NS: Psychoses and related disorders

Question 1

Antipsychotic drugs can treat what aspects of Schizophrenia?

Answer 1

They can relieve positive psychotic symptoms such as thought disorder, hallucinations and delusions, and prevent relapse.

They are usually less effective on negative symptoms such as apathy and social withdrawal.

Question 2

The first-generation antipsychotic drugs act predominatly via what mechanism?

Answer 2

By blocking dopamine D2 receptors in the brain.

1st gen antipsychotic drugs are not selective for any of the four dopamine pathways in the brain and so can cause a range of side-effects, particularly extrapyramidal symptoms and elevated prolactin.

Question 3

Why do 1st generation antipychotic drugs cause a range of side-effects?

Answer 3

1st gen antipsychotic drugs are not selective for any of the four dopamine pathways in the brain and so can cause a range of side-effects, particularly extrapyramidal symptoms and elevated prolactin.

Question 4

What are the different groups of 1st generation antipychotic drugs?

Answer 4

1. Phenothiazine derivatives
2. Butyrophenones
3. Thioxanthenes
4. Diphenylbutylpiperidines
5. Substituted benzamides

Question 5

The 1st generation antipsychotics the phenothiazine derivatives can be divide into 3 main groups nbased on their side effect profiles. Which are in Group 1?

Answer 5

Group 1: chlorpromazine, levomepromazine and promazine are generally characterised by pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects.

Group 2: pericyazine, generally characterised by moderate sedative effects, but fewer extrapyramidal side-effects than groups 1 or 3.

Group 3: fluphenazine decanoate, perphenazine, prochlorperazine and trifluoperazine, generally characterised by fewer sedative and antimuscarinic effects, but more pronounced extrapyramidal side-effects than groups 1 and 2.

Question 6

What are the group 2 phenothiazine derivative generation 1 antipsychotics?

Answer 6

Group 1: chlorpromazine, levomepromazine and promazine are generally characterised by pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects.

Group 2: pericyazine, generally characterised by moderate sedative effects, but fewer extrapyramidal side-effects than groups 1 or 3.

Group 3: fluphenazine decanoate, perphenazine, prochlorperazine and trifluoperazine, generally characterised by fewer sedative and antimuscarinic effects, but more pronounced extrapyramidal side-effects than groups 1 and 2.

Question 7

What recommendations are there regardinf the use of antipsychotics in the elderly? (3)

Answer 7

1. Antipsychotic drugs should not be used in elderly patients to treat mild to moderate psychotic symptoms.
2. Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, co-morbidity, and concomitant medication.
3. Treatment should be reviewed regularly.

Question 8

Extrapyramidal symptoms occur most frequently with what antipsychotics?

Answer 8

1st generation.

Question 9

What are extrapyramidal symptoms? (4)

Answer 9

1. Parkinsoniam symptoms (including tremor).
2. Dystonia and dyskinesia (abnormal face and body movements).
3. Akathisia (restlessness)
4. Tardive dyskinesia (rhythmic, involuntary movements of tongue, face and jaw)

Question 10

Why is tardive dyskinesia the most serious manifestation of extrapyramidal symptoms?

Answer 10

It may be irreversible on withdrawing therapy and treatment is usually ineffective.

In children, tardive dyskinesia is more likely to occur when the antipsychotic drug is withdrawn.

Question 11

Most antipyschotic drugs, both 1st and 2nd generation, increase prolactin concentration why?

Answer 11

Because dopamine inhibits prolactin release.

Question 12

Why does aripiprazole cause reduced prolactin production while most antipsychotic drugs cause increased prolactin production?

Answer 12

Most antipsychotics increase prolactin concentration to some extent because they inhibit dopamine and dopamine usually inhibits prolactin release.

Aripiprazole reduces prolactin because it is a dopamine-receptor partial agonist.

Question 13

Which antipsychotics are most likely to cause symptomatic hyperprolactinaemia? (3)

Answer 13

Risperidone
Amisulpride
1st Gen in general

Question 14

What are the clinical symptoms of hyperprolactinaemia? (5)

Answer 14

Sexual dysfunction
Reduced bone mineral density
Menstrual disturbances
Breast enlargement
Galactorrhoea.

Question 15

What is one of the main causes of non-adherence to antipsychotic medication?

Answer 15

Sexual dysfunction.
Antipsychotic-induced sexual dysfunction is caused by more than one mechanism:

Reduced dopamine transmission and hyperprolactinaemia decrease libido.

Antimuscarininc effects can cause disorders of arousal.

Alpha1-adrenocepter antagonists are associated with erection and ejaculation problems in men.

Risperidone and haloperidol commonly cause sexual dysfunction.

Question 16

Antipsychotic-induced sexual dysfunction is caused by more than one mechanism. What are these mechanisms? (3)

Answer 16

Reduced dopamine transmission and hyperprolactinaemia decrease libido.

Antimuscarininc effects can cause disorders of arousal.

Alpha1-adrenocepter antagonists are associated with erection and ejaculation problems in men.

Risperidone and haloperidol commonly cause sexual dysfunction.

Question 17

Antipyschotic drugs have been associated with cardiovascular side-effects such as what?

Answer 17

Tachycardia, arrhythmias, and hypotension.

QT-interval prolongation is of particular concern with pimozide and haloperidol.

Question 18

Antipsychotic drugs have been associated with cardiovascular side-effects such as tachycardia, arrhythmias, and hypotension. QT-interval prolongation is a particular concern with which drugs?

Answer 18

Antipsychotic drugs have been associated with cardiovascular side-effects such as tachycardia, arrhythmias, and hypotension. QT-interval prolongation is a particular concern with pimozide and haloperidol.

Question 19

Hyperglycaemia, and sometimes diabetes, can occur with antipychotic drugs, particularly which ones? (4)

Answer 19

1. clozapine
2. olanzapine
3. quetiapine
4. risperidone

Question 20

All antipsychotic drugs may cause weight gain, but the risk and extent varies. Which two commonly cause weight gain?

Answer 20

All antipsychotic drugs may cause weight gain, but the risk and extent varies. Clozapine and olanzapine commonly cause weight gain.

Question 21

Hypotension and interference with temperature regulation are dose-related side-effects that are liable to cause dangerous falls and hypothermia or hyperthermia in the elderly. Which four antipsychotics can cause postural hypotension (especially during initial dose titration) which may be associated with syncope or reflex tachycardia in some patients?

Answer 21

Hypotension and interference with temperature regulation are dose-related side-effects that are liable to cause dangerous falls and hypothermia or hyperthermia in the elderly. Clozapine, chlorpromazine, lurasidone, and quetiapine can cause postural hypotension (especially during initial dose titration) which may be associated with syncope or reflex tachycardia in some patients.

Question 22

What is neuroleptic malignant syndrome?

Answer 22

Neuroleptic malignant syndrome (hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence) is a rare but potentially fatal side-effect of all antipsychotic drugs.

Question 23

What are the symptoms of neuroleptic malignant syndrome?

Answer 23

Neuroleptic malignant syndrome (hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence) is a rare but potentially fatal side-effect of all antipsychotic drugs.

Question 24

With neuroleptic malignant syndrome, why is discontinuation of the antipsychotic drug essential?

Answer 24

Discontinuation of the antipsychotic drug is essential because there is no proven effective treatment, but bromocriptine and dantrolene have been used. The syndrome, which usually lasts for 5–7 days after drug discontinuation, may be unduly prolonged if depot preparations have been used.

Question 25

What treatments are there for neuroleptic malignant syndrome? (2)

Answer 25

Discontinuation of the antipsychotic drug is essential because there is no proven effective treatment, but bromocriptine and dantrolene have been used. The syndrome, which usually lasts for 5–7 days after drug discontinuation, may be unduly prolonged if depot preparations have been used.

Question 26

Which antipychotics may be better at treating the negative symptoms of shizophrenia?

Answer 26

Second generation

Question 27

What antipyschotics should be presribed if extrapyramidal side-effects are a particular concern?

Answer 27

Second-generation.

Least likely to cause extrapyramidal side effects are: aripiprazole, clozapine, olanzapine and quetiapine.

Question 28

What generation of antipsychotics are less likely to cause diabetes?

Answer 28

1st gen least, 2nd most.

Question 29

What drugs have the lowest risk of diabetes of the 2nd gen drugs?

Answer 29

Amisulpride and aripiprazole.

Question 30

The antipsychotics with the lowest risk of sexual dysfunction are what?

Answer 30

Aripiprazole and quetiapine.

Question 31

Patients should receive an antipsychotic drug for how long before it is deemed ineffective?

Answer 31

4-6 weeks before it is deemed ineffective.

Question 32

Clozapine is licensed for the treatment of schizophrenia in what?

Answer 32

Patients who are unresponsive to, or intolerant of, other antipsychotic drugs Clozapine should be introduced if schizophrenia is not controlled despite teh sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic for at least 6-8 weeks)

Question 33

If patients do not respond adequately to an optimised dose of clozapine, what should happen?

Answer 33

The plasma-clozapine concentration should be checked BEFORE adding a second antipsychotic drug to augment clozapine; allow 8-10 weeks’ treatment to assess response.

Question 34

What is required at the start of therapy with antipsychotic drugs and then annually thereafter? (3)

Answer 34

1. FBC
2. U+Es
3. LFT monitoring

Question 35

What monitoring is required at the start of therapy with antipsychotics, at 3 months and then yearly? (2)

Answer 35

Blood lipids and weight should be measured at baseline, at 3 months (weight should be measured at frequent intervals during the first 3 months), and then yearly.

Question 36

How often should fasting blood glucose level be monitored with antipsychotic therapy?

Answer 36

At baseline, at 4-6 months, and then yearly.

Question 37

What antipsychotics can be used for intractable hiccup?

Answer 37

Chlorpromazine and haloperidol

Question 38

The value of the use of benperidol in what condition is not established?

Answer 38

deviant antisocial behaviour.