psychosis + schizophrenia

Question 1

what is the most common psychotic disorder

Answer 1

schizophrenia

Question 2

name some “positive” symptoms of schizophrenia

Answer 2

hallucinations and delusions,

Question 3

name some “negative” symptoms of schizophrenia

Answer 3

emotional apathy (lack of motivation, emotion) and social withdrawal

Question 4

what is the aim of treatment in schizophrenia

Answer 4

To reduce acute phase symptoms and return patient to baseline level of functioning. During the acute phase, patients get “positive” symptoms (hallucinations + delusions)

*note in some cases, “negative” symptoms can remain as part of daily life despite treatment. “negative symptoms= emotional apathy + social withdrawal”

Question 5

how long should a schizophrenia patient be on antipsychotics before you deem it as ineffective

Answer 5

patient should be taking the antipsychotic drug at an optimum dose for 4–6 weeks before it is deemed ineffective

Question 6

what is the treatment for schizophrenia

Answer 6

An oral antipsychotic drug + psychological therapy

• choice of antipsychotic is a trial for each individual patient. there is no first-line choice
• doses should be started low and slowly titrated up to the minimum effective dose according to patient response and tolerability
• note choice of drug depends on: factors such as the potential to cause extrapyramidal symptoms (including akathisia), cardiovascular adverse effects, metabolic adverse effects (including weight gain and diabetes), hormonal adverse effects (including increase in prolactin concentration), and patient and carer preference*

Question 7

why should you only prescribe one antipsychotic drug at a time in schizophrenia

Answer 7

more than one antipsychotic increases risk of:

• adverse effects such as extrapyramidal symptoms
• QT-interval prolongation
• sudden cardiac death

note in exceptional circumstances e.g changing medication during titration, patient may on on more than one antipsychotics

Question 8

when would you treat a patient with Clozapine for schizophrenia

Answer 8

if schizophrenia is not controlled despite the sequential use of at least 2 different antipsychotic drugs (one of which should be a second-generation antipsychotic drug). Patients must be registered with a clozapine patient monitoring service.

Question 9

how do first-generation antipsychotics (typicals) work

name some examples of first generation antipsychotics

Answer 9

first generation antipsychotics also known as typicals/conventional. They block dopamine D2 receptors in the brain

examples:
- phenothiazine derivatives: prochlorperazine, promazine hydrochloride, chlorpromazine

• butyrophenones: benperidol and haloperidol
• Note: it is thought that in schizophrenia some dopamine pathways are overactive which cause positive symptoms. so blocking dopamine receptors, reduces hyperactivity of d2 dopamine receptors, so less/no positive symptoms*

Question 10

which class of antipsychotics are more likely to cause acute extrapyramidal symptoms and hyperprolactinemia as adverse effects

Answer 10

• first-generation antipsychotic drugs (also known as typical or conventional) more likely to cause this than second generation antipsychotics (also known as atypical)
• extrapyramidal symptoms are dose-related so more likely to occur at higher doses

first generation antipsychotics likely to cause these: fluphenazine decanoate, trifluoperazine, benperidol and haloperidol

Question 11

how do second generation antipsychotics (atypicals) work

name some examples of second generation antipsychotics

Answer 11

second-generation antipsychotic drugs (also referred to as atypical) act on a range of receptors

examples: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, and risperidone

Question 12

which class of antipsychotics can cause weight gain and glucose intolerance as a side effect

Answer 12

second-generation antipsychotic drugs (also referred to as atypical)

Question 13

are high dose antipsychotics more effective than standard dose in schizophrenia

Answer 13

no robust evidence that high doses of antipsychotic drug treatment is any more effective than standard doses. higher dose= higher risk of adverse effects

note a high dose antipsychotic is when the total daily dose of a single antipsychotic drug is more than the maximum licensed dose for that indication + for that patients age. if 2 or more antipsychotics are being used, a high dose is a higher dose than the licensed maximum using the percentage method

Question 14

what are the risks of using antipsychotics in elderly patients with dementia (mhra warning)

Answer 14

increased risk of:
 - mortality
-  stroke
-  transient ischaemic attack
elderly patients are also at higher risk of postural hypotension.

Question 15

describe how antipsychotics should be prescribed in elderly patients

Answer 15

• Do not use antipsychotics in elderly patients with dementia, unless they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress
• The lowest effective dose should be used for the shortest period of time.
• Treatment should be reviewed regularly; at least every 6 weeks (earlier for in-patients

Question 16

name the 4 types of Extrapyramidal symptoms patients can experience as a side effect of some antipsychotics

Answer 16

• parkinsonian symptoms (including bradykinesia, tremor)
• dystonia (uncontrolled muscle spasm in any part of the body
• akathisia (restlessness) which can occur within hours to weeks. may be mistaken for psychotic agitation
• tardive dyskinesia (abnormal involuntary movements of lips, tongue, face, and jaw). in some patients it can be irreversible
• note these symptoms are dose-related and are most likely to occur with high doses of high-potency first-generation antipsychotic drugs*

Question 17

what should you do if a patient develops parkinsonian symptoms or Tardive dyskinesia as part of extrapyramidal symptoms from antipsychotic

Answer 17

• review treatment and reduce the dose.
• any changes to dose or drug should be made gradually, over weeks or months, to minimise the risk of withdrawal tardive dyskinesia

Question 18

which classes of antipsychotics can cause Hyperprolactinemia

what are the symptoms of Hyperprolactinemia

Answer 18

• both first + second generation antipsychotics can cause this as they all increase prolactin secretion to some extent. (first-generation - typicals more likely)

symptoms of hyperprolactinemia:

• sexual dysfunction
• reduced bone mineral density
• menstrual disturbances
• breast enlargement
• galactorrhoea (milky nipple discharge that is not normal breast milk)
• possible increased risk of breast cancer.

Question 19

name the antipsychotic that decreases prolactin concentration unlike other antipsychotics which can cause hyperprolactinemia

Answer 19

Aripiprazole

Question 20

seuxal dysfuntion is a side effect of all antipsychotics. Name some antipsychotics that have the highest risk for this and the lowest risk

Answer 20

risk of causing sexual dysfunction:

• highest: Risperidone, haloperidol, and olanzapine
• lowest: aripiprazole and quetiapine.

Question 21

what cardiovascular side effects are associated with antipsychotics

Answer 21

• tachycardia, arrhythmias, and hypotension

- QT-interval prolongation is a particular concern with pimozide.

Question 22

what increases the risk of a patient having QT-interval prolongation as a side effects from antipsychotics

Answer 22

• any intravenous antipsychotic drug

- or any antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.

Question 23

which antipsychotic drug has the highest risk of causing QT-interval prolongation as a side effect

Answer 23

pimozide

Question 24

postural hypotension is a common side effect of antipsychotics. which class of antipsychotics are most likely to cause this

Answer 24

second-generation antipsychotics (atypicals) particularly clozapine and quetiapine

• Slow dose titration is commonly used to minimise postural hypotension.

Question 25

The risk of diabetes is increased in all patients with schizophrenia who take antipsychotic drugs. which antipsychotics have the lowest risk of this

Answer 25

overall second generation antipsychotics (atypicals) more likely to cause this than first-generation (typicals).

• lowest risk first-generation: fluphenazine decanoate and haloperidol
• lowest risk second-generation: Amisulpride and aripiprazole

Question 26

All antipsychotic drugs may cause weight gain but risk and extent varies. Name 2 antipsychotics that commonly cause weight gain

Answer 26

Clozapine and olanzapine

Question 27

what should you do if a patient experiences Neuroleptic malignant syndrome (a potential side effect of all antipsychotics)

what are the symptoms of Neuroleptic malignant syndrome

Answer 27

• discontinue the antipsychotic drug for at least 5 days, preferably longer until symptoms stop completely

symptoms of Neuroleptic malignant syndrome:

• hyperthermia
• fluctuating level of consciousness
• muscle rigidity,
• fever/ sweating
• tachycardia
• labile blood pressure (fluctuating blood pressure)

Question 28

what monitoring should occur for all antipsychotics

Answer 28

• weight
• Fasting blood glucose, HbA1c
• Blood pressure
• ECG may be required, particularly if physical examination identifies cardiovascular risk factors (e.g. high blood pressure)
• full blood count + electrolytes
• liver function test

note all of these should be done at the start of therapy, then after 6/12 weeks, then annually

Question 29

when would you use long-acting depot injections in patients with psychosis or schizophrenia

Answer 29

Use long-acting depot injections:
- in patients who prefer it after an acute episode
or
- where avoiding non-adherence to antipsychotic medication is a clinical priority.