Psychosis Flashcards
Define what schizophrenia is.
6 or more mths in length of 1 or more mths accompanied by 2 or more of these symptoms:
-Delusions
-Hallucinations
-Disorganized Speech / Behaviors
-Negative Sx (ie. Blunted Affect, Less Spoken Words, Absence of Pleasure, No Motivation)
Describe what psychosis is.
Impaired sense of reality in the absence of patient awareness
Define what TRS is.
No sx improvement in spite of trialing two or more APs (from two different classes).
How is Schizophreniform Disorder (SPD) similar to full blown Schizophrenia?
1 - 6mths of same symptoms, but social / occupational function is not compromised (is in Schizophrenia).
How does Schizoaffective Disorder (SAD) differ from Bipolar?
Social / Occupational function is not impaired in spite of psychotic symptoms being present.
How does a Brief Psychotic Disorder (BPD) differ from Schizophreniform Disorder (SPD)?
BPD lasts less than a month, with a return to premorbid function (if it persists beyond 1mth or impairs function, then consider it SPD).
Which illicit street drug shows the highest rates of Substance-Induced Psychosis (SIP) development?
Crystal Meth
How might a patient with Delusional Disorder present (in comparison to somebody with a schizo-type disorder)?
1 or more months of delusions, but hallucinations are not prominent & behavior is not evidently bizarre (function is only mildly impaired).
Does schizophrenia affect women more than men?
Nope (equal distribution).
What are some of the more prevalent comorbidities seen in those with schizophrenia?
Obesity / Diabetes
CVD
Suicide
Smokers (60 - 90%)
What are some of the barriers that prevent schizophrenic patients from adhering to their medications?
-Reduced AP motivational drive
-Side effects
-Stigma
-$$$
-Ethnic Minority
The key theory underlying pathophysiologic progression of Schizophrenia is ______ dysregulation.
Dopamine
What other NTs play a role in Schizophrenia?
Serotonin, GABA, Glutamate dysregulation
Dopamine blockade at the level of the Nigrostriatal pathway leads to the patient experiencing what types of symptoms?
EPS (ie. Movement Disorders)
Dopamine blockade within the Mesolimbic pathway blunts what experiences?
Positive Symptoms (ie. Pleasure / Reward, Desires, Motivational Behaviors)
Dopamine blockade within the Mesocortical pathway leads to what?
Akathisia (unable to remain still, “ants in pants” feeling)
The most common types of hallucinations experienced by schizophrenic patients are _____ & ______ in nature.
visual, auditory
What are the more common catatonic presentations of schizophrenic patients?
-Sudden onset, waxy muscle rigidity & mutism (most common); sometimes excessive motor activity w/o obvious cause.
-Echoing speech also common.
Leading cause of premature death in those with schizophrenia is _______.
suicide
CYP1A2 hyperactivation in those who smoke alters the effectiveness of what two agents used to treat schizophrenia?
Olanzapine, Clozapine
What three interesting patient groups should be screened for schizophrenia as they are considered to be “high risk”?
Syphilis, Hep C, HIV
What agents predominantly bring upon psychosis?
Pro-Dopamine agents
-Amphetamines / Cocaine
-Bupropion
-Caffeine
-Cannabis
-Chloroquine
-Efavirenz
-Ketamine
-Steroids
What are considered to be the five major antipsychotic receptor targets?
A1
D2
H1
Muscarinic
5-HT2A
2nd Gen APs are more commonly associated with what types of adverse effects?
Metabolic
1st Gen APs are more commonly associated with what types of adverse effects?
Movement (EPS)
3rd Gen APs are more commonly associated with what unique side effect?
Akathisia
How does Serotonin 2A / 2C antagonism improve negative schizophrenic symptoms?
Increases Dopamine release in Mesocortical Pathway.
D2 antagonism improves positive symptoms of schizophrenia, but causes what types of adverse effects?
-EPS
-Elevated Prolactin (boob development, abnormal periods, osteoporosis)
-Sexual Dysfunction
Alpha 1 / 2 antagonism causes what types of adverse effects?
-Postural Hypotension
-Dizzy
-Reflex Tachycardia
-Drooling
Muscarinic antagonism causes what types of adverse effects?
-Dry Mouth
-Constipation
-Blurry Vision
-Urinary Retention
-Confusion / Memory Disturbances
Haloperidol is a FGA that has pronounced ___ receptor antagonistic activity.
D2
Risperidone is a SGA that has ______, ___, & _____ adrenergic receptor activity.
5-HT2, D2, Alpha-Adrenergic
Aripiprazole is a Third-Gen AP that has partial agonist activity at ______ / ___ receptors, as well as antagonistic activity at _____ receptors.
Agonist: 5-HT1A, D2
Antagonist: 5-HT2A
Clozapine has most distinctive activity at ___, _______, ____, & ____ receptors.
D4, 5-HT2A, A1, M1
Chlorpromazine & Methotrimeprazine are considered _____ (high or low) potency FGAs.
low
Low potency FGAs are more commonly associated with what types of side effects?
Anticholinergic
High potency FGAs (ie. Haloperidol, Fluphenazine, Perphenazine, Flupenthixol) are more commonly associated with what types of side effects?
Movement Disorders
Daily Risperidone doses of above ___ mg/day show greater rates of EPS.
6mg/day
Which SGA demonstrates the highest rates of prolactin production increases, sexual dysfunction & EPS?
Risperidone
Significant CYP2D6 DDI with Risperidone users that can bring upon EPS signs?
Fluoxetine
What SGA is actually the active metabolite of Risperidone?
Paliperidone
Are the following side effects more or less experienced by those on Paliperidone (compared to Risperidone):
Orthostatic Hypo
Insomnia
Wt Gain
Sexual Dysfunction
OH: Less
Insomnia: More
Wt Gain: Less
Sex Dys: Similar
Big issues with Olanzapine (compared to other SGAs)?
-Wt Gain (»>)
-AC / Muscarinic SEs
-Metabolic Disorders
-Smoking (sig. interaction)
In what indication type would we see the highest Quetiapine dose being given:
Antidepressant
Hypnotic
Antipsychotic
Antipsychotic
What becomes an increased risk at higher Quetiapine doses?
Diabetes / Dyslipidemia
Unique administration instructions for those on Ziprasidone?
Give with lots of food (>/= 500kcal in order to max out absorption).
Benefits of Ziprasidone compared to other SGAs? Contraindications?
Benefits: Much less metabolic side effect experiences.
C/Is: QT Prolongation, Recent MI, Concurrent QT Prolonging Drugs.
Unique side effects of Asenapine?
Mouth Numbness x 1hr post-doses
Admin instructions / benefits to Lurasidone use over other SGAs?
TWF (350 kcal), less metabolic concerns.
Third Gen APs demonstrate greater rates of what side effect compared to other classes?
Akathisia (Aripiprazole worst in its class, Brexipiprazole slightly better).
On what receptors is Aripiprazole a partial agonist? Antagonist?
PA: 5HT1A / D2
Antagonist: 5HT2A
Because of its long t1/2, we cannot increase Aripiprazole doses more frequently than q__ wks.
2wks
How often is an IM Aripiprazole injection given?
q4wks (requires 2wks po overlap)
Is Aripiprazole more activating or sedating in nature?
More activating (typically)
Does Aripiprazole have pronounced effects on wt gain?
Minimal
Which third gen AP has a longer t1/2: Aripiprazole or Brexipiprazole?
Brexipiprazole
Does Cariprazine have a higher or lower affinity for D2 receptors than Ari & Brexi?
Lower
At low doses, Cariprazine has a _____ (higher / lower) affinity for D3 receptors than it does D2 receptors.
higher
What benefit does Cariprazine’s high D3 affinity at lower doses have?
Potentially better treatment of negative Schizophrenia symptoms.
In terms of binding affinity, a lower Ki value means a drug has _____ (higher / lower) affinity.
Higher (inverse relationship between number & strength of affinity).
Benefits of using LAIAs over po agents for treating Schizophrenia?
-Reduced relapse risk
-Reduced hospitalizations
-Reduced caregiver burden
-Improved adherence
The Canadian Schizophrenic Guidelines endorse maintenance AP therapies for at least what length of time?
2yrs
What is the minimum treatment duration for First Episode Psychosis (FEP)?
18mths
What is the first line agent for TRS?
Clozapine
Clozapine acts upon what receptors?
D1 / D2 / D4
5HT2A
A1
M1
Common Clozapine side effects?
-Constipation
-Blurry Vision
-Dizzy / Drowsy
-Drooling
-Wt Gain
-Incr. Chol / Sugars
-OH / Ref Tachy
Serious Clozapine side effects?
-Decr. WBCs
-Myocarditis
-Cardiomyopathy
-Constipation
-Seizures
-NMS
Agranulocytosis is most likely to occur with Clozapine usage within the first ____ mths of treatment.
6
Myocarditis is most likely to occur with Clozapine usage within the first __ - __ wks of treatment.
4 - 8wks
How is myocarditis monitored for with Clozapine users?
CRP / Troponin qwkly x first 6wks of starting drug
What are some objective signs a recently started Clozapine patient might be experiencing myocarditis / cardiomyopathies?
-Orthostatic BP changes
-Fatigued / Decr. Exercise Tolerance
-Chest Pains
-Palpitations w Incr. HR
-SOB
-Peripheral Edema
-Fever
What is unique about Clozapine’s CBC?
Is a differential (measures amount of each specific type of WBC).
What WBC Ct is particularly important when monitoring Clozapine?
Absolute Neutrophil Count (ANC)
My patient is registered with AA-Clozapine. Can I dispense another brand of Clozapine for them in the situation of a backorder?
Nooooo
145 / 187
bleh
