psychoses and schizophrenia

Question 1

what is the most common psychotic disorder

Answer 1

schizophrenia

Question 2

symptoms of psychosis and schizophrenia are usually divided into …

Answer 2

positive symptoms e.g. hallucinations, delusions
negative symptoms e.g. emotional apathy, social withdrawal

Question 3

typically patients will present with prodromal period which is characterised by

Answer 3

deterioration in personal functioning and emergence of negative symptoms

Question 4

what type of symptoms do you get in the prodromal phase

Answer 4

negative e.g. emotional apathy, social withdrawal

Question 5

what is the prodromal phase followed by

Answer 5

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

Question 6

will treatment get rid of symptoms

Answer 6

positive symptoms may resolve or reduce following treatment
in some cases negative symptoms can remain and interfere with daily functioning

Question 7

what is the initial aim of treatment

Answer 7

reduce acute phase symptoms (this is when there is marked positive symptoms) and return pt to their baseline level of functioning

Question 8

once treated does schizophrenia go

Answer 8

many pt who have one episode will go on to have further episodes and generally require maintenance antipsychotics to prevent relapses

Question 9

in which phase of schizophrenia are antipsychotics effective in

Answer 9

acute episodes - more effecting at alleviating positive than negative symptoms

Question 10

which type of symptoms are antipsychotics more effective at alleviating

Answer 10

positive e.g. hallucinations, delusions

Question 11

what needs to be offered to all pt with schizophrenia (2)

Answer 11

oral antipsychotic drug + psychological therapy

Question 12

choice of antipsychotic drug depends on …

Answer 12

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

Question 13

what is akathisia

Answer 13

inability to remain still
sense of inner restlessness

Question 14

how long should a pt receive an antipsychotic before it is deemed ineffective?

Answer 14

4-6 weeks at an optimum dose

Question 15

prescribing more than one antipsychotic at a time should be avoided except in exceptional circumstances e.g.

Answer 15

clozapine augmentation
changing medication during titration

Question 16

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….

Answer 16

increased risk of adverse effects e.g. extrapyramidal, QT interval prolongation, sudden cardiac death

Question 17

when should clozapine be offered

Answer 17

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)

Question 18

what to do if symptoms do not respond adequately to an optimised dose of clozapine

Answer 18

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

Question 19

check plasma clozapine conc before adding a second antipsychotic to augment clozapine and allow …. weeks treatment to assess response

Answer 19

8-10 weeks

Question 20

in which pt may you consider long acting depot injectable antipsychotic drugs

Answer 20

pt with psychosis and schizo where it is a clinical priority to avoid non adherence

Question 21

how do the 1st gen (conventional, typical) antipsychotics work & what are the typical SE

Answer 21

predominantly by blocking D2 receipts in the brain
more likely to cause a range of SE, esp acute extrapyramidal symptoms and hyperprolactinaemia

Question 22

which generation of antipsychotics are more likely to cause hyperprolactinaemia and acute extrapyramidal symptoms

Answer 22

1st gen

Question 23

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)

Answer 23

1st gen

Question 24

sulpiride is 1st gen or 2nd gen

Answer 24

1st

Question 25

phenothiazine derivatives (-promizine, -phenzine, -azine) are 1st gen or 2nd gen

Answer 25

1st

Question 26

benperidol and haloperidol are 1st gen or 2nd gen

Answer 26

1st

Question 27

pimozide is 1st gen or 2nd gen

Answer 27

1st

Question 28

2nd gen (atyical) antipsychotics work in this way…
and their side effects include …

Answer 28

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

Question 29

which gen of antipsychotics are associated with weight gain and glucose intolerance

Answer 29

2nd gen

Question 30

what is tardive dyskinesia

Answer 30

involuntary movements of the jaw and face

Question 31

which gen of antipsychotics are the following drugs : amisulpride, aripiprazole, asenapine, cariprazine, clozapine, lurasidone hydrochloride, olanzapine, paliperidone, quetiapine, and risperidone.

Answer 31

2nd gen

Question 32

olanzapine is 1st gen or 2nd gen

Answer 32

2nd

Question 33

amisulpride is 1st gen or 2nd gen

Answer 33

2nd

Question 34

aripiprazole is 1st gen or 2nd gen

Answer 34

2nd

Question 35

lurasidone is 1st gen or 2nd gen

Answer 35

2nd

Question 36

clozapine is 1st gen or 2nd gen

Answer 36

2nd gen

Question 37

quetiapine is 1st gen or 2nd gen

Answer 37

2nd

Question 38

risperidone is 1st gen or 2nd gen

Answer 38

2nd

Question 39

define high dose antipsychotic

Answer 39

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.

Question 40

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

Answer 40

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

Question 41

how often to monitor a patient when prescribing an antipsychotic for admin in emergency e.g. for rapid tranquilisation

Answer 41

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

Question 42

are high doses of antipyschotics more effective than standard doses for treatment of schizo

Answer 42

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

Question 43

use of antipsychotics in elderly patients with dementia

Answer 43

• 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)

Question 44

how often do you need to review use of antipsychotics in elderly pt with dementia

Answer 44

regularly every 6 weeks, earlier for in-pt

Question 45

prescribing antipsychotics in pt with learning diabilities

Answer 45

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