Treatment of psychosis and psychotic disorders

Question 1

What is psychosis?

Answer 1

• patients lose contact with reality
• can involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions)

Question 2

What is Schizophrenia?

Answer 2

• form of psychosis
• dysfunction in a person’s ability to think clearly, manage emotions, make decisions, relate to others
• symptoms can be positive, negative or cognitive

Question 3

What is the major difference between psychosis and schizophrenia?

Answer 3

• psychosis refers to losing touch with reality
• schizophrenia is a disorder characterised by a number of symptoms, including psychotic symptoms (hallucinations for example)

Question 4

Dopamine is major neurotransmitter in the brain. What is the function of dopamine in the brain?

1 - excitatory only
2 - inhibitory only
3 - excitatory and inhibitory

Answer 4

3 - excitatory and inhibitory
- depends on the D receptor it binds with
- D1 = excitatory, but D2 is inhibitory
- there are 5 types of dopamine receptors (D1-D5)

Question 5

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. Where does this pathway begin and end?

1 - begin at SN and ends at dorsal striatum (caudate nucleus and putamen)
2 - begins at VTA and ends at pre-frontal cortex
3 - begins at VTA and ends at NAcc (striatum)
4 - begins at hypothalamus and ends at brain stem

SN = substantia niagra
VTA = ventral tegmental area
NAcc = nucleus accumbens, striatum

Answer 5

3 - begins at VTA and ends at NAcc (striatum)

Question 6

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesocortical pathway. Where does this pathway begin and end?

1 - begin at SN and ends at dorsal striatum (caudate nucleus and putamen)
2 - begins at VTA and ends at pre-frontal cortex
3 - begins at VTA and ends at NAcc (striatum)
4 - begins at hypothalamus and ends at brain stem

SN = substantia niagra
VTA = ventral tegmental area
NAcc = nucleus accumbens, striatum

Answer 6

2 - begins at VTA and ends at pre-frontal cortex

Question 7

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the nigrostriatal pathway. Where does this pathway begin and end?

1 - begin at SN and ends at dorsal striatum (caudate nucleus and putamen)
2 - begins at VTA and ends at pre-frontal cortex
3 - begins at VTA and ends at NAcc (striatum)
4 - begins at hypothalamus and ends at brain stem

SN = substantia niagra
VTA = ventral tegmental area
NAcc = nucleus accumbens, striatum

Answer 7

1 - begin at SN and ends at dorsal striatum (caudate nucleus and putamen)

Question 8

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the tuberoinfundibular pathway. Where does this pathway begin and end?

1 - begin at SN and ends at dorsal striatum (caudate nucleus and putamen)
2 - begins at VTA and ends at pre-frontal cortex
3 - begins at VTA and ends at NAcc (striatum)
4 - begins at hypothalamus and ends at brain stem

SN = substantia niagra
VTA = ventral tegmental area
NAcc = nucleus accumbens, striatum

Answer 8

4 - begins at hypothalamus and ends at brain stem

Question 9

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. The pathway begins at the ventral tegmental area and ends at the nucleus accumbens, striatum. What is the main function of this pathway?

1 - reward and salience
2 - regulates prefrontal cortex
3 - regulates the HPA axis
4 - regulates the basal ganglia

Answer 9

1 - reward and salience
- regulates limbic (behaviour and emotion) system
- rewards = pleasure
- salience = threat evaluation

Question 10

The nigrostriatal pathway runs from the substantia nigra in the midbrain to the dorsal striatum. What 2 parts of the brain make up the dorsal striatum?

Answer 10

1 - caudate nucleus
2 - putamen

Question 11

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. The pathway begins at the ventral tegmental area and ends at the nucleus accumbens, striatum. The main function of this pathway is the regulation of the limbic (behaviour and emotion) system, specifically rewards = pleasure, and salience = threat evaluation. In psychosis what happens to this pathway?

1 - increases salience
2 - increases reward stimulus
3 - inhibits salience
4 - inhibits reward stimulus

Answer 11

1 - increases salience
- patients can believe they are under threat due to hyperactivty

Question 12

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. The pathway begins at the ventral tegmental area and ends at the nucleus accumbens, striatum. The main function of this pathway is the regulation of the limbic (behaviour and emotion) system, specifically rewards = pleasure, and salience = threat evaluation. In psychosis the salience (threat evaluation) aspect of this pathway becomes hyperactive. What is the aim of drugs in treating this pathway in psychosis?

1 - increases salience
2 - increases reward stimulus
3 - inhibits salience
4 - inhibits reward stimulus

Answer 12

2 - increases reward stimulus
- increases feelings of pleasure

Question 13

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. The pathway begins at the ventral tegmental area and ends at the nucleus accumbens, striatum. The main function of this pathway is the regulation of the limbic (behaviour and emotion) system, specifically rewards = pleasure, and salience = threat evaluation. In psychosis the salience (threat evaluation) aspect of this pathway becomes hyperactive. Drugs to treat this pathway in psychosis target the reward processing part of the pathway and thus increase feelings of pleasure. However, what can chronic drug use cause, such as amphetamines, which are a brain stimulant?

Answer 13

• dysregulation of the salience part, causing drug-induced psychosis
• patients have hyperactive salience stimulation

Question 14

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesocortical pathway. The pathway begins at the ventral tegmental area and ends at the pre-frontal cortex. What is the main function of this pathway?

1 - reward and salience
2 - regulates prefrontal cortex
3 - regulates the HPA axis
4 - regulates the basal ganglia

Answer 14

2 - regulates prefrontal cortex
- modulates important functions including cognition, social involvement and motivation

Question 15

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesocortical pathway. The pathway begins at the ventral tegmental area and ends at the pre-frontal cortex. This pathway regulates the prefrontal cortex (PFC) and governs important functions including cognition, social involvement and motivation. What happens to this pathway in psychosis?

Answer 15

• dysfunction of the system making it hypoactive
• contributes to cognition symptoms and negative symptoms (social involvement and motivation)

Question 16

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesocortical pathway. The pathway begins at the ventral tegmental area and ends at the pre-frontal cortex. This pathway regulates the prefrontal cortex (PFC) and governs important functions including cognition, social involvement and motivation. In psychosis there is dysfunction of the system making it hypoactive, which can cause negative symptoms of psychosis. What 3 common negative symptoms?

1 - disordered thoughts, reduced motivation, social withdrawal
2 - impaired cognition function, delusions, social withdrawal
3 - hallucinations, reduced motivation, social withdrawal
4 - impaired cognition function, reduced motivation, social withdrawal

Answer 16

4 - impaired cognition function, reduced motivation, social withdrawal

Question 17

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the nigrostriatal pathway. This pathway begins at the substantia nigra in the midbrain and ends at the dorsal striatum. What is the main function of this pathway?

1 - reward and salience
2 - regulates prefrontal cortex
3 - regulates the HPA axis
4 - regulates the basal ganglia

Answer 17

4 - regulates the basal ganglia
- important for movement (especially the initiation of movements)

Question 18

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the nigrostriatal pathway. This pathway begins at the substantia nigra and ends in the midbrain. The main function of this pathway is to regulates the basal ganglia, which is crucial for movement (especially the initiation of movements). This system is not thought to be affected by schizophrenia, but can be affected by what?

Answer 18

• drugs used to treat schizophrenia
• can affect basal ganglia causing parksinon like symptoms

Question 19

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the tuberoinfundibular pathway. This pathway begins at the hypothalamus and ends at the brain stem. What is the main function of this pathway?

1 - reward and salience
2 - regulates prefrontal cortex
3 - regulates the HPA axis
4 - regulates the basal ganglia

Answer 19

3 - regulates the HPA
- controls the endocrine system (including sex and growth hormones)

Question 20

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the tuberoinfundibular pathway. This pathway begins at the hypothalamus and ends at the brain stem. The main function of this pathway is regulation of the HPA, which controls the endocrine system (including sex and growth hormones). Although this pathway is not directly affected by schizophrenia, antipsychotic medication can interfere with it, causing what?

Answer 20

• hormonal problems

Question 21

What are antipsychotic medications?

Answer 21

• medications used to treat psychotic disorders

Question 22

All antipsychotic drugs target which neurotransmitter system?

1 - dopamine
2 - glutamate
3 - serotonin
4 - GABA

Answer 22

1 - dopamine
- all are post-synaptic antagonists

Question 23

All antipsychotic drugs target the dopaminergic system, and all are post-synaptic antagonists. In order for a drug to have an anti-psychotic effect, what % of post-synaptic dopamine receptors must they bind with?

1 - 20-30%
2 - 30-50%
3 - 60-70%
4 - >90%

Answer 23

3 - 60-70%

Question 24

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesolimbic pathway. The pathway begins at the ventral tegmental area and ends at the nucleus accumbens, striatum. The main function of this pathway is the regulation of the limbic (behaviour and emotion) system, specifically rewards = pleasure, and salience = threat evaluation. In psychosis what do typical (1st generation) anti-psychotic drugs do to this pathway?

1 - dopaminergic receptor antagonist (reduced salience and reward)
2 - inhibits dopamine, accentuates negative but inhibiting positive symptoms
3 - inhibits salience only
4 - inhibits reward only

Answer 24

1 - dopaminergic receptor antagonist (reduced salience and reward)
- creates a generalised unhappiness, restlessness, dissatisfaction, or frustration

Question 25

Dopamine is involved in inhibitory and excitatory pathways in the brain. One of the those pathways is the mesocortical pathway. The pathway begins at the ventral tegmental area and ends at the pre-frontal cortex. This pathway regulates the prefrontal cortex (PFC) and governs important functions including cognition, social involvement and motivation. What happens to this pathway when a patient takes anti-psychotic drugs?

1 - dopaminergic receptor antagonist (reduced salience and reward)
2 - inhibits dopamine, accentuates negative but inhibiting positive symptoms
3 - inhibits salience only
4 - inhibits reward only

Answer 25

2 - inhibits dopamine, accentuates negative but inhibiting positive symptoms

Question 26

When we talk about anti-psychotic drugs we refer to them as typical and atypical. Atypical, also known as second generation drugs, have what affects on the positive and negative symptoms associated with psychosis?

1 - inhibit positive but not negative
2 - inhibit negative but not positive
3 - inhibits positive and negative symptoms

Answer 26

3 - inhibits positive and negative symptoms
- BUT do not have normal neurological side effects
- BUT can cause metabolic and CVD side effects

Question 27

When we talk about anti-psychotic drugs we refer to them as typical and atypical. What does typical, also known as first generation drugs mean?

Answer 27

• older drugs that have anti-psychotic effects
• can cause neurological side effects
• do not cause metabolic or CVD effects

Question 28

When we talk about anti-psychotic drugs we refer to them as typical and atypical. Atypical drugs, also known as second generation drugs mean are newer drugs that offer the same anti-psychotic effects (both positive and negative symptoms improved), BUT do not have normal neurological side effects, BUT can cause metabolic and CVD side effects. Why do they not have the same negative side effects on the neurons as the typical drugs?

Answer 28

• do not bind with post synaptic receptors as long as typical receptors
• therefore they do not overstimulate and cause side effects
• also stimulate 5-HT receptors so more dopamine released

Question 29

Atypical drugs, also known as second generation drugs mean are newer drugs that offer the same anti-psychotic effects (both positive and negative symptoms improved), BUT do not have normal neurological side effects, BUT can cause metabolic and CVD side effects. They do not cause the same side effects as typical drugs as they do not bind to the post-synaptic receptors as long. They also have a secondary function that is able to increase dopamine release that typical drugs do not posses. What is this?

1 - bind serotonin receptors on post synapse increasing dopamine release
2 - bind serotonin receptors on pre synapse inhibiting dopamine breakdown

Answer 29

1 - bind serotonin receptors on post synapse increasing dopamine release
- binding serotonin receptors increases dopamine release from the pre-synaptic membrane and the neurological side effects

Question 30

Of all the anti-psychotic drugs, which is the most effective?

1 - Aripiprazole
2 - Clozapine
3 - Chlorpromazine
4 - Haloperidol

Answer 30

2 - Clozapine
- BUT generally last line drug treatment

Question 31

Of all the anti-psychotic drugs, clozapine is an atypical drug the most effective. Which 2 neurotransmitter receptors does this drug act on?

1 - dopamine and glutamate
2 - dopamine and serotonin
3 - dopamine and GABA
4 - dopamine and acetylcholine

Answer 31

2 - dopamine and serotonin
- serotonin (pre synapse) = increase dopamine release
- dopamine (post synapse) = decrease dopamine binding

Question 32

Of all the anti-psychotic drugs, clozapine is the most effective. It acts on both serotonin and dopamine neurotransmitter receptors. What is the mechanism of action of this drug?

1 - D2 antagonist on post synapse and serotonin receptor on pre- synapse
2 - D2 agonist on post synapse and serotonin receptor on pre- synapse
3 - D2 antagonist on post synapse and agonist serotonin receptor on pre- synapse
4 - D2 agonist on post synapse and antagonist on serotonin receptor on pre- synapse

Answer 32

1 - D2 antagonist on post synapse and serotonin receptor on pre- synapse
- D2 antagonist inhibits dopamine binding on post synapse, where dopamine levels are high causing positive symptoms, such as in the mesolimbic system
- if serotonin binds to pre-synapse it inhibits dopamine release. Antagonist of this means more dopamine will be released and able to bind to receptors where dopamine is low causing negative symptoms, like in the nigrostriatal pathway

Question 33

Of all the anti-psychotic drugs, clozapine is the most effective, due to its ability to bind serotonin receptors on the pre-synapse (increasing dopamine release) and dopamine receptor binding (inhibiting dopamine binding) on the post-synaptic receptors. Is this drug used for everyone?

Answer 33

• no
• it is the last line of anti-psychotic drugs

Question 34

Of all the anti-psychotic drugs, clozapine is the most effective, due to its ability to bind serotonin receptors on the pre-synapse (inhibiting dopamine release) and dopamine receptor binding on the post-synaptic receptors. Clozapine is the last line of anti-psychotic drugs. What are the common side effects of this drug?

1 - Parkinson like symptoms, toxic side effects
2 - sedative effects, reduces WBCs, tremors
3 - toxic side effects, sedative effects, reduces WBCs
4 - Parkinson like symptoms, immunosuppressive

Answer 34

3 - toxic side effects, sedative effects, reduces WBCs

Question 35

If a patient with psychosis is not treated what happens to their quality of life?

Answer 35

• worsens

Question 36

Are patients on anti-psychotics likely to have better outcomes that those patients not on anti-psychotics?

Answer 36

• yes
• patients on placebo are generally worse off, BUT some can recover without medication

Question 37

Although second generation drugs are good at reducing the neurological side effects that can be caused by first generation drugs, there are still some common side effects. One of the effects is that it impacts upon the hypothalamus. What does that then cause?

1 - decreased primal drive, weight loss
2 -increased HPA activity and cortisol levels
3 - increased primal drive, weight gain

Answer 37

3 - increased primal drive, weight gain
- increases reproduction, eating, drinking
- patients tends to overeat and become obese

Question 38

Although second generation drugs are good at reducing the neurological side effects that can be caused by first generation drugs, there are still some common side effects. One of the effects is that it impacts upon the blood lipid and cholesterol profiles. What does that then cause?

Answer 38

• increases risk of CVD

Question 39

Although second generation drugs are good at reducing the neurological side effects that can be caused by first generation drugs, there are still some common side effects. One of the effects is that it impacts upon the blood glucose levels and insulin production. What does that then cause?

Answer 39

• patients are more likely to develop T2DM

Question 40

Although second generation drugs are good at reducing the neurological side effects that can be caused by first generation drugs, there are still some common side effects. They can increase the risk of T2D, cholesterol and lipid profiles and overeating. Combined what do these increase the risk of ?

Answer 40

• CVD

Question 41

Patients with psychosis generally lose 15-20 years of their lives. which is often from CVD. Is this solely due to second generation medication?

Answer 41

• plays a large part
• BUT social inequalities also influences this

Question 42

Although anti-pyschotic drugs are the main stay for psychosis, there are 3 other commonly used treatments. One of which is Cognitive behavioural therapy (CBT), what is this and how does it help patients?

Answer 42

• helps patients understand links between thoughts, feeling and behaviours
• reduces distress related to symptoms and reduce intensity of abnormal perceptions and beliefs.

Question 43

Although anti-pyschotic drugs are the main stay for psychosis, there are 3 other commonly used treatments. One of which is art therapy, what is this and how does it help patients?

Answer 43

• helps learn new ways of relating to other people, show how one is feeling, accept and understand these feelings

Question 44

Although anti-pyschotic drugs are the main stay for psychosis, there are 3 other commonly used treatments. One of which is family intervention, what is this and how does it help patients?

Answer 44

• family work with mental health professionals to help to manage their interactions and relationships

Question 45

Typical (1st generation) anti-psychotic medication tend to target specifically all D2 receptors in the brain. Why can this be bad when we consider the 4 dopamine pathways: mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular? (image below)

Answer 45

• inhibits all D2 receptors
• can have beneficial and negative side effects

Question 46

The nigrostriatal pathway runs from the substantia nigra in the midbrain to the dorsal striatum. What are the 2 parts of the substantia nigra, and which part is key in the initiation of movement as part of the direct pathway?

Answer 46

1 - pars compacta = key in direct pathway
2 - pars reticula
- releases dopamine as part of direct and indirect pathways

Question 47

If a patient does not want to be admitted to hospital, but needs to be admitted to hospital for psychiatric admission, which part of the mental health act would be suitable?

1 - section 7
2 - section 2
3 - section 28
4 - section 14

Answer 47

2 - Section 2
- patients can be admitted for a period of up to 28 days for a period of assessment and treatment

Question 48

What is section 2 of the mental health act?

Answer 48

• compulsory admission for assessment
• assessment followed by medical treatment, for a duration of up to 28 days

Question 49

What is section 1 of the mental health act?

Answer 49

• defines the mental disorder

Question 50

Aripiprazole is a core anti-psychotic drug that is first line treatment for psychosis. What is the mechanism of action of Aripiprazole?

1 - agonist of dopaminergic receptors and antagonist of serotonin receptors
2 - antagonist of dopaminergic receptors and antagonist of serotonin receptors
3 - partial agonist of dopaminergic receptors and agonist of serotonin receptors
4 - partial agonist of dopaminergic receptors and antagonist of serotonin receptors

Answer 50

4 - partial agonist of dopaminergic receptors and antagonist of serotonin receptors
- antagonist of serotonin receptors causes increased dopamine release
- partial agonist of dopaminergic receptors modulates dopamine binding post-synaptically

Question 51

Clozapine is atypical (2nd generation) drug that is a core anti-psychotic drug. It is generally used as a last line drug treatment for psychosis, when up to 2 other drugs have already been tried, 1 of which must have been an atypical drug. What is the mechanism of action of Clozapine?

1 - agonist of dopaminergic receptors and antagonist of serotonin receptors
2 - antagonist of dopaminergic receptors and antagonist of serotonin receptors
3 - partial agonist of dopaminergic receptors and agonist of serotonin receptors
4 - partial agonist of dopaminergic receptors and antagonist of serotonin receptors

Answer 51

2 - antagonist of dopaminergic receptors and antagonist of serotonin receptors
- antagonist for dopamine receptors
- serotonin 5HT2A antagonist

Question 52

Refractory or non-responsive schizophrenia, is essentially a disorder when patients generally do not respond to anti-psychotic medication. What would generally be the drug of choice when up other drugs have failed in patients with refractory or non-responsive schizophrenia?

1 - clozapine
2 - chlorpromazine
3 - aripiprazole
4 - haloperidol

Answer 52

1 - clozapine

Question 53

Although not exactly known, why is it that atypical (2nd generation) anti-psychotics have less side effects than 1st generation (typical) anti-psychosis medication, given that they act as both a dopamine antagonist and agonist?

Answer 53

• they have lower affinity
• do not bind as long so effects are shorter lasting
• less time to develop adverse effects