Rapid review II: psychosis, personality, and substance, with the drug that goes with each

SCHIZOPHRENIA — six months of disturbance with positive features (hallucinations, delusions, disorganized speech and behavior) and negative features (avolition, alogia, anhedonia, flat affect, asociality). Hook: negative features respond least to medication and are routinely mistaken for depression or for laziness.

THE OTHER PSYCHOTIC DISORDERS — brief psychotic disorder resolves within one month, schizophreniform disorder runs one to six months, schizoaffective disorder adds a full mood episode with at least two weeks of psychosis without mood symptoms. Delusional disorder shows a fixed false belief with otherwise intact function. Hook: duration is the discriminator, not severity.

ANTIPSYCHOTICS AND EXTRAPYRAMIDAL SYMPTOMS — acute dystonia appears in hours to days as a sustained spasm of the neck, jaw, or eyes and is treated with intramuscular benztropine or diphenhydramine; laryngeal dystonia is an airway emergency. Akathisia appears in days to weeks as inner restlessness with an inability to sit still. Pseudoparkinsonism appears in weeks as tremor, rigidity, shuffling gait, and mask-like face. Tardive dyskinesia appears after months as involuntary lip smacking, tongue movement, and grimacing, and may not reverse. Hook: akathisia answered with a dose increase is the classic wrong action, because it is misread as anxiety or worsening psychosis.

SECOND-GENERATION AGENTS — lower extrapyramidal burden, higher metabolic burden. Monitor weight, waist, glucose, and lipids. Ziprasidone prolongs the QT interval.

CLOZAPINE — reserved for treatment resistance and for persistent suicidality in schizophrenia. Absolute neutrophil count monitoring is mandatory under its risk program. It also carries myocarditis, seizure at higher doses, heavy sedation, drooling, and severe constipation progressing to ileus. Hook: sore throat and fever in a clozapine patient is a neutrophil problem until proven otherwise. → BOOK 07 · P6

CLUSTER A — paranoid, schizoid, schizotypal. Odd, guarded, detached. Response: be consistent, factual, and non-intrusive; keep the same nurse when possible; do not force warmth or group participation.

CLUSTER B — antisocial, borderline, histrionic, narcissistic. Dramatic, erratic, emotionally intense. Response: identical limits from every staff member, one team message, written care agreements, and matter-of-fact care after self-harm without extra attention paid to the behavior. Hook: splitting is defeated in report, not at the bedside.

CLUSTER C — avoidant, dependent, and obsessive-compulsive personality disorder. Anxious and fearful. Response: require decisions the patient makes alone; doing it for them reinforces the pattern.

SUBSTANCE USE AND THE DRUGS THAT TREAT IT — alcohol use disorder is treated with naltrexone, acamprosate, or disulfiram, and disulfiram requires teaching about hidden alcohol in mouthwash, sauces, and cold preparations. Opioid use disorder is treated with methadone or buprenorphine, and naloxone is given for overdose. Thiamine precedes glucose in every alcohol-dependent patient to prevent Wernicke encephalopathy. Hook: alcohol and sedative withdrawal can kill; opioid withdrawal is agonizing but rarely fatal in adults.

Withdrawal windows — alcohol: tremor and anxiety at 6 to 12 hours, perceptual disturbance at 12 to 24 hours, withdrawal seizure at 12 to 48 hours, delirium tremens at 48 to 96 hours with fever, gross tremor, disorientation, and autonomic storm. Sedative-hypnotic withdrawal from longer-acting agents starts later and carries a wider seizure window. Short-acting opioid withdrawal begins at 8 to 12 hours and peaks at 36 to 72 hours. Stimulant withdrawal is a crash with hypersomnia and dysphoria, and suicide risk is highest during it.

Memory hook: DYSTONIA in hours · AKATHISIA in days · PARKINSONISM in weeks · TARDIVE in months.

Watch outdelirium tremens is a mortality event, not an agitation problem. → BOOK 14 · P6

Takeawayfor antipsychotics, the time since the dose changed tells you which adverse effect you are looking at.