Psychosis Flashcards
What is schizophrenia?
delusions, hallucinations, blunted affect for >6 months and >1 month of at least 2 sx
(Can’t distinguish what is real)
What is psychosis?
gross impairment of reality= delusions, hallucinations without awareness of the patient
Is schizophrenia psychosis?
Schizophrenia can cause psychosis
What is considered treatment resistant schizophrenia?
no improvement despite >2 AP from 2 different classes for 6-8 weeks
What is difference between schizophreniform and schizophrenia?
Schizophreniform does not need social functional impairment and only up to 6 months
What is schizoaffective?
> 2 weeks of delusions without mood sx and periods of manic or depressive
What is duration of brief psychotic disorder?
1 day to 1 month
What is delusional disorder?
hallucinations not prominent, and function is only mildly impaired
What time period could a substance be blamed for psychosis?
within 1 month of use or withdrawal
Why do people with schizophrenia die on average earlier?
stop taking care of themselves, substance use, CVD, suicide
How does schizophrenia happen>
issues with dopamine amounts
dopamine can be influenced by serotonin, GABA and glutamate
Typically, at what age does schizophrenia often present?
15-35
What legal substance increases risk of psychosis?
cannabis use
Why do schizophrenia patients tend to smoke?
intensifies cravings for tobacco
What generally happens with blocking dopamine at each pathway?
mesolimbic- relief of (+) sx (desire, pleasure, motivation)
Nigrostriatal- EPS (movement disorders)
Mesocortical (midbrain to frontal cortex)- treats (-) sx, worse communication and social function
tuberoinfundibulnar- weight gain, ED, hyperprolactemia, osteoporosis
What are some prodromal features of schizophrenia?
not very social, not involved, bizarre ideas, preoccupation with religion, don’t like to be touched
What are positive sx of schizophrenia?
(new sx)
hallucination, paranoia, delusions, bizarre behaviour, catatonia
What are negative sx of schizophrenia?
(loss of sx)
loss of emotion, motivation, poor self care, alogia
What are the four sx clusters of schizophrenia?
Positive, negative, cognitive and mood
What are cognitive sx of schizophrenia?
memory impair, can’t concentrate
What are the mood sx of schizophrenia?
depressive, mania
What is catatonia?
no speak, rigid movements, mimicing
Why do schizo patients love smoking? and why is it an issue?
cravings- cant refrain
smoking induces metabolism of clazapine and olanzapine
What does nigrostriatal tract do in schizophrenics?
motor coordination
What does the mesolimbic tract do in schizophrenics?
positive sx due to D excess
What does the mesocortical tract do in schizophrenics?
cognitive, emotion, social function (lower)
What does the tuberoinfundibular tract do in schizophrenics?
prolactin
What happens to the nigrostriatal tract if we use dopamine-blocking drugs?
EPS
What happens to the mesolimbic tract if we use dopamine-blocking drugs?
relief of positive sx
What happens to the mesocortical tract if we use dopamine-blocking drugs?
akathsia and treatment of negative sx= increase dopamine here= 5HT
D2 action is WORSENING of - sx
What happens to the tuberoinfundibular tract if we use dopamine-blocking drugs?
hyperprolactinemia, osteoporosis, sex dfx
What drugs can induce psychosis?
stimulant use/withdrawal, caffeine, cannabis, steroids, ketamine, bupropion, alcohol
How do first generation AP work?
D2 antagonism
How do second gen AP work?
D2 antagonism
5HT 2A/2C anatgonism
How do third gen AP work?
D2 PARTIAL antagonism
5HT 2A antagonism
5HT 1A/2C agonism
For 1st gen AP what is their limiting s/e?
EPS
For 2nd gen AP, what is their limiting s/e?
metabolic
For 3rd gen AP what is their limiting s/e?
akathisia
What is THE most effective AP?
clozapine
True or false 1st gen AP are less efficacious than 2nd gen?
FALSE all the same efficacy
Which receptor is for positive sx and negative?
+= D2
-= 5HT
Difference between acute dystonia and tardive?
Acute= grimace, neck spasm
tardive= mouth spasm,
What are the 1st gen AP?
Haloperidol, fluphenazine, perphenazine, flupenthixol, chlorpromazine, methotrimeprazine
In regards to s/e how is risperidone unique?
NO anticholinergic
BUT
bad prolactin/ sex dfx
Is EPS related to dose?
OBVIOUSLY especially at 8 mg
Which 2nd gen has worst prolactin?
risperidone
Which 2nd gen has worst sex dfx?
risperidone
IN regards to palperidone what is unique?
metabolite of risperidone
MORE insomnia
less weight gain COMPARED to risperidone
WHy is olanzapine not used much?
WEIGHT GAIN, dizziness, smoking issues
Why is the use of quetiapine so low?
T2DM and dislipidemia
Which 2nd gens NEED food to be administered?
ziprasidone, lurasidone
Why do we titrate ziprasidone so fast?
overcome hypomanic s/e
What 2nd gen is weight neutral?
ziprasidone
What 2nd gen has highest risk of QT prolongation?
ziprasidone
Which agent does not have good evidence for schizophrenia?
asenapine
What is the weird s/e of asenapine?
mouth numbness
What agent has highest level of akathisia?
aripiprazole
What is the goldilocks principle?
for aripiprazole because it is a partial antagonist and may stabilize dopamine
What is good about brexipirazole?
less akathisia
What are the 3rd gen AP?
prazoles, and cariprazine
In regards to affinity what is special about cariprazine?
lower D2 which may be more helpful for cognitive sx and more D3
What are the half lives of 3rd gens?
SUPER long like 3-4 days
What is the evidence surrounding cariprazine?
not enough evidence,
Which generation is the go to for psychosis?
2nd generation
What happens to the brain during a psychotic episode?
LOSE brain matter
When should long acting injectables be used?
if relapse or issues with adherence
If switching to injections what must we check?
oral overlap periods
What are the injectable options?
aripiprazole, paliperidone, risperidone
What monitoring is needed for AP use?
vitals, behaviours, CBC, LFT, ECG
What is duration of therapy?
18 months but usually lifelong as relapse rate is incredibly high
What is an adequate trial of an antispychotic?
4-6 weeks
What is the response rate of clozapine?
30%
Why is it useful as a switch option if people get EPS?
works in parkinsons as well
S/e of clozapine?
constipation, blurred vission, dizzy, drowsy, weight gain, metabolic, tachycardia, drool
What is an odd and not well understood s/e of clozapine?
drooly
Serious s/e of clozapine?
agranulocytosis, myocarditis, cardiomyopathy, constipation
How do we mitigate agranulocytosis with clozapine?
Mandatory registration in monitoring
Which CBC specifically do we need to monitor for clozapine?
ANC
How can we mitigate myocarditis/cardiomyopathy?
troponin- heart cell damage
CRP- inflammation
Given that the serious s/e of clozapine can happen at any time, when do they usually occur?
Agranulocytosis- 6 months
myocarditis- 4-6 weeks
cardiomyopathy- years
What type of reaction occurs in myocarditis?
allergic like
Can we switch brands of clozapine?
FUCK NO
Which registry will new patients be put on?
AA-Clozapine- SHA approved= AASPIRE
When do you have to retitrate clozapine?
missed doses for 2 days
Describe the frequency of lab monitoring for clozapine.
weekly for 6 months, if good,
q2weeks for 6 months, if good,
q4 for 6 months
If quitting clozapine what must the patient do?
weekly tests for 4 weeks
When must the monitoring be changed to weekly?
if missed dose for 3 days or in yellow
WHat is green ANC?
> 2
What is yellow ANC?
1.5-2
What is red ANC?
under 1.5
WHat happens if you have yellow ANC?
dispense BUT test 2x weekly until stable
What happens if in red ANC?
STOP and see ER
NEVER START AGAIN
How much clozapine can we dispense?
as much to get to next blood test
How much does smoking decrease clozapine?
40%
How long after smoking does the induction last?
1 week
True or false: Do e cigarettes also have the interaction?
NO
What is the only antipsychotic that lowers suicide risk?
clozapine
How long is an adequate trial of clozapine?
8 weeks
If clozapine not working what do we do?
No evidence for combo or switch
ECT,CBT, Trans magnetic stimulation
WHy is transmagnetic stim used?
Not much evidence but more tolerated thaan ECT
What can we do for tardive sx?
only treat not cure and preventative
What is acute dystonias?
head and neck spasms
life threatening if issues with swallow or breathing
How can we treat dystonia?
benztropine
How soon can dystonia present?
1 week
when does akathisia occur
6 weeks
How to treat akithisia?
reduce or change AP, benzo, propranolol, mirtazapine
When does pseudoparkinsons happen and how can we treat?
6 weeks
reduce or change AP
benztropine
What is pisa and rabbit syndrome?
pisa= lean
rabbit= quivering lip
What scale can we use for tardive dyskinesia?
AIMS
When does tardive dyskinesia happen?
> 3 months
Treatment for TD?
switch to clozapine or quetiapine
What agents can cause neuroleptic malignant syndrome?
ANY AP
What is neuroleptic malignant syndrome?
SEVERE rigidity, fever, confusion, elevated WBC and CK
What can we do for neuroleptic malignant syndrome?
stop AP
supportive care
bromocriptine
