Prescribing in Anxiety and Psychosis

Question 1

what is the primary treatment in paranoid schizophrenia?

Answer 1

atypical antipsychotics

• risperidone/olanzapine for 6-8 weeks up until max dose
• if both fail at max dose, then clozapine

Question 2

primary mechanism of action of antipsychotics?

Answer 2

dopamine antagonists

Question 3

what are the dfferences between typical and atypical antipsychotics?

Answer 3

typical
- only work on dopamine receptors
- more side effects (extra-pyramidal side effects)
atypicals
- work on other receptors as well as dopamine (5HT receptors etc)
- less side effects
- better effects on negative symptoms

Question 4

what can be given for aggressive/violent and dangerous patients?

Answer 4

sedation

• haloperidol
• benzodiazepines (lorazepam)

Question 5

what are the dangers of long term antipsychotic use?

Answer 5

tardive dyskinesia (rare)
metabolic syndrome (type 2 diabetes rsk due to effect on serotonin)
sexual dysfunction/infertility
daytime sleepiness - impact on job etc

Question 6

how can antipsychotics be delivered?

Answer 6

oral
IM depot
- good if compliance is a concern

Question 7

how does clozapine work?

Answer 7

dopamine antagonist

alpha, muscarinic and 5-HT2A receptor antagonist

Question 8

side effects of clozapine?

Answer 8

bowl obstructive constipation
- be aware if anyone taking clozapine presents with abdominal pain
agranulocytosis
myocarditis
hyepersalivation
sedation
weight gain
reduced seizure threshold

Question 9

what should be monitored while taking clozapine?

Answer 9

FBC
CRP
troponin

Question 10

how do benzodiazepines work?

Answer 10

enhance GABA transmission

Question 11

symptoms of benzodiazepine withdrawal?

Answer 11

abdominal cramps
insomnia
anxiety seizures

Question 12

how should a benzodiazepine detox take place?

Answer 12

gradual reduction

reduce by 2mg every 2-3 days if inpatient or every week in the community

Question 13

appropriate treatments in GAD?

Answer 13

CBT
SSRI
pregabalin or augmentive therapy more as last resort

Question 14

action of haloperidol?

Answer 14

typical antipsychotic

D2 receptor antagonist

Question 15

contraindications of haloperidol?

Answer 15

parkinsons (reduces dopamine further and also causes movement disorders)
long QT syndrome

Question 16

side effects of haloperidol?

Answer 16

extra-pyramidal 
anticholinergic
agitation
amenorrhoea
galactorrhoea
gynaecomastia 
long QT
movement disorders/parkinsonism
hypotension

Question 17

general monitoring in antipsychotics?

Answer 17

ECG before starting treatment and during if administered IM

prolactin before, then 6 monthly, then yearly

Question 18

mechanism of chlorpromazine?

Answer 18

typical antipsychotic

blocks D2, D3 and D5 receptors

Question 19

side effects of chlorpromazine?

Answer 19

increased muscle tone
urinary retention
anxiety
impaired glucose tolerance

Question 20

mechanism of arapiprazole?

Answer 20

partial agonist of D2 receptors

Question 21

3 side effects of arapiprazole?

Answer 21

agitation
amenorrhoea
occasionally agranulocytosis

Question 22

mechanism of risperidone?

Answer 22

dopamine antagonist (D1 and D2, mainly D2)
also acts on serotonin receptors (can be agonist or antagonist)

Question 23

side effects of risperidone?

Answer 23

extra pyramidal
weight gain
orthostatic hypotension
sedation
amenorrhoea
gynaecomastia

Question 24

mechanism of olanzapine?

Answer 24

blocks dopamine and 5-HT2

Question 25

side effects of olanzapine?

Answer 25

increased appetite
weight gain
joint pain
arrhythmias
dry mouth
parkinsonism
amenorrhoea
galactorrhoea