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Clinical Pharmacology & Applied Therapeutics > Psychosis > Flashcards

Psychosis Flashcards

1
Q

State the definition of psychosis.

A

Clinical state of mind characterised by loss of contact with reality. Patients might experience perceptual disturbances (e.g. hallucinations, delusions).
Negative symptoms -blunting of affect, avolition, alogia.
Social or occupational dysfunction.
Clear sensorium

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2
Q

What is the difference between hallucinations and delusions?

A

Delusions are fixed unshakeable beliefs.
Hallucinations are perceptions without adequate stimuli.

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3
Q

What are the symptoms of delirium?

A

Medical emergency
Impaired awareness, confusion, disorientation

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

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4
Q

List the causes of delirium.

A

DIMTOP

Drugs, Infections, Metabolic, Trauma, Oxygen, Psychological

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5
Q

Explain the pathogenesis of psychosis.

A

Dopamine hypothesis of schizophrenia - excessive dopaminergic activity.

Increased dopamine activity at mesolimbic pathway: leads to positive symptoms (hallucinations, delusions, thought disorders)

Nigrostrial pathway: often affect by antipsychotic treatment which can lead to motor side effects (Parkinsonism)

Tuberinfundibular pathway: involved in regulation of prolactin secretion (dopamine blockage can lead to hyperprolactinemia as side effect)

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6
Q

What are the causes of psychosis?

A

Functional psychosis
- schizophrenia
-bipolar mood disorder

Psychotic disorders due to medial conditions
- medical conditions (epilepsy, Alzheimer’s dementia, HIV, neurosyphilis)
- illicit drugs (cannabis, mantras, cocaine, amphetamines)
-prescription (steroids, antiparkinsonism, atropine)

Other
- postpartum psychosis

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7
Q

Outline the approach to management of psychosis.

A

Depends on aetiology and onset of psychosis.

Acute:
- goals of therapy is to clam the patient down and achieve containment
-antipsychotic and/or benzodiazepine

Chronic:
- goals of therapy is to prevent relapse of acute psychotic symptoms
- antipsychotic drugs & supportive psychotherapy for patient and family

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8
Q

Name the two main classes of neuroleptics? And what is there mechanism of action?

A

Classical neuroleptics
- dopamine 2 receptor antagonists
- tendency to cause extra pyramidal side effects

Atypical neuroleptics
- D2 and D3 receptor antagonists
- D2 and serotonin receptor antagonist

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9
Q

What are the indications for neuroleptics?

A

Primary:
- schizophrenia, mania, organic psychosis

Others:
- nausea + vomiting, intractable hiccups, Tourette’s syndrome, behaviour disorders, anaesthesia

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10
Q

Name of the different classes (with examples) of traditional neuroleptics.

A

Phenothiazines
- alipathic (chlorpromazine)
- piperazine (fluphenazine, prochloperazine)
- piperidine (thioridazine)

Butyrophenones
- haloperidol, droperidol

Thioxanthenes
- flupenthixol, zuclopenthixol

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11
Q

In which cases is the short acting vs long acting depot preparations injectable performed?

A

Short acting - acute management

Long acting - preferred if compliance is a problem

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12
Q

List the indications for using chlorpromazine.

A

Schizophrenia
Mania
Organic psychosis
Transquilization in emergency aggressive behavioural disturbances

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13
Q

What are the contraindications of chlorpromazine?

A

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

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14
Q

Name the oldest neuroleptic of low potency.

A

Chlorpromazine

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15
Q

What are the adverse effects of chlorpromazine?

A

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

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16
Q

Which drug classes does chlorpromazine have drug interactions with?

A

Anticholinergics
Anti-epileptics
Anti hypertensives
Anti Parkinsonism
CNS depressants
Enzyme inducers

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17
Q

What is onset of action in chlorpromazine? Also mention their half life. `

A

Onset 30-60 hours after oral ingestion and 15min after injections

18
Q

At what doses should chlorpromazine be taken?

A

Initially 25mg TDS but maintenance range 75-300mg
IM 25-50mg be respected 3-4 times in 24 hours as necessary

19
Q

Name a very potent antipsychotic drug.

A

Haloperidol

20
Q

In which patients is haloperidol contraindicated?

A

In Parkinson’s and patient with history of EPSEs from neuroleptics

21
Q

What are the adverse effects of haloperidol?

A

Less anticholinergic, hypotensive, least epileptogenic but increased risk of EPSEs

22
Q

Which drug does haloperidol have drug interactions with?

A

Lithium -neurotoxicity

23
Q

What are the adult doses of haloperidol ?

A

Initially 0.5 - 5mg 2-3 times daily then reduce to lowest effective dose. Usual maintenance dose is 2-10mg daily

24
Q

Describe the onset of action of haloperidol . Also mention its half life.

A

Onset of action - 10 minutes after IM injection
Max 4-6 hours after oral ingestion.
Half life 13-35 hours. Metabolised in liver extensively

25
Q

Name an atypical neuroleptic.

A

Clozapine

26
Q

Indication for clozapine?

A

Resistant psychosis

27
Q

Contraindication in clozapine?

A

In history of drug induced agranulocytosis.

28
Q

What are the adverse effects of clozapine?

A

Weight gain,
Agranulocytosis
Neutropenia
Sedation
Postural hypotension
Anticholinergic

29
Q

What are the adult doses for clozapine?

A

12.5 - 25mg daily then increase to therapeutic levels in 2 - 3 weeks.

30
Q

List the complications of EPSEs.

A

Acute dystopia reaction - spasm of uncles of tongue, face, neck and back
Onset 25-48 hours
Risk factor (young male)

31
Q

List the complications of Parkinsonism.

A

Bradykinesia, rigidity, tremor
Onset: weeks or moths
Common in older patients

32
Q

List the complications of akathisia.

A

Motor restlessness vs anxiety
Onset: days - weeks

33
Q

What is the treatment for the complication of EPSEs?

A

Biperiden 2mg IM/IV,
Benzodiazepine if necessary
(f complains of pain (analgesia)

Stop neuroleptic until symptoms full resolution

34
Q

What is the treatment for the complication of Parkinsonism?

A

Reduce dose - lowest effective dose
Prescribe anticholinergic orphenadrine 50-150 mg

35
Q

What is the treatment for the complication of akathsia?

A

Reduce dose, add anticholinergic if necessary

36
Q

What are the risks of neuroleptic malignant syndrome?

A

Increased ambient temperature
Dehydration
Intercurrent mildly febrile illness
Catatonia

37
Q

How does neuroleptic malignant syndrome present?

A

hyperpyrexia
Sweating
Unstable BP
Changes in LOC (stupor or catatonia like state)
Muscle rigidity

38
Q

How long do the synonyms of NMS last for?

A

5-7 days, longer if depot prep used

39
Q

How do the atypical neuroleptics compare to the typical?

A

Newer + expensive
Less EPSEs, prolactin effects. Increased weight gain, associated with QT prolongation

40
Q

List the special populations which should be accounted of when prescribing?

A

Pregnancy or lactation
- all neuroleptics cross the placenta
- phenothiazoines are excreted in breast milk behavioural changes in infants

Children
- use only if necessary as EPSEs can occur after 1st dose

Elderly
- more susceptible to cardiovascular side effects +anticholinergic side effects

Hepatic diseases
- need dose adjustment

41
Q

List the causes of treatment failure.

A

Low efficiency rate (40-60%)
Inter and intra individual variability
Under dosing - lowest effective dose
Malabosrptiom
Drug interactions ‘wring diagnosis
Non compliance

42
Q

List the causes of treatment failure.

A

Low efficiency rate (40-60%)
Inter and intra individual variability
Under dosing - lowest effective dose
Malabosrptiom
Drug interactions ‘wring diagnosis
Non compliance

Clinical Pharmacology & Applied Therapeutics (3 decks)

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