Schizophrenia Flashcards
organic disorder
eplielpsy
cerebral lesions
nervous system illness: infection, GC
endocrine disorders
metabolic disorders/physiological disturbances altering nervous system
IATROGENIC
PSYCHOSIS RELATED TO ALCOHOL/PSYCHOACTIVE SUBSTANCE MISUSE
parkinson disease
dementia
affective
mania
psychotic depression
post-partum depression
schizophrenia
psychosis sx
what is the primary pathophysiology of schizophrenia
dysfunction in DA, 5HT & glutamatergic function
what can precipitate schizophrenia?
drug, substance use
what can prolong course of disorder?
non adherence
DSM-5 criteria
2 or more of the following for at least 1 month:
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized/catatonic behaviour
5. negative symptoms
social/occupational dysfunction
duration: continuous, at least 6 months
schizoaffective/mood disorder excluded
exclude other medical conditions and substance use
non-pharm?
individual CBT
neurostimulation: electroconvulsive therapy (ECT), reptitive transcranial magnetic stimulation (rTMS)
psycosocial rehabilitation programs
pharm treatment goal for acute stabilization?
minimize threat to self & others
minimize acute symptoms
(improve role functioning, identify appropriate psychosocial interventions, collab w fam & caregivers)
pharm treatment goal for stabilization
minimize/prevent relapse
promote medical adherence
optimize dose & manage adverse effects
pharm treatment goal for maintenance
improve function & QoL
(maintain baseline functioing, optimise dose vs adverse effects, monitor for prodromal Sx of relapse, monitor & manage adverse effects
antipsychotics?
generally tranquilize without impairing consciousness & without causing paradoxical excitement
in short term, they are useful to calm disturbed patients
common indication for antipsychotics
schizophrenia
adjunct for MDD (esp SGA)
short term adjunctive management of severe anxiety/psychomotor agitation, violent behaviour
mania
what happens if you block dopamine receptors in mesolimbic tract?
improve +ve symptoms
overactivity in this region responsible for +ve symptoms in schizophrenia
what happens if you block dopamine receptors in mesocortical tract
cause/worsen -ve symptoms
hypofunction in this region results in -ve symptoms
what happens if you block dopamine receptors in nigrostriatal pathway
EPSE
tract modulates body movement
what happens if you block dopamine receptors in tuberoinfundibular tract
hyperprolactinemia
in anterior pituitary
affinity to D2 receptors? (antagonism)
improve +ve symptoms
causes EPSE, hyperprolactinemia
5HT1A receptor agonism?
anxiolytic
5HT2A receptor antagonism?
improve -ve symptoms
5HT2c receptor antagonism?
weight gain
H1 receptor antagonism?
sedation, weight gain
a1 adrenoreceptor antagonism
orthostatic hypotension, sedation
M1 receptor antagonism
dry mouth, blurred vision, constipation
IKr antagonism
QTc prolongation
when do you consider clozapine?
treatment resistant - those that had fail 2 or more adequate trial of different antipsychotics (at least 1 should be SGA)
long acting IM injection?
risperidone microspheres
haloperidol decanoate
aripiparazole LAI
paliperidone prolonged, release suspension
precautions for antipsychotic use includes?
CVD: QTc prolongation, ECG monitoring
parkinson disease: cause EPSE
epilepsy, conditions predisposing to seizures
depression
myasthenia gravias
acute angle glaucoma
severe respiratory disease
prostatic hypertrophy
blood dyscrasia - esp clozapine
hx of jaundice
elderly with dementia
what to do during aucte agitation?
pt cooperative –> PO lorazepam 1-2mg
pr uncooperative –> IM lorazepem 1-2mg/IM olanzapine/IM aripiparazole/IM haloperidol/ IM promethazine
if patient is catatonic?
bezondiazepine: PO/IM lorazepem
what are the antipsychotic that require divided doses?
chlorpromazine
clozapine
quetapine
sulpride
amisulpride
siprasidone
FGA?
chlorpromazine
sulpride
trifluoperazine
perphenazine
haloperiodl
SGA?
amisulpride
brexpiparazole
cariprazine
lurasidone
paliperidone
risperidone
aripiparazole
clozapine
quetapine
olanzapine
which should be administer with/after food to increase bioavailability?
lurasidone, ziprasidone
EPSE SE?
dystonia, pseudo-parkinsonism, akathisa, tardive dyskinesia
dystonia how manage
IM anticholinergivs
what is dystonia
muscle spasms
risk factor for dystonia?
high potenscy antipsychotic, neuroepileptic-naive, young male
management for pseudo-parkinsonism
decrease antipsychotic dose/switch to lower risk
anticholinergic PRN
what is akathisia?
EPSE, restleness, onset hr-weeks
risk factor for akathisia?
high potency anti-psychotic
risp > olanz > quet/cloz
management for akathisia
decrease antipsychotic dose/switch to SGA
clonazepam low dose PRN
proponalol 20mg tds
anticholinergic unhelpful
what is tardive dyskinesia?
ororfial movements (eg lip chewing, tongue protrusion)
irreversible
onset months to year
risk factor for tardive dyskinesia
FGS > SGA
worsen with anticholinergic drug
management for tardive dyskinesia
discont any anticholinergic
decrease antipsychotic dose/switch to SGA
Valbenazine (vestibular monoamine transporter 2 reversible inhibitor) 40-80mg/day
clonazepem PRN
which antipsychotic has higher risk for hyperprolactinaemia?
FGAs, Pali >/= Risp >other SGAs
management for hyperprolactenemia
decrease FGA dose
Dopamine agonist (e.g. amantadine,
bromocriptine)
Switch to Aripiprazole
which anti psychotic has higher risk for metabolic side effects
high : olan cloz
mod: CPZ, quiet, risp
low: aripiparazole, lura, zip, halo
management for metabolic SE
Lifestyle modification: diet, exercise
Treat diabetes (e.g. with metformin),
hyperlipidemia
Switch to lower risk agents
what is Neuroleptic malignant
syndrome (NMS):
Muscle rigidity, fever, autonomic dysfunction (increase PR, labile BP, diaphoresis), altered consciousness, increase CK
management for NMS
IV Dantrolene 50mg TDS
Oral dopamine agonist (e.g. amantadine, bromocriptine), supportive measures.
Switch to SGA
how to manage agranulocytosis?
discon antipsychotic if severe
mostly with clozapine
what are the monitoring parameter?
BMI, FBG, Lipid panel, BP, EPSE
WBC & ANC (for clozapine)
what to be caution in pregnancy?
olanzapine & clozapine watch out for gestational diabetes
what drugs for breastfeeding?
olanzapine & quetapine suitable
any pt on clozapine should cont drug & not breastfeed
what drugs for renal impairment?
Oral Aripiprazole preferred; Avoid sulpiride and Amisulpride
what drugs for hepatic impairment?
Sulpiride, Amisulpride preferred.
what to caution in elderly?
Avoid drugs with high propensity for alpha-1 adrenergic blockade
(orthostatic hypotension) or anticholinergic side effects (constipation,
urinary retention, delirium); start low go slow; simplify regime ; avoid
adverse interactions; avoid long T ½ drugs
Precaution: FGAs and SGAs reported to increase mortality and CVAs in dementia patients
when does agitation decrease?
in 1st week
when does paranoia & hallucinations decrease?
2-4 weeks
when does delusion & -ve symptoms improve?
6-12 weeks
when does cognitive symptoms improve?
3-6 months
