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CNS Module: Exam 2 > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

When does Schizophrenia typically take effect?

A

late adolescence

Males: 15-24 years old
Females: 24-35 years old

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2
Q

What is the dysregulation hypothesis?

A

Dopamine blocking properties to treat positive sx

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3
Q

With which types of symptoms might a patient with Schizophrenia present?

A
  • positive symptoms: “added on”
  • negative symptoms: “taken away”
  • cognitive symptoms
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4
Q

What are some positive symptoms?

A

psychotic or affective | “added on”

  • hallucinations
  • sensory (auditory, visual, tactile, olfactory, gustatory)
  • delusions (fixed, false beliefs)
  • thoughts/ speech disorders: (tangential, disorganized, circumstantial)
    “thought blocking”, “word salad”
  • movement disorders (agitated, catatonic)
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5
Q

What are some negative symptoms?

A

affective | “taken away”

  • social withdrawal
  • diminished emotional expression, speech, and thought
  • depressive sx
  • poor self-care
  • sleep/appetite disturbances
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6
Q

Secondary causes of negative sx:

A
  • medications
  • mood disorders
  • social issues
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7
Q

What are the cognitive symptoms?

A

deficiencies in:

  • attention
  • processing
  • verbal/visual memory
  • working memory
  • problem solving
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8
Q

What are the likely causes of schizophrenia?

A
  • genetic
  • altered brain chemistry
  • ?
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9
Q

Comorbid medical illnesses:

A
  • T2DM
  • COPD
  • obesity
  • poor diet
  • poor sleep
  • tobacco abuse
  • drug/ETOH use
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10
Q

Comorbid psychosocial issues:

A
  • poor hygiene
  • impaired self-care
  • difficulty living independently
  • difficulty forming relationships
  • difficulty providing for themselves/ maintaining employment
  • isolation
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11
Q

What is a comprehensive assessment?

When do we use it?

A
  • physical/neurological exam
  • history
  • Labs:
    • BMP
    • UA
    • LFTs
    • Thyroid profile
    • serum pregnancy
    • syphilis serology
    • urine (for toxicology)

This is to rule out other conditions with similar presentations

Patients with symptoms of psychosis should be treated with antipsychotic monotherapy (APM)
- depression/anxiety should also be treated if indicated

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12
Q

Nonpharmacologic therapy:

A
  • psychosocial interventions*
  • social skills training
  • CBT
  • cognitive remediation
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13
Q

What do we need to do/remember when a patient’s symptoms have improved?

A

continue treatment with the SAME antipsychotic medication

this should never be switched if they are stable (insurance formularies should not change and affect this)

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14
Q

What did the CATIE trial reveal about SGA?

A

SGA may be more effective for:

  • relapse prevention
  • affective/negative sx
  • cognitive function
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15
Q

Adverse Effects | FGA

A
  • sedation
  • EPS
  • tardive dyskinesia (repetitive, involuntary movements)
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16
Q

Adverse Effects | SGA

A
  • QTC prolongation
  • Metabolic effects
    • weight gain
    • incr. blood sugar
    • DLP
    • incr. risk for DM
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17
Q

Which FGA are most likely to cause EPS?

A

Fluphenazine & Haloperidol (high risk)

trifluoperazine, thiothixene, perphenazine, loxapine (moderate)

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18
Q

Which FGA are most likely to cause sedation?

A

chlorpromazine & thioridazine (high risk)

loxapine (moderate)

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19
Q

Which FGA are most likely to cause anticholinergic side effects?

A

thioridazine > chlorpromazine

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20
Q

Which FGA are most likely to cause CV side effects?

A

chlorpromazine & thioridazine (high risk)

loxapine (moderate)

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21
Q

Which FGA are most likely to cause seizure/QTc prolongation?

A

THIORIDAZINE

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22
Q

EPS: Acute Dystonia

  1. Time of onset
  2. Risk factors
  3. S&S
  4. Management
A
  1. 24-96 hours (1-4 d) after starting or increasing dose
  2. young males & high potency FGA
  3. muscle spasms (abnorm position or spasm of head, neck, limb, and trunk muscles)
  4. IM diphenhydramine or benztropine

*treat immediately and aggressively

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23
Q

EPS: Akathisia

  1. Time of onset
  2. Risk factors
  3. S&S
  4. Management
A
  1. within months
  2. young pts & high potency FGA
  3. inner restlessness, rocking, tapping, inability to sit for long periods (“ants in your pants”)
  4. reduce dose OR switch to another antipsychotic
    (then anticholinergics (benztropine), beta-blockers (propanolol), BZD)
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24
Q

EPS: Pseudo-Parkinsonism

  1. Time of onset
  2. Risk factors
  3. S&S
  4. Management
A
  1. 1-2 weeks (higher % in elderly)
  2. older pts, females, higher doses, depressive sx
  3. presents like Parkinson’s (stooped posture, tremors, slowed movements, stiffness, mask-like facial expressions)
  4. Anticholinergics/antiparkinson’s agents OR decrease dose vs change drug

*this is NOT parkinsons, and is likely caused by the medications

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25
Q

EPS: Tardive Dyskinesia

  1. Time of onset
  2. Risk factors
  3. S&S
  4. Management
A
  1. 3+ mo of tx
  2. older pts, females, African Americans, longer duration of tx, PMH of EPS, substance abuse, mood disorders, DM
  3. Choreiform & Athetoid Movements (lip smacking, tongue protrusions, grimacing)
  4. STOP tx & switch to another antipsychotic
    (consider VMAT2, valbenazine, deutetrabenazine)
  • sx may get worse initially after switch
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26
Q

What are Choreiform movements?

A

rapid, objectively purposeless, irregular, spontaneous

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27
Q

What are Athetoid movements?

A

slow, irregular movements in face, neck, trunk, extremities

28
Q

What is Neuroleptic Malignant Syndrome (NMS)?

A

life-threatening idiosyncratic reaction to antipsychotic drugs (FGA/SGA)

29
Q

What are the sx of NMS?

How is it treated?

A

sx:

  • fever
  • mental status changes
  • muscle rigidity
  • autonomic stability

tx: supportive care, bromocriptine, dantrolene
* recognition and supportive tx are the MOST important

30
Q

What SGA are most likely to cause anticholinergic SE?

A

clozapine (SVR)

olanzapine (mod)

31
Q

What SGA are most likely to cause EPS?

A

Aripiprazole Brexpiprazole (SVR)

Risperidone, paliperidone, cariprazine (mod)

32
Q

What SGA are most likely to cause orthostatic HOTN?

A

clozapine (SVR)

risperidone, paliperidone, quetiapine, lioperidone

33
Q

What SGA are most likely to cause incr. prolactin?

A

risperidone, paliperidone (SVR)

34
Q

What SGA are most likely to cause QTc prolongation?

A

quetiapine, ziprasidone, iloperidone

35
Q

What SGA are most likely to cause sedation?

A

clozapine, quetiapine (SVR)

Iloperidone (mod)

36
Q

What SGA are most likely to cause wt gain?

A

clozapine & olanzapine (SVR)

risperidone, paliperidone (mod)

37
Q

What SGA are most likely to cause incr. glucose?

A

clozapine & olanzapine (mod)

38
Q

What SGA are most likely to cause incr. lipids?

A

clozapine & olanzapine (SVR)

quetiapine (mod)

39
Q

How do we monitor EPS?

A

Abnormal Involuntary Movement Scale (AIMs)
–> evaluate pt for any EPS sx when on APM

  • ideally it would be the same person evaluating the same patient at the same time
40
Q

What are common AE with risperidone or paliperidone tx?

A
  • higher doses increase incidence of EPS
  • hyperprolactinemia
  • amenorrhea
  • galactorrhea
  • gynecomastia
41
Q

Risk factors for QTc prolongation:

A
  • congenital QT syndrome
  • arrhythmias
  • DM
  • female gender
  • hypoK
  • hypoMg
  • hyperNa
42
Q

What are the inhibitors & inducers of CYP1A2?

A

inhibitor: fluvoxamine
inducer: cigarette smoking

43
Q

What are the inhibitors & inducers of CYP2D6?

A

inhibitors: fluoxetine, paroxetine, sertraline, bupropion
inducer: CBZ

44
Q

What are the inhibitors & inducers of CYP3A4?

A

inhibitors: erythromycin, some antifungals, protease inhibitors
inducers: barbiturates, phenytoin, rifampin, CBZ, glucocorticoids

45
Q

What are the LAI FGAs?

What are the pros & cons?

A
  • Haloperidol decanoate
  • Fluphenazine decanoate

pro: less expensive
con: high potency…EPS more likely

46
Q

What are the LAI SGAs?

What are the pros & cons?

A
  • Zyprexa Relprevv
  • Risperidal Consta
  • Abilify maintena
  • Aristada
  • Aristada Initio
  • Invega Trinza

Pros: improved adherence, less SE (even serum [ ]s)
Cons: must be administered in clinic or pharmacy (adherence issues), none of these are generically available…so EX$PEN$IVE

  • we should remember these pts are typically paranoid, and not very adherent
47
Q

Tx: adolescents

A
  1. intensive & comprehensive highly structured environments that include special ed and psycho-ed
  2. SGA if psychotic sx cause impairment or interfere

abilify, zyprexa, risperidal, invega

48
Q

Most common SE from tx in children?

A

EPS, wt gain

49
Q

Concerning SE from tx in kids?

A
  • sedation

- anticholinergic effects (effect school performance)

50
Q

Tx: elderly

A

START low and GO sloooooooow
- more vulnerable to SE

BBW: increased motality if dementia + APM
(weigh risk v benefit: may want to keep them at home and treat instead of hiring an aid or moving them to a care facility)

51
Q

Tx: substance dependence/abuse

A
  • poorer response to FGA
  • more EPS in pts abusing substances
  • more likely for NONADHERENCE
  • make sure mental health illness AND substance abuse are treated
52
Q

Tx: resistant pts

A

persistent (+) sx despite tx with 2+ different APM given at adequate doses for 4-6 wks

  • CLOZAPINE (alone or in combo)

(may also augment with FGA, SGA, mood stabilizer, or ECT)

53
Q

Key notes: Clozapine

A

treatment-resistant schizophrenia: after 2 failed tx of antipsychotic monotherapy OR severe sx + suicidality
- (also approved for treating aggression and suicidality)

BBW: agranulocytosis, myocarditis, cardiomyopathy, mitral valve incompetence, seizures

54
Q

Clozapine SE

A
  • orthostatic HOTN
  • bradycardia
  • syncope
  • sedation
  • enuresis
  • anticholinergic effects
  • metabolic syndrome
  • hyper-salivation (…lovely)
55
Q

Tx: acute psychotic pts

A

pharmacologic + psychological intervention
- IM SGA +/- IM Lorazepam
(geodon, abilify, zyprexa)

SGA preferred, but FGA (haloperidol) is acceptable

*these are the cases where the police are called and the pt is brought to the ER (danger to themselves or others), likely sedated to get them more manageable

56
Q

Tx: Pregnancy & Lactation

A

high potency FGA

(APM usually continued if risk of relapse is more detrimental to both baby and mother)
if APM tx continued:
- limb defects, dyskinesias
- risk for EPS & withdrawal in newborns (3rd TRIMESTER)

relapse: increases stress on infant and increases risk of complications (growth abnormalities & disabilities)

57
Q

Do high or low potency FGA if used in pregnancy have a higher risk of limb defects & dyskinesias?

A

low potency FGA = higher risk

58
Q

Schizophrenia + pregnancy have an increased risk of:

A
  • stillbirth
  • infant death
  • preterm delivery
  • low birth weight
  • small for gestational age

lack of prenatal care; higher rates of smoking while pregnant :(((

59
Q

Which drugs do we actually want to use in pregnancy & lactation?

A

Clozapine & lurasidone (B)

higher potency FGAs (and all others lol) (C)

60
Q

Metabolic syndrome

A

3+ of the following:

  • waist circumference (M > 40 in | F > 35 in)
  • HDL (M < 40 mg/dL | F < 35 mg/dL)
  • TGLs 150+ mg/dL (or on meds)
  • BP > 130/85 (or on meds)
  • FBG > 100 mg/dL (or on meds)
61
Q

Medication classes causing: QTc prolongation

A
  • antiarrhythmic agents
  • FGAs
  • antibiotics
  • antidepressants
62
Q

Medication classes causing: sedation

A
  • sleep aids
  • antihistamines
  • pain meds
  • antidepressants
  • anticonvulsants
  • BZDs
63
Q

Medication classes causing: HOTN

A
  • antihypertensives
  • pn meds
  • antidepressants
  • BZDs
64
Q

Medication classes causing: anticholinergic effects

A
  • anticholinergics
  • antihistamines
  • antidepressants
65
Q

Medication classes causing: wt gain/ metabolic abnormalities

A
  • antidepressants

- anticonvulsants

66
Q

ANC Level & Tx recommendation

A

1500+/uL —> required for tx initiation

<500/uL —> interrupt tx, don’t restart unless benefits outweigh risk (severe neutropenia)

CNS Module: Exam 2 (8 decks)

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