Management of Schizophrenia

Question 1

What are some currently used antipsychotics?

Answer 1

Flupentixol, perphenazine, olanzapine, clozapine, aripiprazole, sulpiride, quetiapine, prochlorperazine, lurasidone, haloperidol, chloropromazine

Question 2

What are some examples of typical antipsychotics?

Answer 2

Chloropromazine, perphenazine, zuclopenthixol, prochlorperazine, trifluperazine, flupentixol, haloperidol, amisulpride, sulpiride

Question 3

What are some examples of atypical antipsychotics?

Answer 3

Clozapine, quetiapine, lurasidone, risperidone, palperidone, olanzapine, aripiprazole

Question 4

How effective are antipsychotics?

Answer 4

Reduce overall symptoms and relapse prevention
2nd generation antipsychotics increased percentage responding to 41% in acute treatment
Maintenance treatment reduced relapse rates to 22% within 10 months

Question 5

What are the dopaminergic side effects of antipsychotics?

Answer 5

Extra pyramidal side effects, neuroleptic malignant syndrome, hyperprolactinaemia, akathisia/restless legs

Question 6

What are some examples of extra pyramidal side effects?

Answer 6

Acute dystonic reactions, Parkinsonism, tardive dyskinesia

Question 7

What are some features of acute dystonia?

Answer 7

Onset in minutes = increasing muscle tone, energetic, torticolis, oculogyric crisis, tongue protrusion

Question 8

What are the features of Parkinsonism?

Answer 8

Bradykinesia, cogwheeling rigidity, resting tremor, shuffling gait, dead-pan facial expression

Question 9

What are the features of tardive dyskinesia?

Answer 9

Long term and often permanent
Responds fairly poorly to treatment
May involve limbs and/or trunk
Involuntary repetitive orofacial movements = blinking, grimacing, pouting, lip smacking

Question 10

How are extra pyramidal side effects treated?

Answer 10

Procyclidine 5mg, trihexyphenidyl, orphenadrine

Question 11

What are some features of neuroleptic malignant syndrome?

Answer 11

Rare = 1-2 per 10000 of patients on antipsychotics
Onset over 24-72hrs and lasts for days if untreated
Fatal in up to 20% (oral) or 30% (depot) if untreated
Investigate using creatine kinase

Question 12

What are the symptoms of neuroleptic malignant syndrome?

Answer 12

Increasing muscle tone, pyrexia, changing pulse or BP
Leads to rhabdomyolysis then acute renal failure
Coma develops which may progress to death

Question 13

How is neuroleptic malignant syndrome treated?

Answer 13

Stop antipsychotic
Rapid cooling and renal support
Skeletal muscle relaxants = dantroline
Dopamine agonists = bromocriptine

Question 14

Why do antipsychotics cause hyperprolactinaemia?

Answer 14

Prolactin release inhibited by dopamine = blockade of dopamine by antipsychotic leads to increased prolactin levels

Question 15

How does hyperprolactinaemia present?

Answer 15

Women = galactorrhoea, decreased libido and arousal, anorgasmia, anovulation, amenorrhoea
Men = gynaecomastia, erectile dysfunction, oligospermia, decreased libido

Question 16

What effect does hyperprolactinaemia have on bone density?

Answer 16

Decreases bone mineralisation = reduced bone density so increased risk of osteoporosis

Question 17

What are some features of akathisia?

Answer 17

Affects up to 20% and manifests days-weeks = pacing, rocking from foot to foot, unable to sit or stand still, poor sleep as a result, links to increased suicide risk

Question 18

What are some anticholinergic side effects?

Answer 18

Dry mouth, blurred vision, constipation

Question 19

What are some side effects linked to serotonin?

Answer 19

Implicated in weight gain and metabolic syndrome

Question 20

What are some other side effects of antipsychotics?

Answer 20

Anti-adrenergic = postural hypotension

Hepatoxicity, prolonged QT interval, photosensitivity

Question 21

What kind of side effects do 1st generation antipsychotics cause?

Answer 21

Extra pyramidal side effects

Question 22

What kind of side effects do 2nd generation antipsychotics cause?

Answer 22

Weight gain and sedation

Question 23

What are the benefits of clozapine?

Answer 23

20% better efficacy than others = better for treatment of non-responders, good for negative symptoms, antisuicidal

Question 24

What are the side effects of clozapine?

Answer 24

Agranulocytosis = leads to neutropenic sepsis
Constipation = leads to gastric paresis and perforation
Myocarditis, sedation, weight gain, siallorrhoea

Question 25

What are some illness factors in disease prognosis?

Answer 25

Poverty = wealth, choice, social mobility, housing
Poor diet, poor access to transport, lack of support, amotivation, poor concentration
75% have at least one other chronic illness
Higher rates of smoking and drug use

Question 26

What are some treatment factors in disease prognosis?

Answer 26

Medication induces weight gain
Falls due to extra pyramidal side effects
Cognitive effects of anticholinergics
Osteoporosis due to raised prolactin
Sedation leads to immobility
Negative symptoms lead to lack of exercise