psychosis + schizophrenia Flashcards
what is the most common psychotic disorder
schizophrenia
name some “positive” symptoms of schizophrenia
hallucinations and delusions,
name some “negative” symptoms of schizophrenia
emotional apathy (lack of motivation, emotion) and social withdrawal
what is the aim of treatment in schizophrenia
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”
how long should a schizophrenia patient be on antipsychotics before you deem it as ineffective
patient should be taking the antipsychotic drug at an optimum dose for 4–6 weeks before it is deemed ineffective
what is the treatment for schizophrenia
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*
why should you only prescribe one antipsychotic drug at a time in schizophrenia
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
when would you treat a patient with Clozapine for schizophrenia
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.
how do first-generation antipsychotics (typicals) work
name some examples of first generation antipsychotics
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*
which class of antipsychotics are more likely to cause acute extrapyramidal symptoms and hyperprolactinemia as adverse effects
- 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
how do second generation antipsychotics (atypicals) work
name some examples of second generation antipsychotics
second-generation antipsychotic drugs (also referred to as atypical) act on a range of receptors
examples: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, and risperidone
which class of antipsychotics can cause weight gain and glucose intolerance as a side effect
second-generation antipsychotic drugs (also referred to as atypical)
are high dose antipsychotics more effective than standard dose in schizophrenia
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
what are the risks of using antipsychotics in elderly patients with dementia (mhra warning)
increased risk of: - mortality - stroke - transient ischaemic attack elderly patients are also at higher risk of postural hypotension.
describe how antipsychotics should be prescribed in elderly patients
- 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
name the 4 types of Extrapyramidal symptoms patients can experience as a side effect of some antipsychotics
- 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*
what should you do if a patient develops parkinsonian symptoms or Tardive dyskinesia as part of extrapyramidal symptoms from antipsychotic
- 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
which classes of antipsychotics can cause Hyperprolactinemia
what are the symptoms of Hyperprolactinemia
- 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.
name the antipsychotic that decreases prolactin concentration unlike other antipsychotics which can cause hyperprolactinemia
Aripiprazole
seuxal dysfuntion is a side effect of all antipsychotics. Name some antipsychotics that have the highest risk for this and the lowest risk
risk of causing sexual dysfunction:
- highest: Risperidone, haloperidol, and olanzapine
- lowest: aripiprazole and quetiapine.
what cardiovascular side effects are associated with antipsychotics
- tachycardia, arrhythmias, and hypotension
- QT-interval prolongation is a particular concern with pimozide.
what increases the risk of a patient having QT-interval prolongation as a side effects from antipsychotics
- any intravenous antipsychotic drug
- or any antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.
which antipsychotic drug has the highest risk of causing QT-interval prolongation as a side effect
pimozide
postural hypotension is a common side effect of antipsychotics. which class of antipsychotics are most likely to cause this
second-generation antipsychotics (atypicals) particularly clozapine and quetiapine
- Slow dose titration is commonly used to minimise postural hypotension.
The risk of diabetes is increased in all patients with schizophrenia who take antipsychotic drugs. which antipsychotics have the lowest risk of this
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
All antipsychotic drugs may cause weight gain but risk and extent varies. Name 2 antipsychotics that commonly cause weight gain
Clozapine and olanzapine
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
- 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)
what monitoring should occur for all antipsychotics
- 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
when would you use long-acting depot injections in patients with psychosis or schizophrenia
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.
