of action of antipsychotic agents (e.g., phenothiazines,
butyrophenones, thioxanthenes) was blockade of D 2
dopamine receptors. These “typical” antipsychotics
resulted in a substantial reduction of positive symptoms
(and, to a lesser extent, disorganization symptoms) in
about 60% of cases, limited reduction in about 30% of
cases, and no response in about 10% of cases.
Maintenance doses also helped reduce the recurrence
of active phases. But typical antipsychotics had a min-
imal effect on negative symptoms and were associated
with a high rate of serious side effects, including seda-
tion and movement disorders. In the 1980s, “atypical”
antipsychotics (e.g., clozapine, amisulpiride) were
introduced. Their mechanism of action is more wide-
spread than that of typical antipsychotics; they affect
the serotonergic and adrenergic systems, in addition to
the dopaminergic system. Atypical antipsychotics are at
least as effective as typical antipsychotics in reducing
positive symptoms (even in cases where typical
antipsychotics are ineffective), and they may also
reduce negative symptoms. They also have serious neg-
ative side effects, however, and are very expensive. The
effectiveness of pharmacological treatment has greatly
reduced the use of other, more invasive somatic treat-
ment, such as electroconvulsive therapy and prefrontal
lobotomy; it has also greatly reduced the frequency of
long-term institutionalization.
Psychosocial interventions are frequently used to
manage active symptoms, reduce active symptoms that
are refractory to pharmacological treatment, improve
social functioning following an active phase, and reduce
the risk of recurrence. Institutionalization or respite care
is used when it is difficult to deliver appropriate services
in the community and when risk of suicide or violence
is acute. Psycho-educational programs for patients and
their families are used to improve compliance with other
treatments and to reduce the rate of relapse. Cognitive
behavioral therapy is used to manage active psychotic
symptoms, such as delusions and hallucinations, as well
as to improve compliance with other treatment. “Dual
disorder” or “co-occurring disorder” programs are used
to treat symptoms of substance use disorders in people
who also suffer from psychotic disorders. Rehabilitation
and social skills programs are used to improve interper-
sonal and occupational functioning.
Most often, treatment of psychotic disorders is long-
term and multimodal: Pharmacological interventions
are used in combination with one or more psychosocial
interventions. Delivery of services may be most effec-
tive when coordinated using assertive case management
techniques.Forensic Relevance
In the law, competency to make important decisions
typically requires that the person can accurately per-
ceive the environment, rationally manipulate informa-
tion about the environment, and communicate desires
and intentions to others. These specific decision-mak-
ing capacities may be impaired by the presence of
psychotic symptoms, especially positive and disorga-
nization symptoms. For this reason, psychotic disor-
ders are particularly important in psycholegal
evaluations of adjudicative competencies (e.g., stand
trial, waive the right to counsel, confess) and culpabil-
ity in criminal settings and evaluations of other com-
petencies (e.g., consent to treatment, testify, make
wills, sign contracts) in civil settings. For example,
research on adjudicative competencies and culpability
indicates that as many as 80% to 90% of people who
are found legally incompetent, or nonculpable, may
suffer from psychotic disorders or from other disor-
ders (e.g., cognitive or mood disorders) with promi-
nent psychotic symptoms.
With respect to the ability to control one’s behav-
ior, the law typically requires that the person can
freely form goals or intentions appropriate to the situ-
ation; develop plans to achieve those goals; and
implement, evaluate, and modify those plans as neces-
sary. These specific capacities also may be impaired
by psychotic symptoms of all types. In criminal set-
tings, psychotic disorders may be important in psy-
cholegal evaluations of culpability and in civil matter
evaluations of other competencies (e.g., consent to
treatment, testify, make wills, sign contracts) in civil
settings. In both criminal and civil settings, an issue of
particular concern is serious violence associated with
psychotic symptoms, particularly positive and disor-
ganization symptoms. In some cases, the nature of the
psychotic symptoms is directly related to the violence
(e.g., a person with persecutory delusions assaults
someone he believes is trying to poison him); in oth-
ers, the psychotic symptoms interact with other fac-
tors (e.g., substance use) to generally destabilize
social adjustment and increase interpersonal conflict
that may result in violence. Research suggests that
psychotic disorders cause a twofold increase in the
odds that a person will engage in serious violence.Stephen D. Hart
and Laura S. GuySee alsoDelusions; Hallucinations654 ———Psychotic DisordersP-Cutler (Encyc)-45463.qxd 11/18/2007 12:43 PM Page 654