Psychosis And Schizophrenia

Question 1

Antipsychotics aka. Neuroleptics and tranquillisers

Answer 1

• Used short term to calm disturbed patients who may be suffering from schizophrenia,brain damage,mania,delirium or agitated depression
• used to alleviate severe anxiety but only used short term
• aim of the treatment is to alleviate suffering of the patient and carer and improve the social and cognitive functioning
• many patients will require life long treatment with antipsychotic medication

Question 2

What are positive symptoms and negative symptoms??

Answer 2

Positive are things that are being added, negatives are things being removed from a person

Question 3

Examples of positive symptoms

Answer 3

• thought disorder
• hallucinations
• delusions
  (Antipsychotic drugs will relieve the positive psychotic symptoms and less effect on negative symptoms) but second generation are better at treating the negative symptoms

Question 4

Negative symptoms

Answer 4

-social withdrawal
- apathy and lack of interest and enthusiasm vb

Question 5

What’s the difference between 1st and 2nd Gen?

Answer 5

1st gen have more extrapyramidal side effects

Question 6

1st gen examples

Answer 6

• chloropromazine
• levomepromazine
• promazine
• pericyazine
• fluphenazine
• perohenazine
  -prochlorperazine
• trifluoperazine
• Butyrophenones (haloperidol and benperidol)
• Thioxanthenes (flupentixol and zuclopenthixol)
  -Diphenylbutylpiperidines (pi oxide)
• sulpride

Question 7

Second generation antipsychotics

Answer 7

• amisulpride
• ariprazole
• clozapine
  -lurasidone
  -olanzapine
• palliperidone
• quetiapine
• Risperidone

Question 8

Trick for 1 st gen

Answer 8

• majority end in Azine or ol

Question 9

Second gens

Answer 9

End in apine and one

Question 10

1st generation MOA

Answer 10

• Act predominantly by clocking D2 receptors in the brain
• Non selective for Amy of the 4 dopamine pathways in the brain,hence can cause a range of side effects, especially extrapyramidal side effects and elevated prolactin

Question 11

2nd Gen MOA

Answer 11

• Act on a variety of receptors but are more selective, act on specific D receptors hence less side effects
• Better at treating negative symptoms of schizophrenia

Question 13

1st Gen’s - 3 groups = GROUP 1

Answer 13

• Chlorpromazine,levopromazine and promazine
• pronounced sedation

Question 14

Group 2 - 1st Gen

Answer 14

Pericyazine and pipotiazine

• least EPSE
• moderate sedation

Question 15

Group 3 - 1st gen

Answer 15

• prochlorperazine, fluphenazine, perphenazine
• Most EPSE
• Less sedation

Question 16

Another few groups

Answer 16

• Butyrophenones - benperidol and haloperidol which resemble group 3 in clinical properties
• thioxanthenes - Flupentixol and zuclopentixol (moderate sedation,antimsucarinic and EPSE effects)
• Diphenylbutylpiperdines - pimozide - substituted benzamides - sulpride (reduced sedative,antimuscarinic and extrapyramidal side effects)

Question 17

Second generations have a what?

Answer 17

• they are atypical antipsychotics and have a higher affinity for specific D receptors hence- less side effects

Question 18

Prescribing in elderly

Answer 18

• balance the risk and benefit
• antipsychotics are related to small cases of stroke,tia and mortality, in elderly especially with dementia
• susceptible to postural hypotension and hyperthermia and hypothermia in cold/hot weather
• do not use in elderly to treat mild to moderate psychotic symptoms
• reduce the initial dose in elderly and review their treatment regularly

Question 19

What are EPSE? AND WHICH MEDS?

Answer 19

• First Gens
• Parkinsonian symptoms (tremor) - antipsychotics block dopamine (Parkinson’s is lower dopamine)
• acute dystonia - involuntary contractions of muscle,face,neck,abnormal face and body movements
• akathsia - (restlessness and inability to stay still)
  -Tardiva dyskinesia - rhythmic, involuntary movement of jaw,younger and face
• increased prolactin concentration and hyperprolactinaemia, sexual dysfunction, reduced bone density,breast enlargement,menstrual changes and galactorrhoea
• parkinsonian symptoms can be suppressed if antimuscarincs given
• tardive dyskinesia is most serious manifestation EPSE and often irreversible
• stopping drug at earliest signs can stop full progression

Question 20

EPSE (ADAPPT)

Answer 20

Acute Dystonia(painful neck and spine spasm)
Akathisia
Parkinsonism
Prolactinaemia
Tardive dyskinesia

Question 21

Which antipsychotics cause - Weight gain?

Answer 21

• Clozapine,olanzapine (more common in second gens) so, we give:

Amisulpride,apriprazole and haloperidol

Question 22

Which antipsychotics cause - Diabetes and hyperglycaemia?

Answer 22

Risperidone,quteiapine,clozapine and olanzapine
So, we give:
1st gens,haloperidol and fluphenazine

Question 23

Which antipsychotics cause - Postural hypotension

Answer 23

Cloazapine and quetiapine

Question 24

Which antipsychotics cause - hyperprolactinaemia?

Answer 24

-Risperidone,amisulpride,sulpride and 1st gens antipsychotics

So, we give - Ariprazole,clozapine and quetiapine

Question 25

Which antipsychotics cause - Cardiact side effects (qt prolongation,tachycardia,arrhythmias,hypotension)

Answer 25

- all antipsychotics esp. pimozide So we give, Ariprazole,clozapine,olanzapine,Risperidone,prochlorperazine,flupentixol

Question 26

Which antipsychotics cause - decreased Libido?

Answer 26

Risperidone and haloperidol

Question 27

Which antipsychotics cause - ESPE (ADAPPT)

Answer 27

1ST gen drugs 2nd gens (clozapine,olanzapine, quetiapine and ariprazole)

Question 28

Which antipsychotics cause - Sexual dysfunction?

Answer 28

Risperidone, haloperidol and olanzapine So we give, Ariprazole and quetiapine

Question 29

Monitoring Antipsychotics

Answer 29

- FBC,Urea,electrolytes,liver function at the start with antipsychotic and then annually - Blood lipids,weight,fasting blood glucose, ECG - BP, prolactin concentration,physical health monitoring (including CVD risk ) at least once a year

Question 31

Treatment cessation

Answer 31

- higher risk of relapse if medication is stopped after 1-2 years -withdrawal after long term should be gradual - monitor patient for 2 years after withdrawal for Gigi’s of relapse

Question 32

Patient and carer advice

Answer 32

Photosensitisation - may occur at high doses, avoid direct sunlight - Driving - drowsiness may affect performance of skilled tasks especially at the start of treatment

Question 33

Clozapine!!!!

Answer 33

Clozapine is a D1,D2 and 5HT2A alpha adrenoreceptor and muscadine receptor antagonist - indication for schizophrenia in patients that are unresponsive to conventional antipsychotics and psychosis in Parkinson - clozapine we are closing the door as the final resort - clozapine is licensed in the treatment of schizophrenia in pts unresponsive or intolerant to other antipsychotics

Question 34

MHRA/CSM Warning!!!!

Answer 34

1) potentially fatal risk of intestinal obstruction,faecal impaction and paralytic ileum - patients should seek help if experiencing constipation 2) clozapine and other antipsychotics - monitor blood concentration for toxicity - on it or blood conc for toxicity in certain clinical situations (eg. Stop smoking,switching to ecigs, pneumonia or serious illness) - in certain clinical situations it neeeds extra monitoring because it has a narrow therapeutic index - blood monitoring should be carried out to manage risk of agranulocytois - smoking is an inducer - if you stop smoking, conc goes up

Question 35

Contraindications

Answer 35

- bone marrow disorders,history of agranulocytosis, drug intoxication , history of neutropenia, paralytic ileum, severe cardiac disorder and uncontrolled epilepsy

Question 36

Clozapine - close the bloody door

Answer 36

- close DA BLOODY DOOOORR - DA- Dopamine and alpha 1 receptors - close door- last option - Bloody - Agranulocytosis and blood disorder

Question 37

Monitoring clozapine

Answer 37

- prolactin - monitor signs of hyperlactinaemia eg. Breast enlargement and galactorrhoea - patients with schizophrenia should have physical health monitoring and CVD risk assessment at least once a year - monitor leukocytes and blood count - monitor blood clozapine concentration in certain clinical situations - Close supervision during initiation (risk of collapse due to hypotension and convulsions) -Monitor blood lipids and fasting glucose

Question 38

Patient and carer advice

Answer 38

- photosensitive at higher doses ( avoid direct sunlight) - Driving and skilled tasks - drowsiness may affect especially at the start of treatment, effects of alcohol are enhanced - patients and carers should be given advice on how to administer clozapine - oral suspension and orodispersible tablets - suspension = shake well for 90 seconds when dispensing. Or if visibly settled and strand for 24 hrs before use - otherwise shake well for 10 seconds before. MAY BE DILUTED WITH WATER Orodispersible - place on the tounge - allow to dissolve and swallow

Question 39

ANTIPSYCHOTICS DEPOT INJECTIONS

Answer 39

Depot - more EPSE than oral - for pts that can’t comply with oral Zupentixol (prevents relapse ) and flupentixol ( agitated and aggressive patients)