doses of
antipsychotics before trailing the most dangerous one, one which
patients don't like and which kills them quicker. It recommends they
also use atypicals I think though there's no advice to get people off
typical antipsychotics. The
only named drug is clozapine and the latest third generation
antispychotics aren't mentioned at all if I remember right.
The drugs have different neurochemical effects and I guess psychiatrists
learn which one to use based on their own judgement system. There are
papers which compare the effects of different antipsychotics and there
must be some that compare their effects on positive and negative
systems. There must be research that compares the effect of different
atypical antipsychotics on the different prognoses - I've seen at least
one obersvational paper that compared drugs in a population study in
Finland. But there's no operational criteria, at least from what I've
read so far. The BNF doesn't say which drugs are best for which types of
schizophrenia. The NICE guidelines really only state the use of one by
name for what's considered neuroleptic treatment resistant schizophrenia
- but even this group could have high heterogeneity in their response ot
the drug.
I'm thinking totally biomedically about measures, outcomes, prognosis
and all that. By this I mean totally psychopathologically based on
theortectical constructs of schizophrenia as a brain disease to be
treated using neuroleptic medication and outcomes measured on reduction
of psychopathology based on scales like PANSS rather than social or
occupational outcomes. Don't think anyone's even bothered to consider
what operational definitions could be used to identify the types that
correlate with the variety of social outcomes experienced by people with
sz in different countries. That would be some proper funky shit though.
Real science applied to mental health (based on the construct of
psychopathology as genuine illness needing to be treated at the level of
the individual).
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