Psych Conference III

Question 1

Paranoid delusion definition and example

Answer 1

Fixed, false fear/belief, not bordered in reality and not consistent with cultural beliefs. I.e. pt believes eagle is going to shoot her

Question 2

Definition and example of auditory hallucinations

Answer 2

hearing perceptions int he absence of external stimuli (i.e. hearing jesus telling her to do things. a visual one would be seeing a ligh that is not actually there(

Question 3

pt treated with perphenazine for Undifferentiated shizophrenia. What’s the drug act on, what are the side effects seen with it?

Answer 3

Typical neuroleptic that blocks 5HT2 receptors (agitation, nervousness, insomnia, sexual dysfunction), blocks D2 receptors, and alpha1 blockers.

Side effect of these medium potenency antispychotis (and in high potency) is Extrapyramidal Side Effects (EPS). exp,anation in another card.

Question 4

What are the 4 main EPS signs?

Answer 4

Acute Dystonia: acute face, heck, torso muscle spasms/contractions. Very dangerous if throat shuts.

Akinesia: Parkinsonian symptoms (tremor, bradykinesia, cogwheel rigidty)

Akathisia: subjectives and objective motor restlessness

Tardive Dyskinesia: involuntary movements of the face, mouth, and tongue

Question 5

In addition to EPS, what are two other important side effects of antispychotics, specifically the high potency generation?

Answer 5

1. EPS
2. Neuroleptic Malignant Syndrome: Rigidity, myoglobinuria, autonomic instability, hyperpyrexia (really high fever), increased CK, can be fatal
3. Endocrine effects due to prolactin release since dopamine is inhibited and thus no longer inhibiting prolactin: galactorrhea and amenorrhea in women, gynecomastia and impotence in men

Question 6

What drug can be used to treat EPS side effects? What class of drugs DOESNT work to treat EPS?

Answer 6

Beta blocker (propranolol) often provide dramatic relief, especially for Akathesia. Benzodiazapines also help relax them.

Anti-cholinergics DO NOT work.

Question 7

While anti-cholinergics dont work to treat EPS, what is one sign from EPS that you treat with anticholinergics?

Answer 7

Dystonia: if throat shuts, treat with IM anti-cholinergic. (side effect often seen from haloperidol).

Question 8

In terms of drug classes, what is the relationship bewteen anticholinergic and EPS?

Answer 8

low potency drugs: higher anticholinergic, less EPS

high potency drugs: lower anticholinergic, more EPS.

Question 10

In terms of treating schizo, how does a drug like perphanazine help?

Answer 10

While it treats positive symptoms (hallucinations), negative symptoms usually persist (withdrawn, reduced corns for appearance and hygiene, poverty of speech, apathy, flat affect)

Question 11

Typical antispychotics (high potency) produce pseudoaprkininan akinesia, including mask-like facial expressions, and reduced motivations, which are similar in appearance to core negative symptoms of schizophrenia. What is they hypothesis of endogenous negatve symptoms in schizophrenia and how typical antipsycotics contribute to them? What atypical antipsychotic also has this effect?

Answer 11

Risperidone at higher doses also produce this pseudoparkinian akinesia side-effect.

Hypothesis: deficit in frontal dopaminergic activity; typical antipsychotics further reduce frontal lobe dopaminergic activity

Question 12

What are extrapyramidal structures? What do they do?

Answer 12

Basal ganglia, caudate, substantia nigra.
Control voluntary movement outside of pyramidal tracts: restlessness/akathesia, parkinsonian gait, masked face, tardive dyskinesia, dystonia (suddent stiffening/spasm)

Question 13

Ratio of what neurotransmitters is associated with akathesia/restlessness? It’s treatment?

Ratios of what is assocaited with other EPS i.e. dystonia? Treatment?

Answer 13

Akathesia: Dopamine/NE; treat with beta blocker or benzos

Dystonia: Dopamine/Ach; treat with anti-cholinergic

Question 14

The atyipcals (i.e. olanzapine) are called “big shotgun drugs.” What are some pharmacologic differences between olanzapine and perphenazine (typical) that are thought to give olanzapine a broader spectrum of action?

Answer 14

• Olanzapine has both broader and more focused pharm effects comapred to typical agents
• broader receptor activity: 5HT-2 receptor blocker is thought to ENHANCE dopamine release in the frontal lobes, helping to reduce the negtive symptoms
• Focal effects: dopamine bockate, more targeted effects on the meso-limbic system instead of the nigro-striatial system (which is responsible for parkinson-like symptoms)

Question 15

Dysfunction of what brain region(s) can produce an apathetic clinical picture?

Answer 15

Dysfunction of the frontal lobe (where initiations of voluntary movement is)

• especially the anterior cingulate gyrus
• damage to any of the interconnected components of the cortical-striatal-thalamic-cortical loop associated with anterior cingulate gyrus are similarily produce apathetic clinical syndrome

*striatum = putamen + caudate

Question 16

worsts 2 antipsychotics for weight gain. Which drug has the least effect on wegiht?

Answer 16

Worst: olanapine and clozapine (atypicals)

Least weight gain effect: Ziprazidone and Aripripazole

Question 17

What are the characteristic symptoms in terms of diagnosis criteria for Schizophrenia?

Answer 17

• 2 or more of the following, each present for a significant portion of time during a 1-month period. Atleast one of these are item 1, 2, or 3.

1. delusions

2. hallucinations

3. disorganized speech (e.g. frequent derailment of incoherence)

4. grossly disorganized or catonic behavior (immobility)
5. negative symptoms i.e. affect flattening, avolition, alogia/no speech

Question 18

Describe the social/occupational dysfunction inherent in the diagnostic criteria for Schizophrenia

Answer 18

1+ major areas of functioning (work, interpersonal relations, self-care) are very below level their normal status before onset.

For a significant portion of the time since the onset of the disturbance

Question 19

What is the duration for diagnostic critera for Schizophrenia?

Answer 19

• Continuous signs of the disturbance for atleast 6 months
• this must include ATLEAST 1 month of symptoms and may include periods of prodromal or residual symptoms: the signs ma be only negative symptoms or two or more symptoms in Cirterion A

Question 20

How do you rule out Schizoaffective Disorder and Mood Disorder with Psychotic Features when diagnosing Schizophrenia?

Answer 20

1) no Major depressive, manic, or mixed episodes have ocured concurrently with active-phase symptoms
2) if mood episodes have occured during active-phase symptoms, their total duration has been brief relative to the duration fo the active and residual periods.

Question 21

What are two clases of meds are used for involuntary administration to the agitated and potentially violent patient? MOA and effect

Answer 21

violent: benzodiazepine

• GABAergic, calming and sedative effect
• direct effects on fear and anxiety also reduce agidation. Synergistic with antipsychotics

psychotic: Antipsychotics

• Dopamine receptor blocker- direct tranquilizing effects to reduce psychic drive
• directly reduce agitation secondary to paranoia or hallucinations
• Haloperidol- IV reduces EPS compared to IM administration, often reducing the need for co-administration of anti-cholinergics (i.e. benotropine IM)

Question 22

if pt has rapid devlopment of insight after a short period teratment fro psychosis, what does this tell you about their disease?

Answer 22

-initial hallucinations, delusions, and agitation would suggest Schizophrenia, but since the pt recovered so quickly, it is more common to think of a MEDICAL condition with psychosis and preserved intellect, such as deymyelination in patients with MS.

Question 23

What are the 5 subtypes of Schizophrenia?

Answer 23

• paranoid (delusions)
• disorganized (with regard to speech, behavior, and affect)
• cataonic (automatism-disturbance in a person’s movement. dramatic reduction of activity or dramatic increase.)
• undifferentiated (elements of all types)
• resiudal

Question 24

Pt with suspected catatonic schizophrenia is started on risperidone (atypical antipsychotic-blocks D2 eceptors and 5HT2A receptors) and now is noted to be diaphoretic, febrile, restless, agitated, increased BP, generalized muscle rigidity, increased BUN, increased CPK and WBC. What is the cause?

Answer 24

NEUROLEPTIC MALIGNANT SYNDROME: an extrapyramidal symptom / side effect from the drug

• hypodopaminergic hyperpyrexia syndrome
• situational, see big fevers, muscle rigidity and breakdown.

Question 25

What are risk factors for Neuroleptic Malignant Syndrome (NMS)? (4)

Answer 25

• dehdyration
• rapid dose escalation
• high potenecy agent
• catatonia

others include: agitation, increased ambient temp, substance withdrawal states, parenteral antispychotic, affective disorder, conrurrent treatment with lithium or TCA

Question 26

What is Rebound Neuromuscular Malignant Syndrome?

Answer 26

-seen afer rapid removal of dopaminergice agnets i.e. levodopa, amantidin, cocaine; dopamine depleting agnets (reserpine), or non-antipsychotic dopamine receptor antagonists

Question 27

How do you treat neuroleptic malignant syndrome?

immediate, spportive, for extreme cases

Answer 27

Immediate: stop neuroleptic risperidone (or whatever drug was administered)

Supportive: IV fluids to flush out kidneys, maintain high urine output to protect against renal damage, cooling blankets, monitor vital signs, antipyretics (fever reducing)

Extreme: Bromocriptine (direct dopamine agonist), Dantrolene (interferes with sarcoplasmic reticulum calcium channels to block muscle rigidity and heat production),

Question 28

Why do you think you see muscle rigidity in neuroleptic malignant syndrome?

Answer 28

you are low in dopamine (because youre on an antipsychotic that blocks D2 receptors), so you get parkinsoninan like effects!