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Autonomic Nervous System > Psychosis > Flashcards

Psychosis Flashcards

1
Q

Definition

A

Clinical state of mind characterised by loss of contact with reality

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2
Q

Clinical signs

A

Patients might experience perceptual disturbances e.g. hallucinations that are generally auditory as well as disturbances of thought content i.e. delusions
Negative symptoms- blunting of affect, avolition, alogia
Social or occupational dysfunction
clear sensorium

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3
Q

Delirium with acute confusion and aggression - clinical signs

A

Impaired awareness, confusion, disorientation

Others : restlessness, agitation and hallucinations, ANS symptoms, aggressiveness etc

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4
Q

Causes of delirium can be due to

A

DIMTOP (drugs, infection, metabolic, trauma, oxygen, psychological)

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5
Q

Pathogenesis of psychosis

A

UNKNOWN
Dopamine hypothesis of schizophrenia
Excessive dopaminergic activity

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6
Q

Neuroanatomy of psychosis

A

Mesolimbic-mesocortical - behaviour
Nigrostrial-coordination of voluntary movement
Tuberoinfindibular-inhibition of prolactin secretion

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7
Q

Causes of psychosis

A

Functional psychosis (Schizophrenia, Bipolar mood disorder)

Psychotic disorders due to medical conditions (Medical conditions e.g. epilepsy, Alzheimer’s dementia, HIV, neurosyphilis and Drugs - Illicit drugs –cannabis, mandrax, cocaine, amphetamines; prescription drugs- steroids, antiparkinsonism drugs, atropine)

Other- e.g. postpartum psychosis

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8
Q

Management depends on…

A

Aetiology

Onset of the psychosis

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9
Q

Acute management (agitated or acutely disturbed pt)

A

Goals of therapy is to calm pt down and achieve containment

Antipsychotic and/or benzodiazepine of your choice

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10
Q

Chronic management

A

Goal of therapy is to prevent relapse of acute psychotic symptoms i.e. delusions, hallucination so as to maintain functionality
Antipsychotic drugs
Supportive psychotherapy for patient and family

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11
Q

Classes of classical neuroleptics

A

Dopamine 2 receptor antagonists

Tendency to cause extrapyramidal side effects

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12
Q

Classes of atypical neuroleptics

A

D2 & D3 receptor antagonists

D2 & serotonin receptor antagonist

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13
Q

Primary indications for neuroleptics

A

Schizophrenia
Mania
Organic psychosis

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14
Q

Other indications for neuroleptics

A 
Nausea and vomiting
Intractable hiccups
Tourette’s syndrome
Behaviour disorders
Anaesthesia
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15
Q

name 3 classes of Traditional neuroleptics

A

Phenothiazines (side chain)
Butyrophenones
Thioxanthenes

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16
Q

3 classe of phenothiazines and examples of each

A

Aliphatic e.g. chlorpromazine
Piperazine e.g. prochloperazine, fluphenazine
Piperidine e.g. thioridazine*, pericyazine

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17
Q

name 2 examples of Butyrophenones

A

Haloperidol, droperidol

18
Q

name 2 examples of thioxanthenes

A

Flupenthixol, zuclopenthixol

19
Q

Formulations

A

oral
Injectables- usually IM (Short acting- acute management; long acting depot preparations- preferred if compliance a problem)

20
Q

MOA of typical antipsychotics

A

Blocks D2 and D1, preventing dopamine-receptor interaction

21
Q

MOA of adverse effects of typical antipsychotics

A

Blocks H1 and 5-HT2 receptors

22
Q

MOA of atypical antipsychotics

A

block D1

23
Q

MOA of adverse effects atypical antipsychotics

A

Block 5-HT2 and alpha adrenergic receptors

24
Q

Oldest neuroleptic of low potency

A

Chlorpromazine (Piperazine phenothiazine)

25
Q

Indications for chlorpromazine

A

Schizophrenia
Mania
Organic psychosis etc
Tranquillization in emergency aggressive behavioural disturbances

26
Q

Onset of action of Chlorpromazine

A

Onset 30-60min after oral ingestion and 15min after injection

27
Q

Half-life of Chlorpromazine

A

30 hrs

28
Q

Contraindications for Chlorpromazine

A

coma, severe mental depression, severe liver impairment, significant cardiac disorders, glaucoma, bone marrow depression

29
Q

Adverse effects of chlorpromazine

A

EPSEs, sedation, postural hypotension, anticholinergic side effects, epileptogenic, photosensitivity ,jaundice, agranulocytosis

30
Q

Drug interactions Chlorpromazine

A

anticholinergics, antiepileptics, antihypertensives, antiparkinsonism drugs, CNS depressants , enzyme inducers

31
Q

Doses: Chlorpromazine

A

initially 25mg tds but maintenance range 75-300mg.
IM 25-50mg ,can be repeated 3-4 times in 24hrs as necessary
USE THE LOWEST EFFECTIVE DOSE

32
Q

EPSE-complications of antipsychotics

A 
Acute dystonic reaction
Parkinsonism
akathisia
Tardive dyskinesia
Neuroleptic malignant syndrome
33
Q

Explain acute dystonic reaction

A

Acute dystonic reaction- spasm of muscles of tongue, face, neck, and back (torticollis, protrusion of the tongue, facial grimacing, oculogyric crisis, opisthotonus, truncal dystonia and laryngeal spasm) vs seizure
Onset 24-48hrs
Risk factor- young male
Rx –biperiden 2mg IM/IV, benzodiazepine if necessary, if c/o pain analgesia
Stop neuroleptic until symptoms full resolution

34
Q

Explain parkinsonism

A

Parkinsonism –bradykinesia, rigidity, tremor
Onset-weeks or months
Common in older pts
Rx - reduce dose- lowest effective dose
Prescribe anticholinergic orphenadrine 50-150mg

35
Q

Explain akathisia

A

Akathisia-motor restlessness vs anxiety
Onset days-weeks
Rx - Reduce dose, Add anticholinergic if necessary

36
Q

Explain tardive dyskinesia

A

Tardive dyskinesia- syndrome of choreoathetoid and or other involuntary movements, usually of face, lips and tongue +/- arms legs and trunk

Onset-usually >6/12
MOA-? Excess dopamine
Rx- PREVENTION N.B. lowest effective dose for the shortest time - Gradually withdraw , Consider changing to atypical antipsychotics (less tendency for EPSEs)

37
Q

explain Neuroleptic malignant syndrome

A

Neuroleptic malignant syndrome-Rare BUT mortality >10%
Aetiology unknown-?dopamine blockade in hypothalamus
Onset –usually weeks but can occur after 1st dose
Risk- ↑ambient temp, dehydration, intercurrent mildly febrile illness, catatonia

Presents with
-Hyperpyrexia
-Sweating
-Unstable blood pressure
-Changes in LOC (stupor or catatonia like state)
-Muscle rigidity
Lasts 5-7 days, longer if depot prep used

38
Q

Advantages and disadvantage of atypical neuroleptics & uses

A

Newer and expensive
Less EPSEs (not devoid of EPSEs), prolactin effects, ↑weight gain
Clozapine EDL- reserved for treatment resistant psychosis
Major s/e agranulocytosis & neutropenia
Associated with QT prolongation

39
Q

Special populations

A

Pregnancy or lactation

  • No randomised controlled trials
  • All neuroleptics cross the placenta
  • Phenothiazines are excreted in breast milk-behavioural changes in infants

Children
- Use only if necessary as EPSEs can occur after first dose

Elderly
- More susceptible to cardiovascular side effects and anticholinergic side effects

Hepatic diseases
- dose adjustment may be needed

40
Q

Causes of treatment failure

A

Low efficacy rate!!!!! 40-60%
Inter and intraindividual variability
Under dosing- lowest EFFECTIVE dose
Malabsorption- change to depot preparation
Drug interactions
Wrong diagnosis- Rx underlying cause e.g. brain tumours
Non-compliance
- Lack of insight-consider depot preparation vs tablets
- Adverse effects- consider changing classes

Autonomic Nervous System (5 decks)

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