1. Schizophrenia Flashcards by Jessyka Yard

list some key features associated with schizophrenia sprectrum & other psychotic disorders

delusions
hallucinations
disorganized thinking/speech
grossly disorganized or abnormal motor behaviour
negative symptoms

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this is a syndrome which consists of a variety of potential symptoms which result in a loss of contact with reality (individual has trouble distinguishing between what is real and what is not).

note: it is not a disorder itself but a feature of several mental disorders and a defining feature of schizophrenia

psychosis

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what are some symptoms of psychosis?

positive symptoms
- things are present that shouldn’t be (e.g. hallucinations, hearing voices)

negative symptoms
- things are missing (motivation, happiness)

note: we often associate schizophrenia with positive symptoms because its easier to see something that shouldn’t be there compared to looking for something that should be there

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a negative symptom; inability to feel pleasure

anhedonia

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a negative symptom; lowered levels of motivation or drive, lack of energy, decreased ability to start tasks, lack of spontaniety

avolition/apathy

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a negative symptom; monotone & 1 syllable or general reduction in speech

alogia

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a negative symptom; impressive face - little display of emotions

affective flattening

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a negative symptom; lack of interest in other people, poor rapport, impaired relationships, detached

asocial

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this is a complex disorder of brain function with heterogeneity in symptoms (alterations in perceptions, thoughts, mood, cognition & behaviour). characterized by positive symptoms, negative symptoms and often impairments in mood and cognition. there are significant disturbances in the ability to function in society on a daily basis

schizophrenia

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this part of the brain is responsible for positive symptoms

mesolimbic

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this part of the brain is responsible for negative symptoms

mesocortical

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this part of the brain is responsible for cognitive symptoms

dorsolateral prefrontal cortec

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this part of the brain is responsible for affective/mood symptoms

ventromedical prefrontal cortex

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this part of the brain is responsible for aggressive symptoms

orbitofrontal cortec and amygdala

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what are neurochemical imbalances that can lead to development of schizophrenia

if glutamate deficiency occurs than dopamine imbalance can happen

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true or false: there is a genetic component to schizophrenia

true
general population - 1%
1 parent with schiz. - 10%
2 parents with shciz. - 40%
identical twin with schiz. - 30%

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true or false: schizophrenia is more common in males

true

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true or false: there is a high rate of individuals who experience first episode psychosis with good recovery and no further epidoses

false - only 10%

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true or false: there is a high right of relapse in first episode patients within the first 5 years

true - 80%

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true or false: every time someone has a psychotic break, they never fully recover and eventually experience burnout

true

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true or false: leaving psychosis untreated does not change the prognosis

false - untreated psychosis the worse the outcome

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what is the defintion of First Episode Psychosis (FEP)

a week or more of sustained positive symptoms

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true or false: a high dose antipsychotic is usually started in a FEP patient

false - FEP patients are generally more responsive to beneficial effects and more sensitive to side effects of antipsychotic medications therefore usually use lower doses

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what is the critical period for FEP patients recieving tx

first 5 years

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which agent has demonstrated superiority in treatment resistant schizophrenia

clozapine

true or false: there is some evidence that atypical antipsychotics (SGA's and TGA's) are best for treating positive symptoms

false - FGA, SGA and TGA are all fair game

true or false: there is some evidence that atypical antipsychotics (SGA's and TGA's) are best for treating negative symptoms

true

order the antipsychotics associated with movement disorders from greatest risk to lowest risk

HP-FGA's > FGA's > others > CLZ

order the antipsychotics associated with metabolic effects (weight gain, dyslipidemia, T2DM) from greatest risk to lowest risk

CLZ-OLZ > QTP > others *if a multiple choice and both OLZ and CLZ are options: choose CLZ

order the antipsychotics associated with sedation from greatest risk to lowest risk

LP-FGA's (thus have HP for H1), CLZ, OLZ, QTP > others *take dose/biggest part of dose at bedtime

order the antipsychotics associated with seizures from greatest risk to lowest risk

CLZ > LP-FGA > others

order the antipsychotics associated with hyperprolactemia from greatest risk to lowest risk

HP-FGA, PAL, RSP > others > ARP

this medication is SL tablet and cannot have food/drink for 10 mins after dose to ensure all medication is absorbed buccally

asenapine

these two antipsychotics are available in ODT

risperiode and olanzapine

which two antipsychotics have a drug interaction with smoking?

clozapine and olanzapine people who smoke need a higher dose of these medications because smoking induces CYP 1A2; if they stop smoking, clozapine level will be way too high and the risk of having a seizure is increased

which antipsychotics should be avoided in patients with diabetes?

those with high risk of metabolic effects CLZ-OLZ > QTP > others

which antipsychotics should be avoided in patients with dementia

those with anticholinergic side effects LP-FGA's (thus have HP for M1), CLZ, OLZ, QTP > others

true or false: when deciding which dose to recommend for an antipsychotic, the highest dose should be used to optimize therapy

false - lowest effective dose should be used to establish treatment acceptance and minimize adverse effects

how long might it take for plasma concentrations to reach steady state for someone using a long-acting injection (LAI)

2-4 months

this antipsychotic needs to be taken with a minimum of 500 kcal meal otherwise bioavailability will be 1/2

Ziprasidone

this antipsychotic needs to be taken with a small meal (min 350 kcal required) as absorption can be decreased by up to 50% if taken on an empty stomach

Lurasidone

in a patient experiencing FEP, if there is no response after this amount of time after starting tx and tolerability is good, the dose can be increased

2 weeks (2/52)

this antipsychotic requires TDM in order to monitor efficacy

clozapine

what is an adequate trial for most oral antipsychotics

4-6 weeks (clozapine = 8-12 weeks)

explain the washout/start method for switching antipsychotics

taper, stop and washout (4-5 half-lives) initial antipsychotic, then start new antipsychotic

what is a benefit of the washout/start method

minimizes withdrawal reaction

what is a disadvantage of the washout/start method

may increase risk of relapse (therefore often not clinically practical if patient is not well)

explain the stop/start method for switching antipsychotics

stop first AP on day 1 and start new antipsychotic on day 2

in what situation is the stop/start method most commonly used

if there is a serious/significant ADR to the first AP

what are the two disadvantages of the stop/start method

increase risk of relapse and withdrawal reactions

explain the cross taper method

taper down the first AP while simultaneously adding & increasing the dose of the second AP *most common method*

why is the cross taper method the most common?

thought to minimize risk of relapse and withdrawal symptoms

what are the disadvantages of cross taper

- two drugs at once therefore increase ADR's - risk of long term poly pharmacy - if doses are too low may increase risk of relapse

explain the delayed withdrawal method for switching antipsychotics

establish patient on a therapeutic dose of second AP before tapering/dc the first AP

in what situation is the delayed withdrawal method most commonly used

when switching from an FGA/SGA to a TGA

what is a benefit of delayed withdrawal method

decrease risk of relapse b/c patient is on established dose of second agent before even starting to taper the first agent

what is a disadvantage of delayed withdrawal method

risk on long term poly pharmacy and increase ADR's

what are some factors that may exacerbate an acute exacerbation of psychosis

- adherence - substance abuse (cannabis and stimulants are precipitants of episodes of psychosis)

what can you do if a patient is having an acute exacerbation of psychosis and they are on a long acting injections (LAI)?

top up with a little bit of oral formulation

what can you do if a patient is experiencing psychotic ex's ~ 1 week before their injection?

prob breakthrough therefore try a shorter interval (e.g. q 3 weeks instead of q 4 weeks)

this is known as a poor response to adequate trials of at least 2 antipsychotics

treatment resistance schizphrenia

what is the recommended medication for treatment resistant schizophrenia

clozapine

what is an adequate trial of clozapine

8-12 weeks

how long should treatment continue for FEP?

no less than 18 months following remission

how long should treatment continue for someone who has had multiple episodes

2-5 years or long term treatment *AP's reduce the risk of relapse to less than 30% a year

if discontinuing an AP, what is the suggested timeline for doing this

6-24 months

what are the 7 possibilities for managing side effects

1. stop the drug 2. do nothing... provide reassurance 3. change the dose 4. alter the dosing schedule 5. add a non drug tx 6. add a drug tx 7. switch the drug

when is a patient most likely to experience s/e

at tx start and after dose increase

true or false: tolerance usually develops to s/e after a few weeks

true

true or false: if a patient is experiencing urinary retention after being started on a AP such as CLZ, they can stay on the current dose as they may develop tolerance to this in a few weeks

false urinary retention = stop drug

true or false: tolerance does not develop for hyperprolactemia due to dopaminergic block

true

true or false: hyperprolacetmia may occur in a patient taking risperidone

true -less common in other SGA's

true or false: hyperprolactemia may occur in a patient taking aripiprazole

false - less common in TGA'a

true or false: EPS occurs early and TD occurs later

true

true or false: dystonia (posture/muscle spasms), akathisia (restlessness) & Parkinsonism (tremor, rigidly & bradykinesia) are more likely to occur in LP-FGA's

false - HP-FGA's!!

true or false: Benzotropine can be used to treat dystonia, akathisia & Parkinsonism

false - used to treat dystonia & Parkinsonism - propranolol and lorazepam used to treat akathisia/restlessness

true or false: akathisia can occur in TGA's

true

true or false: tar dive dystonia, dyskinesia and akathisia are reversible

false - these are often irreversible

this side effect is an abrupt onset in muscle rigidly, fever, autonomic instability; not as common, more common in the older AP's

neuroleptic malignant syndrome (NMS)

true or false: if a patient experiences NMS with an AP, they can never use that AP again

false - NMS usually resolves once the drug is stopped

true or false: all AP's lower seizure threshold

true

which AP has the highest risk of agranulocytosis

CLZ *As RPh need to check bloodwork & watch for any signs of infection! do not use if WBC's < 3000 blood work is constant (weekly for first 6 months and then bi-weekly)

what is the first line for anti-psychotic induced weight gain after healthy lifestyles?

metformin

based on side effects, what are some baseline parameters that should be collected and followed up on when starting AP's

- weight + waist circumference - fasting lipid profile - WBC's - FBG