Psychosis Flashcards
Positive symptoms
- Too much DA in mesolimbic (ventral tegmentum to limbic) system
Negative symptoms
- Too little DA in mesocortical (ventral tegmentum to cortex)
- Flat affect, alogia, avolition, apathy
- More debilitating re social/occupational
Movement symptoms (Parkinsonian rigidity, bradykinesia, tremors; akathisia, dystonia spasms)
- DA hypoactivity (too little DA to suppress ACh) in nigrostriatal (substantia nigra to basal ganglia)
Hyperprolactinemia SE of antipsychotics
- Too little DA to regulate prolactic release in tuberoinfundibular pathway (hypothalamus to anterior pituitary)
Typical antipsychotics
- D2 receptor blockers
- High potency (EPS): Fluphenazine, Haloperidol, Pimozide
- Low potency (cardiotoxic and anticholinergic): Chlorpromazine, Thioridazine
- 3-5% per year TD, highest in women with affective d/o
- Dystonia highest in young males
Atypical antipsychotics
- SDAs (serotonin-dopamine 2 blockers)
Risperidone (Risperdal)
- More like a typical at doses >6mg daily
- EPS
- Most likely atypical to induce hyperprolactinemia
- Wt gain, sedation dose-dep
Olanzapine (Zyrexa)
- Wt gain, hyperTG, hyperChol, hyperGlycemia, hyperProlactinemia (less than risperidone), Transaminitis in 2%
Quetiapine (Seroquel)
- Most likely to cause orthostatic hypotension
- Wt gain, hyperTG, hyperChol, hyperGlycemia (less than olanzapine)
- Transaminitis in 6%
Ziprasidone (Geodon)
- NO WT GAIN
- QT prolongation
- Hyperprolactinemia (less than risperidone)
- Up to 100% absorption with food
Aripiprazole (Abilify)
- Unique MoA as D2 partial agonist
- NO WT GAIN
- Low EPS, no QT prolong, low sedation
- 2D6 (fluoxetine, paroxetine), 3A4 (carbamazepine, ketoconazole) interactions warrant adj dosing. Potential intolerability d/t akathisia/activation
Clozapine (Clozaril)
- Reserved d/t SE profile
- Agranulocyosis requires weekly blood draws for 6 months, then 12wks for 6 months
- Seizures (esp with lithium)
- Assoc with the most sedation, wt gain, transaminitis
- HyperTG, hyperChol, hyperGly, nonketotic hyperosmolar coma and death
Iloperidone (Fanapt)
- Titrate over 4 days d/t orthostatic hypotension
- BID dosing
- Low EPS, akathisia, wt gain, metabolic d/o
- Inh 2D6 (fluox, parox) and 3A4 (keto, CMZ), can increase blood levels 2x!
- QT prolongation
- Not for hepatic illness
Asenapine (Saphris)
- No titration needed
- BID dosing. SubL
- Sedation, somnolence, akathisia
- Low wt gain and metabolic d/o
- Inh 1A2
- Not for hepatic illness
Lurasidone (Latuda)
- Once daily, no titration
- No QT prolong, less wt gain and metabolic d/o
- Must take with food
- Akathisia, sedation
- Limit to 40mg with renal or hepatic illness
- C/I with 3A4 inhibitor/inducer
Man with schizophrenia presents with muscle rigidity, fever, AMS, orthostatic hypoT. Found to have leukocytosis, CPK, LFTs elevated.
- NMS
Man with schizophrenia presents with acute dystonia, Parkinson syndrome, akathisia.
- EPS. Due to lack of DA inhibition of ACh in nigrostriatal pathway (SN to BG).
- Tx with anticholinergic such as benztropine, trihexyphenidyl, diphenhydramine. DA facilitator Amantadine. BB propranolol.
- Watch for anticholinergic SE if on TCA.
21M admitted for psychosis. Treatment naive. What baseline blood work prior to starting an antipsychotic?
- Fasting lipids, glucose, LFTs, CBC
- If he has high cholesterol, consider using Aripiprazole, Risperidone, or Ziprasidone. (No Quetiapine or Olanzapine)
- Risperidone 3mg BID -> “uncomfortable in my skin like I can’t sit still” = akathisia = increased suicide risk! Tx with anticholinergic or propranolol.
29W presents to ED by police after screaming at Starbucks and threw coffee at barista. “I need to be taken to jail. I contaminated someone with a virus.” WBC 11.2, K 3.2, negative Utox, fully oriented, no LOC.
MDD with psychotic features
Brief psychotic episode
- Delusion/halluc/disorg speech/disorg or catatonic behavior for < 1 month with eventual return to previous functioning
Personality disorders that look like psychosis
Borderline (think they hear people talking trash), paranoid, schizotypal, OCD
Substance induced psychosis
Need to resolve within a month of sobriety (including marijuana). Except for methamphetamine, which can last longer. Otherwise primary psychosis.
Mood congruent delusions
Depression - personal inadequacy, guilt, disease, death, deserved punishment;
Mania - themes of worth, power, knowledge, special relationship to deity;
Mood incongruent - control, persecution, thought broadcasting, thought insertion
MDD with psychotic features
Must have psychosis only while depressed; 18.5% of MDD patients; tx with antidep + antipsych; ECT (especially elderly and pregnant)
ECT in MDD with and with psychotic features
95% remission in MDD with psychosis; 83% in those with just MDD
BD 1, manic or mixed, with psychotic features
Manic or mixed and exhibiting psychotic features; 25% of BD1 patients; Tx with mood stabilizer + antipsychotic; ECT if mixed or nonresponder; catatonia - tx with BZDs
Schizophrenia
> /= 2 symptoms for most of 1 month, continuous signs of disturbance for 6 months. Must have at least one of core positive (delusions, hallucinations, disorganized speech); others: disorganized or catatonic behavior, negative symptoms of flat affect, alogia, avolition, apathy; If hear two voices, only need one symptom; Must cause significant social/occupational dysfx; Affects 1-2% population; Male dx 17-27yo, Females 17-37yo; Only 10% cases after 45yo
Schizophrenia sub-types
Paranoid (most common); Disorganized; Catatonic
Genetics of schizophrenia
Proband increases prevalence of schizoid, schizotypal, schizoaffective, delusional disorder; 40-50% concordance in monozygotic twins; Other 50% unidentified environmental factors including in utero exposure
Pathophysiology of schizophrenia
Increase in normal age-associated pruning FRONTOPARIETAL SYNAPSES during adolescence and young adulthood; MESOCORTICAL and MESOLIMBIC dopamine pathways
Addiction in schizophrenia
47%; 4.6x risk; 3x for EtOH; 6x for drugs
Schizophrenia illness course
90% do not return to pre-ilness social and vocational; 10% die by suicide; 1/3 severe with repeat hospitalization; 1/3 moderate with occasional hosp; 1/3 no further hosp but residual symptoms, interpersonal diff, most cannot maintain employment
Schizoaffective disorder
- Uninterrupted period of MDE or mixed episode after schizophrenia criterion met
- Periods where delusions/halluc present for >2 wks without prominent mood symptoms
- Mood disorder criteria met for substantial portion of illness
- 0.7% prevalence
- Tx antipsychotic; If depressed type add antidep; If BD type add mood stabilizer
Substance-induced psych disorder
- Prominent halluc or delusions
- Evidence that symptoms developed within a month of intoxication or withdrawal (except meth), and substance etiologically related to disturbance
- Symptoms cannot have started prior to taking med or be more sever than could be reasonably caused by amount of substance
- Cocaine, EtOH, amphet, cannabis, LSD, PCP, NMDA, ketamine, inhalants, opioids
Psychosis d/t GMC
- Brain tumor, seizure, delirium, HD, MS, Cushing’s, Vitamin def, ‘Lyte abnormality, thyroid, uremia, SLE, HIV, wellbutrin, steroids, antimalarials
Delusional Disorders
- Delusion of at least 1 month, not schizophrenia, functional, no mood or substance, non-bizarre(?);
- 0.03% prevalence; mean 40yo; females 1.2-1.6>1;
- Subtypes: erotomanic, grandiose, persecutory, jealous, somatic, mixed;
- Tx: generally resistant. If parasitosis delusion, antipsych; therapeutic alignment with non-confrontational approach; focus on reducing the stress
Psychosis NOS
- No other criteria met
