Antipsychotics

Question 1

Psychotic Symptoms

Answer 1

Hallucinations
Delusions
Disorganized Speech

-Two or more present for at least one month

Question 2

Symptoms
3 big categories

Answer 2

Positive
Negative
Cognitive

Question 3

Positive Symptoms

Answer 3

Hallucinations
Delusions
Disorganized speech
Grandiose　大げさな

Question 4

Negative Symptoms

Answer 4

Affective flattening
Anhedonia
Asociality
-Lacking the capacity for
social interaction
Avolition
-Lack of motivation or “drive”
Alogia
-Decreased speech fluency

Question 5

Cognitive Symptoms

Answer 5

Poor concentration
Memory disturbances
Poor abstraction
Impaired decision making

Question 6

Prodromal Phase

Answer 6

Withdrawn
Odd beliefs
Peculiar behavior

Question 7

Acute Episode

Answer 7

Lose touch with reality
Hallucinations
Delusions
Flat or inappropriate affect
Difficulty with self-care

Question 8

Treatment Goals

Answer 8

Prevent harm to self and others
Integrate back into the community
Medication adherence
Improve overall quality of life

Question 9

Pathophysiology of Schizophrenia

Answer 9

Imbalance in dopamine
–Increased dopamine in certain areas of the brain leads to symptoms of psychosis

Question 10

Antipsychotic MOA
a) 1st generation
b) 2nd generation

Answer 10

a) Dopamine blockade
“Typical”
b) Dopamine and Serotonin blockade
“Atypical”

Question 11

Dopamine (D2) Receptor Blockade
a) Therapeutic
b) Adverse Events

Answer 11

1st generation
a) Improved positive symptoms of psychosis
b)Worsening of negative symptoms and cognition
Extrapyramidal movement disorders (EPS) and tardive dyskinesia (TD)

Question 12

Dopamine and Serotonin Receptor Blockade
a) Therapeutic
b) Adverse Events

Answer 12

2nd generation
a)Reduced EPS and risk of TD
improvement in negative symptoms and cognition
b) Sedation
Weight gain

Question 13

Treatment of Schizophrenia

Answer 13

First Generation (Typical)
Second Generation (Atypical)
Non-pharmacological treatment

Question 14

Typical antipsychotics
1st generation

Answer 14

High Potency
–Haloperidol Hola___ idol
–Fluphenazine flu___azine
Most commonly use but most likely to cause EPS!!

–Chlorpromazine
–Thioridazine
–Perphenazine
–Loxapine

Question 15

Extrapyramidal Symptoms (EPS)

Answer 15

Dystonia
Pseudoparkinsonism
Akathisia

Question 16

Dystonia

Answer 16

Sustained muscle contractions
–Twisting, repetitive movements or abnormal postures
–Can look like a tremor or seizure

Painful and scary
Typically involve tongue, jaws, eyes, neck, limbs or toes

Usually occur 24-96 hours after a dose

Question 17

Dystonia
Treatments

Answer 17

Diphenhydramine(Benadryl)
benztropine (Anti-Tremor)
benzodiazepines

Question 18

Pseudoparkinsonism

Answer 18

Akinesia, bradykinesia, slowed speech

Signs
–Resting tremor
–Pill rolling tremor
–Cogwheel rigidity
–Gait/Posture changes

*Usually reversible within weeks of discontinuation
–Persists or worsens in 10-40%

Question 19

Pseudoparkinsonism
Treatments

Answer 19

Benztropine(Anti-Tremor)
Trihexyphenidyl(antispasmodic)

Question 20

Akathisia

Answer 20

Motor restlessness or inability to sit still （着座不能症）

Signs
–Pacing
–Shifting/shuffling
–Foot tapping
–“Inner restlessness”

*Occurs in 20-30% of patients on typical antipsychotics

Question 21

Akathisia
Treatments

Answer 21

Beta-blockers
Benzodiazepines(depressants)

Question 22

EPS Treatment Strategies

Answer 22

Decrease antipsychotic dose
Switch from high- to low-potency typical antipsychotic
Switch from typical to atypical antipsychotic
Use adjunctive medication

Question 23

Tardive Dyskinesia (TD)

Answer 23

Involuntary abnormal movements generally occur after long-term antipsychotic therapy
–Face, tongue, lips, neck, trunk common

Early signs may be reversible!!
Symptoms are progressive.
Important to monitor and stop it early!!!

Question 24

Tardive Dyskinesia
Treatment

Answer 24

Prevention
-most important prevention is intervention because early detection can be reversible

Early detection
*AIMS scale every 3-6 months

Question 25

Tardive Dyskinesia
Treatment with medication

Answer 25

Switch to atypical antipsychotic
Valbenazine
Deutetrabenazine

-Decreases presynaptic dopamine
-Modest symptom improvement
-Sedation and dry mouth >5%

Question 26

Atypical Antipsychotic
2nd generation
Agents

Answer 26

Clozapine
Olanzapine
Quetiapine
Paliperidone
Risperidone
Ziprasidone
Aripiprazole

Question 27

Atypical Effects
Therapeutic Effect

Answer 27

Decreases negative symptoms
Improve cognition

Question 28

Atypical Effects
ADRs

Answer 28

Movement disorders (EPS)
Weight gain
Hyperlipidemia

Question 29

What is “Atypical”?

Answer 29

Reduced risk for EPS
Reduced risk for TD
Potentially better at improving negative symptoms
Potentially better at improving cognition
Greater risk of metabolic ADRs

Question 30

Clozapine
Treatment for

Answer 30

Persistent psychotic symptoms
Negative symptoms
Suicidality

Question 31

Clozapine
ADRs

Answer 31

1-2% develop agranulocystosis
(stop making WBC)
Blood monitoring is required weekly for the first 6 months
Every 2 weeks for 6 months, then monthly thereafter

Must be part of a national registry

Reserved for treatment-resistant patients

Question 32

Clozapine
Black Box Warning

Answer 32

Increased rate of death in elderly patients
with dementia receiving antipsychotics for the
treatment of behavioral disorders.

Question 33

Antipsychotics
Dosage Forms

Answer 33

Oral
–Tablets or capsules
–Liquid
–Quick Dissolving

*Injection
–Short acting
–Long acting

Question 34

In order to be diagnosed with schizophrenia, the symptoms continue for a_____ month a did must persist for b______ month

Answer 34

1 month
6 months

Question 35

Which ESP or TD not reversible?

Answer 35

Tardive dyskinesia(TD)
If not early detacted

Question 36

2nd gen ADRs?

Answer 36

Risk for the serious metabolic effect
Hyperlipidemia or weight gain

Question 37

What medication may cause agranulocytosis?

Answer 37

Clozapine