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CDM 4 Exam 2 > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

Positive symptoms

A

Delusions
Hallucinations
Disorganized Speech
Grossly disorganized/catatonic behavior

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2
Q

Negative Symptoms

A

Blunted affect
Alogia
Avolition
Anhedonia
Asociality

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3
Q

Delusions

A

fixed, false beliefs generally outside of the cultural or societal norms

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4
Q

Hallucinations

A

a sensory perception with no basis in external stimulation

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5
Q

Disorganized speech

A

frequent derailment or loose associations (constantly moving from one topic to another), tangentiality, incoherence, or repetition of words

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6
Q

Grossly disorganized/catatonic behavior

A

may range from silliness to catatonia to purposelessness movement to agitation

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7
Q

Blunted affect

A

emotional blunting or difficulty expressing emotion

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8
Q

Alogia

A

inability to speak

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9
Q

Avolition

A

lack of desire or motivation to pursue self-initiated goals

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10
Q

Anhedonia

A

inability to experience pleasurable emotions

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11
Q

Asociality

A

inability or unwillingness to participate in normal social situations

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12
Q

Schizophrenia DSM 5 diagnosis

A

> 2 symptoms (positive, negative, cognitive) must be present for a significant percent of time during a 1 month period (less if successfully treated)
1 symptom must be delusions, hallucinations, or disorganized speech
1 areas of function (work, relationships, self-care)
lasting at least 6 months

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13
Q

Etiology

A

No known causes
May have genetic link

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14
Q

Onset

A

May be abrupt or insidious; late teens-mid 30s

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15
Q

Mesocortical

A

Function: cognitive, social, emotions, stress response
Low DA –> negative sx and cognitive sx
(Tx: worsens negative sx)

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16
Q

Mesolimbic

A

Function: arousal, stimulus processing, reward, memory
Excess DA –> positive sx
(Tx: relief of positive sx)

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17
Q

Nigrostriatal

A

Function: movement
Normal DA –> no dysfunction
(Tx: extrapyramidal sx)

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18
Q

Tuberoinfundibular

A

Function: regulates prolactin
Normal DA –> no dysfunction
(Tx: hyperprolactinemia)

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19
Q

Acute phase

A

decrease Threat to self/others

decrease Symptoms
Agitation
Hostility
Anxiety
Abnormal sleep

Develop treatment plan

1-2 weeks

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20
Q

Stabilization

A

Prevent relapse

decrease Symptoms
Positive/negative/ cognitive

Optimize med regimen
Dose/adverse effects
Monitoring
Adherence

3-4 weeks

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21
Q

Maintenance

A

Prevent relapse
- increase Functioning
- increase QoL
- Monitoring
Prodromal symptoms
Adverse effects
Adherence

lifelong

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22
Q

Maintenance

A

Prevent relapse
- increase Functioning
- increase QoL
- Monitoring
Prodromal symptoms
Adverse effects
Adherence

lifelong

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23
Q

Non-pharm therapy

A

ACT
cognitive remediation
Family pychoeducation
illness self-management training
supported employment

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24
Q

First Gen Antipsychotics (FGA)

A

acute agititation/deliruim

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25
Q

Tourette’s syndrome FGA

A

Haloperidol, pimozide

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26
Q

Nausea/vomiting FGA

A

Chlorpromazine, perphenazine, prochlorperazine

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27
Q

intractable hiccups FGA

A

Chlorpromazine

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28
Q

FGA MOA

A

blockade of DA2 receptors in the mesolimbic area and mesocortical area of the brain

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29
Q

FGA dosing general

A

Onset is within a few days, may begin to respond within a few weeks, full benefit in 4-6 weeks
Discontinuation should be a slow taper over several weeks to months

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30
Q

FGA dosing Acute treatment

A

Increase dose until behavior improves or adverse effects limit dose
IM/IV formulations are 2-4 x more potent and should only be used in acute settings

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31
Q

extrapyramidal symptoms

A

Most common with high-potency FGAs, especially at high doses
Onset: within 2-3 weeks of starting treatment or dose increase (except for tardive dyskinesia)

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32
Q

Pseudoparkinsonism

A

Tremor (at rest), bradykinesia, shuffling gate, masked facies, stooped posture
Reversible: dose decrease or add anticholinergic agent (e.g. benztropine)

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33
Q

Akathisia

A

Subjective report of “inner restlessness;” pacing; unable to stay still
Reversible: dose decrease or switch antipsychotic, add propranolol or anticholinergic

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34
Q

Acute dystonia

A

Spastic involuntary muscle contractions; usually within 24-96 hours dose change
Moderate/severe: (IV or IM) benztropine 1-2mg or diphenhydramine 25-50mg
Mild: (PO) benztropine 1-2mg daily or twice daily

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35
Q

Tardive Dyskinesia symptoms

A

Myoclonic jerks, tics, chorea, dystonia
Often involving the face/mouth
More likely to occur after long-term antipsychotic treatment (months-years)
Potentially irreversible

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36
Q

Tardive Dyskinesia Risk

A

Long-term, high-dose, high-potency FGA
Older age, female sex

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37
Q

Tardive Dyskinesia Monitoring

A

AIMS or DISCUS
Every 6 months (FGA) or 12 months (SGA)

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38
Q

Tardive Dyskinesia Treatment

A

Discontinue antipsychotic and switch to one with lower risk (limited evidence showing this improves symptoms)
VMAT2 inhibitor

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39
Q

VMAT2 inhibitors MOA

A

reversible inhibition of VMAT2 which is a transporter that packages DA into presynaptic vesicles in preparation for release into synaptic cleft

40
Q

Deutetrabenazine warnings

A

QT prolongation
Parkinsonism
Depression or suicidality

41
Q

Deutetrabenazine ADE

A

Somnolence and fatigue
Diarrhea

42
Q

Deutetrabenazine DDI

A

Strong 2D6 inhibitors: reduce dose
Other drugs with QT prolongation

43
Q

Deutetrabenazine counseling

A

Take with food

44
Q

Valbenazine Warnings

A

QT prolongation (2D6 or 3A4 inhibitors)
Parkinsonism
Depression or suicidality

45
Q

Valbenazine ADE

A

Somnolence and fatigue
Sedation

46
Q

Valbenazine DDI

A

Strong 3A4 or 2D6 inhibitors: reduce dose
Avoid MAOIs and strong 3A4 inducers
Digoxin: monitor and adjust digoxin dose

47
Q

Valbenazine counseling

A

Avoid driving or operating heavy machinery

48
Q

Neuroleptic Malignant Syndrome (NMS) Presentation

A

muscular rigidity, hyperthermia, altered mental status, autonomic dysfunction

49
Q

Neuroleptic Malignant Syndrome (NMS) onset

A

1-2 weeks after initiation/change in dose, can occur as soon as 1-3 days

50
Q

Neuroleptic Malignant Syndrome (NMS) resolution

A

Discontinue antipsychotic, sx usually subside in 1-2 weeks

51
Q

Neuroleptic Malignant Syndrome (NMS) mortality rate

A

12%, up to 20% in patients who receive inadequate NMS treatment

52
Q

Neuroleptic Malignant Syndrome (NMS) reoccurance

A

30-50%; ways to reduce risk are waiting at least 2 weeks to restart antipsychotic therapy or use different class antipsychotic of lower potency

53
Q

FGA monitoring parameters

A

QTc prolongation (EKG and serum K+)
Hyperprolactinemia (screen for symptoms, prolactin level if indicated)
AIMS/DISKUS screening for EPS

54
Q

FGA pro

A

Extremely effective at reducing positive symptoms

55
Q

FGA con

A

Do not treat negative symptoms, often exacerbate them instead
High risk of side effects
Movement disorders are common and can become permanent

56
Q

SGA MOA

A

5HT2-DA antagonism
D2 partial agonism
D2 antagonism with rapid dissociation
5-HT1A partial agonism & 5-HT2A antagonism

57
Q

SGA indications

A

Tx-refractory or suicidal behavior in schizophrenia
-Clozapine

58
Q

SGAs: Dosing

A

Start at low dose and titrate on basis of tolerability and response
Acute psychosis: increase dose until symptoms improve or AE limit dose
Use divided doses for 1-2 weeks to decrease AE; then change to daily dosing

59
Q

SGA tapering

A

Consider half life and patient-specific factors
25% reduction in TDD weekly or slower
Discontinuation symptoms begin 2-3 days after abrupt stop and may last up to 14 days

60
Q

SGA metabolic syndrome risk

A

highest
Clozapine
Olanzapine
Quetiapine
Risperidone
Paliperidone
Iloperidone
Asenapine
Aripiprazole
Lurasidone
Ziprasidone
Lowest

61
Q

5HT2C antagonist

A

Stimulates appetite and thus weight gain

62
Q

M3 antagonist

A

Impaired insulin secretion from pancreas

63
Q

H1 antagonist

A

Sedation; decreased physical activity

64
Q

BMI monitoring

A

Baseline, 1 mo, 2 mo, 3 mo, quaterly

65
Q

Waist monitoring

A

Baseline, annual

66
Q

A1C monitoring

A

Baseline, 3 mo, Annual

67
Q

Lipid monitoring

A

Baseline, 3 mo, annual

68
Q

BP monitoring

A

ALL (Baseline, 1 mo, 2 mo, 3 mo, 6 mo, quarterly, annual)

69
Q

SGA: Hyperprolactinemia symptoms

A

Females
Oligomenorrhea to amenorrhea
Galactorrhea when not pregnant/ breast feeding
Painful intercourse
Hirsutism

Males
Erectile dysfunction
Gynecomastia

70
Q

SGA: Hyperprolactinemia clinical pearls

A

Levels do NOT correlate with symptoms
Only treat/intervene if symptomatic

71
Q

SGA: Hyperprolactinemia worst offenders

A

Risperidone
Paliperidone

72
Q

SGA: Hyperprolactinemia treatment

A

Consider DA partial agonists (prolactin-sparing)
Aripiprazole
Brexpiprazole
Cariprazine

73
Q

All SGA have demonstrated some level of

A

QT prologation

Increased risk: ziprasidone > quetiapine > iloperidone > risperidone ~ paliperidone ~ clozapine

74
Q

Encourage frequent monitoring or discontinuation if QT/QTc ___

A

> 500 ms

75
Q

SGA side effects

A

constipation
dry mouth
sedation
orthostatsis

76
Q

Managing SGA constipation

A

Exercise, increase fluid intake, stool softeners

77
Q

Managing SGA Dry mouth

A

Increase fluid intake, sugarless candy or gum, saliva substitutes, fluoride rinses, mouth washes

78
Q

Managing SGA sedation

A

Administer dose at bedtime, decrease/divide dose between AM and PM, switch to AP with less sedative properties

79
Q

Managing SGA orthostasis

A

Avoid changing posture quickly, decrease/divide dose, switch to AP without antiadrenergic properties

80
Q

Treatment Resistant

A

Lack of significant improvement in symptoms despite treatment with at least two antipsychotics from two different antipsychotic classes at the recommended dosage for a period of at least 2-8 weeks

81
Q

guidelines suggest ____ as treatment of choice for treatment-resistant patients

A

Clozapine

82
Q

Clozapine has a weak affinity for

A

DA receptors, and strong affinity for alpha, muscarinic, and histamine receptors –> SIDE EFFECTS

83
Q

Clozapine warnings

A

Agranulocytosis –> BOXED WARNING
Orthostasis/syncope –> BOXED WARNING
Myocarditis and cardiomyopathy –> BOXED WARNING
Seizures –> BOXED WARNING
QTc prolongation

84
Q

Clozapine CI

A

Myeloproliferative disorders
Clozapine-induced agranulocytosis
Severe CNS depression
Paralytic ileus

85
Q

Clozapine ANC level normal

A

ANC ≥ 1500/mm3

86
Q

Clozapine ANC monitoring

A

Weekly x 6 mo
Every 2 weeks for mo 6-12
Monthly after 12 mo

87
Q

Long-acting injectables pros

A

Easy adherence monitoring
Don’t need to take a med every day
Regular contact with medical staff
Easier to discriminate between non-adherence and lack of response/relapse
decrease overdose risk
More stable plasma concentrations

88
Q

Long-acting injectables cons

A

Long time before effective dose/steady state achieved
Less flexibility with dose adjustments
Injection site reactions
Requires frequent visits with medical staff
Some require overlap with PO formulation until steady state achieved

89
Q

Pregnancy and lactation

A

NOT recommended to stop antipsychotic during pregnancy
Avoid antipsychotics with anticholinergic side effects
Breastfeeding is not recommended

90
Q

Children

A

Children tend to gain more weight than adults and have more EPS

91
Q

Elderly

A

More susceptible to antiadrenergic (falls/orthostasis) and antimuscarinic (urinary retention, constipation, memory) side effects

Boxed warning in older adults for increased mortality in dementia-related psychosis

92
Q

Ziprasidone should be taken with a _____meal

A

500+ calorie

93
Q

Lurasidone should be taken with a ___ meal

A

350+ calorie

94
Q

causes heavy sedation

A

Quetiapine, olanzapine, clozapine

95
Q

causes restlessness

A

Aripiprazole

96
Q

causes gynecomastia

A

Risperidone, paliperidone

CDM 4 Exam 2 (13 decks)

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