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PR3136 > Treatment of Psychosis > Flashcards

Treatment of Psychosis Flashcards

1
Q

Key clinical features/symptoms of Schizophrenia (3)

A
  1. Positive symptoms
  2. Negative symptoms
  3. Functional symptoms
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2
Q

5 domains of Schizophrenia

A
  1. Positive symptoms
  2. Negative symptoms
  3. Depression/anxiety
  4. Aggression
  5. Cognitive impairment
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3
Q

Pathway for +ve symptoms

A

Mesolimbic pathway

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4
Q

Pathway for -ve symptoms

A

Mesocortical pathway

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5
Q

Pathway for EPSE

A

Nigrostriatum pathway

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6
Q

MOA of antipsychotics (2)

A
  1. D2 antagonism
    - all antipsychotics
  2. 5-HT2A antagonism
    - SGA (improve mood & negative symptoms)
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7
Q

SGA

A

Second Generation Antipsychotics

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8
Q

FGA

A

First Generation Antipsychotics

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9
Q

Clinical efficacy of FGA vs SGA

A

FGA :
- more effective for +ve symptoms

SGA :
- more effective for +ve symptoms, mood & ?-ve symptoms

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10
Q

Clinical toxicity of FGA vs SGA

A

FGA :

  • more muscle side effects (EPSE)
  • more hyperprolactinemia

SGA :

  • more metabolic side effects
  • except (5)
    1. Lurasidone
    2. Ziprasidone
    3. Aripiprazole
    4. Brexpiprazole
    5. Risperidone

LZABR

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11
Q

SGA -ines vs -ones/-piprazoles

A

-ines :
more sedation and weight gain
eg clozapine, olanzapine & quetiapine

-ones/-piprazoles :
less sedation and weight gain

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12
Q

Non-pharmacological management (4)

A
  • Cognitive Behavioural Therapy (CBT)
  • Electroconvulsant Therapy (ECT)
  • Repetitive Transcranial Magnetic Stimuation (rTMS) (less invasive)
  • Psychosocial Rehabilitation Program (individual, group & cognitive behavioural)
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13
Q

Psychosocial Rehabilitation Program

A
  1. Individual
    - supportive counselling
    - personal therapy
    - social skills therapy
    - vocational sheltered (employment and rehabilitation)
  2. Group
    - interactive/social
  3. Cognitive Behavioural
    - CBT
    - compliance therapy
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14
Q

Pharmacological treatment algorithm

A

1st line : FGA/SGA

  • 2-6 weeks
  • PO/IM

2nd line : FGA/SGA

  • 2-6 weeks
  • PO/IM

3rd line : Clozapine

  • 3months trial
  • agranulocytosis
  • monitor FBC with Absolute Neutrophil Count (ANC) weekly for 18 weeks then monthly
  • long term treatment often necessary
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15
Q

Adjunctive treatment (2)

A
  1. Benzodiazepines
    - lorazepam
  2. Antidepressants
    - for depression
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16
Q

Treatment Resistant Schizophrenia (TRS)

A
  • not responsive to 2 adequate trials of antipsychotics (at least 1 is SGA)
  • Clozapine for at least 3 months
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17
Q

Acute Stabilisation Phase treatment

A

If acutely agitated/aggressive
- PO antipsychotics +/- Benzodiazepines

If refuse or not possible to administer PO
- IM fast acting antipsychotics +/- IM Lorazepam
eg IM Haloperidol / Olanzapine

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18
Q

EPSE types (4)

A
  1. Dystonia
  2. Pseudo-parkinsonian SE
  3. Akathisia
  4. Tardive dyskinesia
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19
Q

Dystonia management

A

Anticholinergics PRN

eg Benztropine

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20
Q

Pseudo-parkinsonian SE management (3)

A
  • Reduce dose
  • Switch to SGA
  • Anticholinergics PRN
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21
Q

Akathisia management (4)

A
  • Reduce dose
  • Switch to SGA
  • Clonazepam
  • anticholinergics generally unhelpful
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22
Q

Tardive dyskinesia (5)

A
  • Discontinue anticholinergics (dyskinesia worsened by anticholinergics)
  • Reduce dose
  • Switch to SGA
  • Clonazepam
  • Valbenazine
23
Q

Neuroleptic Malignant Syndrome (NMS) treatment (3)

A
  • Switch to SGA
  • IV Dantrolene
  • PO dopamine agonists
24
Q

Acute stabilisation phase goals (2)

A
  1. Minimise threat to others and self

2. Minimise acute symptoms

25
Q

Stabilisation phase goals (3)

A
  1. Prevent/minimise relapse
  2. Optimise dose
  3. Promote medication adherence
26
Q

Stable/Maintenance phase goal

A

Improve functioning & quality of life

27
Q

Poor adherence to PO medications management (3)

A
  1. IM long acting antipsychotics +/- benzodiazepines
    - eg IM Haloperidol Decanoate
  2. Community Psychiatric Nurse
  3. Patient & Family Education (social support)
28
Q

Metabolic side effects management

A
  • maintain on current antipsychotics (to prevent relapse)
  • treat emergent diabetes/dyslipidemia with lifestyle modification or meds
  • switch to antipsychotics with less metabolic side effects
    eg Aripiprazole, Brexpiprazole, Lurasidone, Ziprasidone & Risperidone
29
Q

Daytime sedation

A
  • administer dose in early evening for sedation to wear off
    eg 7pm
  • consolidate to once-nightly dosing
30
Q

Dizziness (orthostatic hypotension)

A
  • rise up slowly from lying position
31
Q

Schizophrenia definition

A
  • one of the more common forms of psychosis
  • disorganised or bizarre thoughts
  • delusions and hallucinations
32
Q

Onset of schizophrenia

A

Late adolescents and early adulthood

33
Q

Organic factors of psychotic symptoms (4)

A
  • iatrogenic causes
  • psychosis related to alcohol & substance misuse
  • parkinson’s disease
  • dementia
34
Q

Predisposing factors of Schizophrenia (2)

A
  1. Genetics

2. Neurodevelopmental effects

35
Q

Precipitating factors of Schizophrenia (2)

A
  1. Drugs
    eg benzodiazepines, barbiturates & antidepressants
  2. Alcohol
36
Q

Perpetuating factors of Schizophrenia (2)

A
  1. Lack of social support

2. Poor adherence to antipsychotic medications

37
Q

Important assessment for patients with Schizophrenia

A

Mental State Assessment (MSE)

  • assess for suicidal/homicidal ideations & risks
  • reassess MSE on every interview to evaluate risks & efficacy
38
Q

Risks of relapse if non-compliant to antipsychotic medications

A
  • medications reduce risk of relapse in stable illness to <30%/year
  • 60-70% risk of relapse within 1 year
  • 90% risk of relapse within 2 year
39
Q

Antipsychotic agents vs Benzodiazepines

A
  • generally tranquillise patients without impairing consciousness
  • without causing paradoxical excitement
  • can be used to calm disturbed patients regardless of the underlying psychopathology
40
Q

Purpose of antipsychotics in patients with Schizophrenia

A
  • Relieve symptoms of psychosis (thought disorder, hallucinations & delusions)
  • Prevent relapse
41
Q

Reason for delay in relapse episodes for several weeks after cessation of treatment

A
  • adipose tissues act as depot reservoir after chronic regular use
  • longer time for relapse for those w chronic use
42
Q

Tuberoinfundibular pathway leads to __

A

Hyperprolactinemia

43
Q

Less potent SGA

A
  1. Quetiapine

2. Clozapine (but agranulocytosis)

44
Q

Haematological side effects management

  • Agranulocytosis
  • reduce ANC
  • reduce WBC
A

Discontinue antipsychotic agent (Clozapine) if severe

  • WBC <3x10^9/L
  • ANC <1.5^10^9/L
45
Q

Parameters to monitor side effects (6)

A
  1. BMI
  2. Fasting Blood Glucose level
  3. Lipid panel
  4. Blood pressure
  5. EPSE
  6. FBC & ANC
46
Q

CYP1A2 DDI with antipsychotics

A

CYP1A2 inhibitors

  • Fluvoxamine
  • Quinolones
  • Macrolides

Victim antipsychotic
- Clozapine (increase serum conc)

47
Q

(DDI) Carbamazepine(anti-epileptic) & Clozapine

A

Agranulocytosis

48
Q

Time course of treatment response

A

Early improvements :
1 week (reduce agitation)
2-4 weeks (reduce hallucinations & paranoia)

Late improvements :
6-12 weeks (reduce delusions)
3-6 months (improve cognitive)

49
Q

(DDI) Antipsychotics & drugs with CNS depressants effect

potential DDI effect

A

Additive CNS depressant effect

50
Q

(DDI) Antipsychotics & drugs with :

  • anticholinergic effect
  • antihistamine effect
  • alpha1 adrenoceptor blockage
  • dopamine blockage
A

Additive effects

  • anticholinergic
  • antihistamine
  • postural hypotension (alpha1 adrenoceptor blockage)
  • parkinsonism (dopamine blockage)
51
Q

(DDI) Antipsychotics & dopamine enhancing drugs

eg anti-parkinson drugs

A

Mutual antagonism

52
Q

(DDI) Antipsychotics & antihypertensive agents

A

Additive hypotension effect

53
Q

Which dopaminergic pathway does antipsychotics act on?

A

Mesolimbic dopaminergic pathway

+ve symptoms

54
Q

Neuroleptic Malignant Syndrome (NMS) symptoms (4)

A
  1. Lead-pipe rigidity
  2. Fever
  3. Elevated creatine kinase
  4. Altered consciousness

PR3136 (19 decks)

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