psychoses and schizophrenia Flashcards
what is the most common psychotic disorder
schizophrenia
symptoms of psychosis and schizophrenia are usually divided into …
positive symptoms e.g. hallucinations, delusions
negative symptoms e.g. emotional apathy, social withdrawal
typically patients will present with prodromal period which is characterised by
deterioration in personal functioning and emergence of negative symptoms
what type of symptoms do you get in the prodromal phase
negative e.g. emotional apathy, social withdrawal
what is the prodromal phase followed by
acute phase marked by positive symptoms e.g. hallucinations and delusions
these may resolve or reduce following treatment, but in some cases negative symptoms can remain and interfere with daily functioning
will treatment get rid of symptoms
positive symptoms may resolve or reduce following treatment
in some cases negative symptoms can remain and interfere with daily functioning
what is the initial aim of treatment
reduce acute phase symptoms (this is when there is marked positive symptoms) and return pt to their baseline level of functioning
once treated does schizophrenia go
many pt who have one episode will go on to have further episodes and generally require maintenance antipsychotics to prevent relapses
in which phase of schizophrenia are antipsychotics effective in
acute episodes - more effecting at alleviating positive than negative symptoms
which type of symptoms are antipsychotics more effective at alleviating
positive e.g. hallucinations, delusions
what needs to be offered to all pt with schizophrenia (2)
oral antipsychotic drug + psychological therapy
choice of antipsychotic drug depends on …
pt/carer choice
potential to cause extrapyramidal symptoms e.g. akathisia
CV adverse effects
metabolic adverse effects e.g. weight gain and diabetes
hormonal adverse effects e.g. increase in prolactin conc
what is akathisia
inability to remain still
sense of inner restlessness
how long should a pt receive an antipsychotic before it is deemed ineffective?
4-6 weeks at an optimum dose
prescribing more than one antipsychotic at a time should be avoided except in exceptional circumstances e.g.
clozapine augmentation
changing medication during titration
prescribing more than one antipsychotic at a time should be avoided except in exceptional circumstances e.g. clozapine augmentation or changing medication during titration because….
increased risk of adverse effects e.g. extrapyramidal, QT interval prolongation, sudden cardiac death
when should clozapine be offered
if schizo is not controlled despite sequential use of at least 2 different antipsychotics (one of which has to be a 2nd gen), each for adequate duration (i.e. 4-6 weeks at optimum dose before considered ineffective)
what to do if symptoms do not respond adequately to an optimised dose of clozapine
consider other causes of non response e.g. adherences concurrent use of other drugs
review diagnosis
check plasma-clozapine conc before adding a second antipsychotic to augment clozapine; allow 8-10 weeks treatment to assess response
check plasma clozapine conc before adding a second antipsychotic to augment clozapine and allow …. weeks treatment to assess response
8-10 weeks
in which pt may you consider long acting depot injectable antipsychotic drugs
pt with psychosis and schizo where it is a clinical priority to avoid non adherence
how do the 1st gen (conventional, typical) antipsychotics work & what are the typical SE
predominantly by blocking D2 receipts in the brain
more likely to cause a range of SE, esp acute extrapyramidal symptoms and hyperprolactinaemia
which generation of antipsychotics are more likely to cause hyperprolactinaemia and acute extrapyramidal symptoms
1st gen
Which gen of antipsychotics consists of the following drugs PHENOTHIAZINE derivatives (chlorpromazine hydrochloride, fluphenazine decanoate, levomepromazine, pericyazine, prochlorperazine, promazine hydrochloride, and trifluoperazine), the BUTYROPHENONES (benperidol and haloperidol), the THIOXANTHENES (flupentixol and zuclopenthixol), the DIPHENYLBUTYLPEPERIDINES (pimozide) and the SUBSTITUTED BENZAMIDES (sulpiride)
1st gen
sulpiride is 1st gen or 2nd gen
1st
phenothiazine derivatives (-promizine, -phenzine, -azine) are 1st gen or 2nd gen
1st
benperidol and haloperidol are 1st gen or 2nd gen
1st
pimozide is 1st gen or 2nd gen
1st
2nd gen (atyical) antipsychotics work in this way…
and their side effects include …
act on a range of receptors in comparison to 1st gen (which primarily act on D2 receptors in brain)
generally associated with lower risk for acute extrapyramidol symptoms and tardiv dyskinesia - extent varies between individiual durgs
however they are associated with other adverse effects e.g. weight gain, glucose intolerance
which gen of antipsychotics are associated with weight gain and glucose intolerance
2nd gen
what is tardive dyskinesia
involuntary movements of the jaw and face
which gen of antipsychotics are the following drugs : amisulpride, aripiprazole, asenapine, cariprazine, clozapine, lurasidone hydrochloride, olanzapine, paliperidone, quetiapine, and risperidone.
2nd gen
olanzapine is 1st gen or 2nd gen
2nd
amisulpride is 1st gen or 2nd gen
2nd
aripiprazole is 1st gen or 2nd gen
2nd
lurasidone is 1st gen or 2nd gen
2nd
clozapine is 1st gen or 2nd gen
2nd gen
quetiapine is 1st gen or 2nd gen
2nd
risperidone is 1st gen or 2nd gen
2nd
define high dose antipsychotic
total daily dose of a single antipsychotic drug which exceeds the maximum licensed dose with respect to the age of the patient and the indication being treated, and a total daily dose of two or more antipsychotic drugs which exceeds the maximum licensed dose using the percentage method.
when prescribing an antipsychotic drug for admin in an emergency situation e.g. rapid tranquilisation, what is the aim of treatment and how should the inital rx be written
to calm and sedate the pt without inducing sleep
inital rx should be written as a single dose and not repeated until effects of inital dose have been reviewed
precribe oral and IM drugs seperately
how often to monitor a patient when prescribing an antipsychotic for admin in emergency e.g. for rapid tranquilisation
monitor for SE and vital signs atleast every hour until no further concerns about physical health status
monitor every 15 mins if high dose antipsychotic
are high doses of antipyschotics more effective than standard doses for treatment of schizo
no robust evidence to show that they are any more effect than standard doses
majority of adverse effects are dose related
clear evidence for greater SE burden with high dose
use of antipsychotics in elderly patients with dementia
- associated with small increased risk of stroke or TIA
- also susceptible to postural hypotension
- do not use in elderly with dementia unless at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing severe distress
- lowest effective dose for shortest period of time
- review regularly, at least every 6 weeks (early for in pt)
how often do you need to review use of antipsychotics in elderly pt with dementia
regularly every 6 weeks, earlier for in-pt
prescribing antipsychotics in pt with learning diabilities
if not experiencing psychotic symptoms, take the following considerations into account
- reduction in dose of discontinuation of long term antipsychotic treatment
- reveiw condition after dose reduction or discontinuation
- referral to psychiatrist experienced in working with pt with learning diabilities and mental health
- annual documentation of reasons for continuing rx if antipsychotic drug is not reduced in dose or discontinued
