Schizophrenia

Question 1

A 20-year-old man presents to the psychiatric emergency center with hallucinations and delusions. On exam, he demonstrates blunted affect, apathy, and circumstantiality. Chart review shows that he has had symptoms for at least six months. Toxicology screen is negative. He is diagnosed with schizophrenia. Which of the following is the best treatment for the management of this acute psychotic episode?

Answer 1

Risparidone or Olanzopine

Question 2

What is the treatment for akathisia (motor restlessness with a compelling urge to move and inability to sit still)?

What class of medications carries the side effect of akathisia?

Answer 2

Benzodiazepines, such as lorazepam

First-generation antipsychotics such as haliparadol

Question 3

What are the positive symptoms associated with schizophrenia?

Answer 3

• Hallucinations: auditory most common, visual, gustatory, tactile, olfactory, or somatic
• Delusions: firm, fixed beliefs despite evidence to the contrary
• Disorganized speech: thoughts are diconnected and tangential rambling
• Behavioral disturbances

Question 4

What are the negative symptoms associated with schizophrenia?

Answer 4

These symptoms “take away” from normal behavior
* Absence of normal cognition
* Affect flattening
* Alogia: poverty of speech, increased latency of response
* Avolition: “lack of will” poor hygiene, grooming
* Anhedonia: lack of interest in stimulating activities (i.e. sex)
* Asociality: failure to engage with others socially, socially withdrawn

Question 5

Although not required for diagnosis, what will be seen on imaging in somone with schizophrenia?

Answer 5

CT Scan: ventricular enlargement (lateral and third) as well as decreased cortical volume and grey matter

PET Scan: hypoactive frontal lobes, hyperactivity in the basal ganglion

Question 6

Which symptom of schizoaffective disorder is a fixed false belief an example of?

Answer 6

Delusion

Question 7

A 24-year-old man presents to the psychiatry clinic with auditory hallucinations and delusions for the past seven months. On exam, the psychiatrist notes disorganized speech and alogia. He is diagnosed with schizophrenia and started on a first-generation antipsychotic. What is the mechanism of action of this medication?

Answer 7

Antipsychotics are dopamine antagonists

First-generation block D2 receptors

Question 8

A 24-year-old man is diagnosed with schizophrenia and is admitted to an inpatient psychiatric facility. He is treated with intramuscular haloperidol. While he is being treated, he describes a sensation of inner restlessness and an inability to sit still. Which common adverse effect of first-generation antipsychotics is he experiencing?

Answer 8

Akathesia (or inability to sit still)

Question 9

What adverse effect limits the use of clozapine?

Answer 9

Agranulocytosis

Question 10

What are the common adverse effects of first-generation antipsychotics?

Answer 10

Extrapyramidal side effects (akathisia, rigidity, bradykinesia, tremor, acute dystonia) and tardive dyskinesia

Question 11

What is the disposition of a patient in acute psycosis?

Answer 11

**Hospital Admission **

Haloperidol, Risperidone, or Paliperidone can be used in acute psychosis. If extremely agitated, IM injection of Ziprasidone, Olanzapine, or Aripiprazole may be used.

Urine tox should be ordered to rule out substance abuse.

Question 12

Which second-generation antipsychotic is known to cause fever, myocarditis, and agranulocytosis?

Answer 12

Clozapine

Question 13

What is the best drug for medication-refractory schizophrenia?

This drug is not typically used first line due to concerns of what?

Answer 13

Clozapine

Myocarditis and agranulocytosis

Question 14

What antipsychotic is known to have a lower incidence of movement disorders and therefore typically used first-line in treatment of schizophrenia?

What antipsychotic has the highest risk of movement disorders?

Answer 14

Quetiapine

Risperidone

Question 15

A 32-year-old woman with no significant medical history and a recent diagnosis of schizophrenia presents to the clinic for a follow-up appointment. She has been taking her medication as prescribed for the past 3 months and has not been experiencing hallucinations or delusions. Vital signs include a heart rate of 65 bpm, blood pressure of 125/78 mm Hg, respiratory rate of 16/minute, oxygen saturation of 98% on room air, and temperature of 98.7°F. Which of the following laboratory values should be monitored in this patient?

A. Creatinine
B. Fasting glucose
C. Hemoglobin
D. Thyroid-stimulating hormone

What should be monitored in patients taking second gen antipsychotics?

Answer 15

Fasting Glucose

weight, waist circumference, BP, fasting glucose, and fasting lipids

Question 16

A 20-year-old man with a history of psychosis treated with haloperidol decanoate 400 mg monthly and olanzapine 20 mg nightly presents to the clinic for a follow-up. During his last visit 4 weeks ago, nightly olanzapine was increased from 10 mg to 20 mg. He has experienced weight gain and daytime sleepiness since the increase, and he continues to hear distressing auditory hallucinations daily. He has been unable to work since beginning treatment 1 year prior and no longer socializes with friends or family. Vital signs include a weight of 200 lbs, height of 70 in, heart rate of 90 bpm, blood pressure of 130/86 mm Hg, respiratory rate of 18/min, oxygen saturation of 97% on room air, and temperature of 97.4°F. Mental status exam reveals increased body habitus, constricted affect, and intact sensorium. Physical exam reveals a regular heart rate and rhythm and clear lung fields. You appropriately change this patient’s medication to the best next pharmacologic agent. Which of the following is required for routine monitoring of the recommended treatment?

A. Baseline echocardiogram
B. Monthly serum drug level
C. Risk Evaluation and Mitigation Strategy enrollment
D. Weekly heart rate monitoring

Answer 16

Risk Evaluation and Mitigation Strategy Enrollmemt

Question 17

What class of medication can cause neuroleptic malignant syndrome?

What are common symptoms?

Answer 17

Antipsychotics

Fever, AMS, muscel rigidity, tachycardia, and hypertension

Question 18

A 35-year-old man with a history of schizophrenia presents to the emergency department with fever, altered mental status, and muscle rigidity. He is tachycardic and hypertensive. On examination, he exhibits profuse diaphoresis and hyperthermia. His current medication regimen includes an antipsychotic medication. What is the most likely diagnosis?

A) Neuroleptic malignant syndrome
B) Serotonin syndrome
C) Anticholinergic toxicity
D) Acute dystonic reaction

Answer 18

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening adverse reaction to antipsychotic medications. It is characterized by fever, altered mental status, muscle rigidity, autonomic dysfunction (such as tachycardia and hypertension), and elevated creatine kinase levels. The patient’s symptoms of fever, altered mental status, muscle rigidity, tachycardia, and hypertension are consistent with NMS.

Question 19

What is a common lab abnormality caused by neuroleptic malignant syndrome?

Answer 19

Elevated creatine kinase levels