Many also become convinced that they are being watched. Psychiatrists may also find they have to help not only the PDP patient but also their caregiver, because research has shown a strong correlation between the clinical emergence of psychosis and increased caregiver stress.

As noted, few patients spontaneously report their psychosis symptoms, making it a challenge to get an accurate patient history. Specific and direct questioning about psychosis symptoms of hallucinations, paranoia, and other delusions is often needed, to enable the diagnosis and treatment of PDP before symptoms worsen.

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Treatment Challenges

Parkinson’s patients are at an increased risk for PDP as they age, develop memory impairment or depression, or if they act out vivid dreams. Psychotic symptoms may also be triggered by infections, such as urinary tract infections, or by the medications used to treat PD or other co-existing medical disorders such as for pain or bladder infections.

Currently, the treatment of PDP is limited and not evidence-based, though reassurance may be useful, and cognitive-behavioral therapy may help. From a pharmacological perspective, reducing potentially offending medications, such as those indicated for the treatment of PDP, can reduce the intensity of psychosis.

Sometimes, an atypical antipsychotic (AP) can be prescribed off-label for PDP, but the use of those agents can exacerbate the motor symptoms.7 In the case of APs, it’s easy to understand why, since they are designed to block dopamine D2 receptors in the brain. In addition, some APs require weekly blood draws to detect potential agranulocytosis.8 Given the undesirable side effects, many patients with PDP do not receive antipsychotic treatment because the ultimate goal is to improve PDP, without worsening the motor symptoms of PD.

Potential New Therapy

At this time, there is a wide recognition of the significant unmet need for better treatment options for PDP. A new, selective serotonin inverse agonist (SSIA) medication in development by Acadia Pharmaceuticals for PDP, pimavanserin (Nuplazid), targets 5-HT2A receptors. If approved by the FDA, pimavenserin will establish a novel and distinctly different (first–in-class) pharmacological approach to treating psychosis. The company recently submitted its NDA to the FDA for approval. 

This article originally appeared on Psychiatry Advisor