Schizophrenia

Question 1

Schizophrenia

Answer 1

Psychotic illness with periods of psychosis (delusions, hallucinations)

Chronic dysfunction of mood, cognition, and social behavior

Question 2

Schizophrenia affect on Males

Answer 2

earlier onset, more severs symptoms, less responsive to meds

Same or slightly more than females

Question 3

Etiology

Answer 3

Unknown. Possible genetic disposition or birth complications

Question 4

Schizophrenia pathology

Answer 4

reduced prefrontal blood flow during cognitive tasks, or hypofrontality, has been note in schizophrenia and linked to diminished dopamine activity

Question 5

Positive Symptoms

Answer 5

Presence of behaviors
- Hallucinations, distributed reality, abnormal motor behaviors (echopraxia, waxy flexibility)

Question 6

Negative Symptoms

Answer 6

Diminished/absent behaviors
- speech, emotions, social withdrawal

Question 7

Cognitive Symptoms

Answer 7

Impaired behaviors
- reduced attention, decreased executive function

Question 8

relative balance between symptoms an help

Answer 8

guide drug treatment choices

Question 9

Dopamine Hypothesis

Answer 9

Dopamine appears to exacerbate positive symptoms
- drugs that block dopamine neural storage (reserpine) or act as agonists reduce symptoms

Question 10

Dopamine Pathways

Answer 10

Several tracts that interface with the limbic system and also regulate behavior

Overactivity of dopamine in mesolimbic/mesocortical tract

Question 11

Dopamine dysregulation plays central role in schizophrenia

Answer 11

Imbalance with overactivity and underactivity in various brain regions

May also be increased densoty of D2-receptors

Question 12

Overall Treatment

Answer 12

Typically antipsychotics.
Positive symptoms easier to treat.
Negative challenging to treat.

Goal: reduce symptoms and med AE while improving function and QoL

Question 13

Drug selection based on:

Answer 13

• AE profile
• past response to meds
• availability of shirt-acting injectable or IV for acute situations
• availability of long-acting injectable for chronically nonadherant pts who have frequent relapse

Question 14

Minimum theraoeutic trial length

Answer 14

4-6 weeks

Question 15

1st gen antipsychotics (FGA)

Answer 15

aka: coventional or typical

marketed before 1990

Previously called “neuroleptics” due to more frequent neurologic AE

Question 16

2nd gen antipsychotics (SGA)

Answer 16

AKA: novel or atypical

marketed after 1990

less EPS and TD = more likely 1st line

Question 17

Extrapyramidal Symptoms (EPS)

Answer 17

Acute dystonia
Akathisia
Parkinsonism
Neuorlepticmalignant Syndrome
Perioral Tremor
Tardive Dyskinesia

Question 18

Acute dystonia

Answer 18

spasm of muscles of tongue, face, neck, back

abnormal muscle tone causing sustained contractions/spasms

Question 19

Akathisia

Answer 19

subjective and objective restlessness; not anxiety or agitation

Finger-taping, pacing

Question 20

Parkinsonism

Answer 20

Bradykinesia, rigidity, variable tremor, mask facies, shuffling gait

Question 21

Neurolepticmalignant Syndrome

Answer 21

extreme rigidity, fever, unstable BP, myoglobinemia, can be fatal

Question 22

Perioral Tremor

Answer 22

rabbit syndrome

Question 23

Tardive Dyskinesia (TD)

Answer 23

orofacial, rarely widespread choreoathetoid or dystonia
(look at quiz question)

Question 24

FDA (first gen)

Answer 24

Haldol

MOA: block D2 receptors in mesolimbic tract where excess DA may contribute to positive sx

2nd line treatment due to AE
D2 receptor block in other areas contribute to EPS and hyperprolactinemia

EPS is acute (parkinsonism, akathisia and dystonic reaction) or delayed (TD, sometimes irreversible)

Question 25

SGA (second gen)

Answer 25

Risperdal, Seroquel, Abilify MOA: block D2 receptors but less that FGA; more affinity for 5-HT - variable effect on histamine, muscarinic and alpha receptors = variable AE 1st line treatment Less frequent EPS Higher risk of metabolic dysfunction (glucose/lipd abnormal, wt gain)

Question 26

AE's

Answer 26

commonly occur at therapeutic doses - D2 receptor blockade - H1 receptor blockade - muscarinic receptor bloclade - a1 receptor blockade

Question 27

AE: D2 receptor blockade

Answer 27

Motor: dystonia, akathisia, tremor, rigidity, bradykinesia, akinesia, TD Endocrine: gynecomastia, galactorrhea, amenorrhea, sexual dysfunction Neuroleptic malignant syndrome

Question 28

AE: H2 receptor blockade

Answer 28

sedation, weight gain

Question 29

AE: Muscarinic receptor blockade

Answer 29

anticholinergic

Question 30

AE: A1 receptor blockade

Answer 30

hypotension, dizziness, syncope, reflex tachycardia

Question 31

EPS Rehab Concerns

Answer 31

blockade of D2-receptors in nigrostriatal dopaminergic pathway causes neuromuscular effects Akathisia: early onset AE, hard to treat Pseudoparkinsonism: may appear early in treatment, more common with haldol TD: late onset AE Dystonia: may begin in early treatment, more common in males

Question 32

FGA: rehab concerns

Answer 32

Risk of cardiac abnormalities: tachycardia, altered ECG, arrhythmia - can turn to sudden death Caution with UV: drugs can cause dermatologic AEs Cautious of overexertion, impaired thermoregulation: - drugs and schizophrenia itself can cause heat intolerance. - observe for signs of heat injury Observe for EPS: high incidence

Question 33

SGA: rehab cocerns

Answer 33

significant weight gain, hyperglycemia, lipid abnormalities increased risk for cardiac abnormality Increased risk for heat intolerance