Schizophrenia Flashcards
(120 cards)
1
Q
Iatrogenic causes of Schizophrenia can be due to __.
A
excessive thyroid or corticosteroids
2
Q
The misuse of __ and __ can cause Schizophrenia.
A
alcohol and psychoactive substances
3
Q
All antipsychotics work by __.
A
post-synaptic block of dopamine receptors
4
Q
Drugs, particularly __ may precipitate Schizophrenia
A
dopamine agonists
5
Q
A lack of __ and __ may prolong the course of schizophrenia.
A
support and adherence
6
Q
Under the DSM-5 Criteria for diagnosis of Schizophrenia, there must be __ with each persisting for a significant portion of at least 1 month. Continuous signs of the disorder should occur for at least __.
A
- 2 or more symptoms (DHDGN)
2. 6 months
7
Q
*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The 1st ‘D’ refers to __.
A
Delusions
8
Q
*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘H’ refers to __.
A
Hallucinations
9
Q
*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The 2nd ‘D’ refers to __.
A
Disorganized speech
10
Q
*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘G’ refers to __.
A
Grossly disorganized or catatonic behavior
11
Q
*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘N’ refers to __.
A
Negative symptoms e.g. Affective flattening, Alogia , Anhedonia, Avolition
(AAAA)
12
Q
It is important to rule out __, __, __ and __ as causes of Schizophrenia.
A
Schizoaffective, Mood disorder, Medical disorder and substance use.
(SMMS)
13
Q
The effects of relapse often occur only __ after stopping treatment.
A
several weeks
14
Q
*Methods to improve compliance in schizophrenic patients include: ICP. ‘I’ refers to __.
A
IM long acting injections
15
Q
*Methods to improve compliance in schizophrenic patients include: ICP. ‘C’ refers to __.
A
Community psychiatric nurse
16
Q
*Methods to improve compliance in schizophrenic patients include: ICP. ‘P’ refers to __.
A
Patient and family (caregiver) education
17
Q
An antipsychotic blocking dopamine receptors in the Mesolimbic tract leads to __.
A
reduction of positive symptoms of Schizophrenia (efficacy)
18
Q
An antipsychotic blocking dopamine receptors in the Mesocortical tract leads to __.
A
negative symptoms (adverse effect)
19
Q
An antipsychotic blocking dopamine receptors in the Nigrostriatal tract leads to __.
A
Extrapyramidal Side Effects (EPSE) (adverse effect)
20
Q
An antipsychotic blocking dopamine receptors in the Tuberoinfundibular tract leads to __.
A
hyperprolactinemia (adverse effect)
21
Q
The main dopamine receptor modulated by antipsychotics is the __.
A
dopamine 2 receptor
22
Q
*An adequate trial of antipsychotics for Schizophrenia is generally defined as __ + __ + __.
A
compliance + at least 2-6wks + optimal therapeutic doses
23
Q
*Clozapine should be considered for treatment resistant Schizophrenia. What defines ‘treatment resistant’?
A
failure of 2 or more adequate trials of different antipsychotics (at least 1 SGA)
24
Q
Routine hematological monitoring is required for __ due to __.
A
patients on clozapine due to risk of agranulocytosis
25
Antipsychotics are to be used with caution in patients with cardiovascular disease due to __.
QTC prolongation (contraindication)
26
Antipsychotics are to be used with caution in __ due to EPSE.
patients with Parkinson's Disease
27
Antipsychotics are to be used with caution in patients with blood dyscrasias, especially for __.
Clozapine
28
Antipsychotics are to be used with caution in __, due to increased risk (2-3x) for mortality and stroke.
Elderly patients with dementia
29
*In acute agitation (psychiatric emergency), what should be the treatment plan if the patient is cooperative?
Consider PO:
Lorazepam 1-2mg or
Antipsychotic i.e. risperidone 1-2mg
30
*In acute agitation (psychiatric emergency), what should be the treatment plan if the patient is uncooperative and remains agitated/aggressive?
```
Consider fast acting IM injection:
Haloperidol 2.5-10mg /Lorazepam 1-2mg or both (common)
Olanzapine (uncommon)
Promethazine (sedating effect only)
Aripriprazole
(CHLOPA)
```
31
The use of haloperidol in acute agitation requires a __ which may be hard to do.
pre-treatment ECG
32
The concurrent use of __ and __ can lead to cardio-pulmonary collapse. Therefore, a lock out period of 1 hr in between use should be observed.
IM Olanzapine
| IM Lorazepam
33
The use of __ is appropriate for a patient presenting with catatonia.
BZDs i.e. PO/IM Lorazepam
34
*For PO Haloperidol (serenance/haldol), state for adults:
| The Usual starting dose
0.5-3mg BD/TDS or 3-5mg BD/TDS (severe symptoms)
35
*For PO Haloperidol (serenance/haldol), state for adults:
| The Usual Dose range
5-15mg/day
36
*For PO Haloperidol (serenance/haldol), state for adults:
| The Max dose
20mg/day
37
*For fast acting Haloperidol IM Injection, state for adults:
| The Usual starting dose
2-5mg/dose
38
*For fast acting Haloperidol IM Injection, state for adults:
| The Usual Dose range
2-10mg/dose/day
39
*For fast acting Haloperidol IM Injection, state for adults:
| The Max dose
18mg/day
40
*For Clozapine (clozaril), state for adults:
| The Usual Starting dose
12.5 MG on/bd (Day 1)
25-50 MG (day 2)
*increase gradually if well tolerated in steps of 25-50 mg/day
41
*For Clozapine, state for adults:
| The Usual Dose range
200-450mg/day
42
*For Clozapine, state for adults:
| The Max dose
900mg/day
43
*For Olanzapine, state for adults:
| The Usual Starting dose
PO: 10 mg/day
IM: 2.5-10mg q2-4hrs, Max 3 doses/day.
44
*For Olanzapine, state for adults:
| The Usual Dose range
5-20mg/day
45
*For Olanzapine, state for adults:
| The Max dose
20mg/day
46
*For Quetiapine (seroquel), state for adults:
| The Usual Starting dose
25 MG bd (Day 1), 50 MG bd (Day 2),
| 100 MG bd (Day 3), 150 MG bd (Day 4)
47
*For Quetiapine (seroquel), state for adults:
| The Usual Dose range
150-500mg/day
48
*For Quetiapine (seroquel), state for adults:
| The Max dose
800mg/day
49
*For PO Risperidone (risperdal), state for adults:
| The Usual Starting dose
2 mg/day in 1 or 2 divided doses
50
*For PO Risperidone (risperdal), state for adults:
| The Usual Dose range
2-6mg/day
51
*For PO Risperidone (risperdal), state for adults:
| The Max dose
16mg/day
52
*For IM Haloperidol decanoate (haldol), state for adults:
| The Usual Starting dose
Test dose 25 – 50 mg
| At least 3-7 days interval before top up dose
53
*For IM Haloperidol decanoate (haldol), state for adults:
| The Usual Dose range
50 - 300mg / 4 weeks
| doses halved if given every 2 weeks
54
*For IM Haloperidol decanoate (haldol), state for adults:
| The Max dose
300mg/ 4 wks
55
*For IM Risperidone (risperdal consta), state for adults:
| The Usual Starting dose
25 mg/ 2 wks (if on oral dose of up to 4 MG/day)
| 37.5 mg/ 2 wks (if on oral dose > 4 MG/day)
56
*For IM Risperidone (risperdal consta), state for adults:
| The Usual Dose range
25 – 37.5 MG / 2 WK
57
*For IM Risperidone (risperdal consta), state for adults:
| The Max dose
50 MG / 2 WK
58
*What should we note when initiating IM Risperidone (risperdal consta)?
Supplement with oral dose during 1st 3 weeks upon initiating 1st injection
59
*For IM Palperidone (invega sustenna), state for adults:
| The Usual Starting dose
Initiate 150mg -> 100mg 1 wk later -> 25-50mg/4wks (if on oral 3mg/day) or 75mg/4wks (if on oral 6mg/day)
60
*For IM Palperidone (invega sustenna), state for adults:
| The Usual Dose range
25-150mg/ 4wks
61
*For IM Palperidone (invega sustenna), state for adults:
| The Max dose
150mg/ 4wks
62
*For IM Palperidone (invega trinza), state for adults:
| The Usual Starting dose
```
Invega sustenna --> Invega Trinza
50MG -> 175MG
75MG -> 263MG
100MG -> 350MG
150MG -> 525MG
```
63
*For IM Palperidone (invega trinza), state for adults:
| The Usual Dose range
175-525mg/3months
64
*For IM Palperidone (invega trinza), state for adults:
| The Max dose
525mg/3months
65
When can patients use IM Palperidone (invega trinza) to take advantage of its 3monthly dosing?
For patients stabilized on monthly IM paliperidone (invega sustenna) over past ≥ 4 months
66
*For patients concerned with weight gain i.e. DM/obese/hyperlipidemia patients, what are good antipsychotic choices?
No weight gain: Lurasidone, aripriprazole, brexipiprazole and ziprasidone (LABZ)
Minimal weight gain: haloperidol
67
*Which antipsychotics will induce the most weight gain and should be avoided in DM/obese/hyperlipidemia patients?
Clozapine and Olanzapine
68
*Which antipsychotics should we choose if the patient is very concerned with EPSE?
SGAs > FGAs
69
* The patient presents with Muscle spasms, e.g. oculogyric crisis, torticollis. The onset of symptoms was within minutes (if IM/IV) or hrs (if PO) of taking antipsychotics.
1. What is the adverse effect the patient is suffering from ?
2. how can we manage it?
1. EPSE: Dystonias
| 2. IM cholinergics i.e. benztropine, diphenhydramine
70
What are the risk factors for dystonias (EPSE) in a patient using antipsychotics?
High potency antipsychotics i.e. haloperidol
Young Males
Neuroleptic naïve patients
(HYN)
71
* The patient presents with Tremors, rigidity, bradykinesia, bradyphrenia, salivation. The onset of symptoms was within days or weeks of taking antipsychotics.
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?
1. EPSE: Pseudo-parkinsonism
2. lower antipsychotic dose, or switch to SGA
Add Anticholinergics PRN, e.g. benzhexol (aka trihexyphenidyl),
72
What are the risk factors for Pseudo-parkinsonism (EPSE) in a patient using antipsychotics?
Elderly females
| Previous neurological damage (e.g. head injury, stroke)
73
* The patient presents with restlessness. The onset of symptoms was within hours to weeks of taking antipsychotics.
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?
1. Akathesia
2. lower antipsychotic dose, or switch to SGA
Add Clonazepam (low dose) PRN
Add Propranolol 20mg TDS (max 160mg/day)
74
*The patient presents with Orofacial movements (lip
chewing, tongue protrusion), choreiform hand movements pelvic thrusting. The onset of symptoms was after months/years of antipsychotic use and is 50% irreversible.
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?
1. Tardive Dyskinesia
2. Discontinue any anticholinergics
Lower antipsychotic dose, or switch to SGA (Clozapine possibly effective)
Add Reversible inhibitor of vesicular monoamine transporter 2 (VMAT2): Valbenazine 40-80mg/day
Add Clonazepam PRN
75
What are the risk factors for Akathesia (EPSE) in a patient using antipsychotics?
High potency antipsychotics > Risperidone > Olanzapine > Quetiapine/Clozapine
(HROQC - HR Owes QC)
76
The use of anticholinergic agents is not helpful in the management of which EPSE?
Akathesia
77
What are the (FACA) risk factors for Tardive dyskinesia (EPSE) in a patient using antipsychotics?
- FGA > SGA
- Patients who develop acute EPSEs when initiated on FGA
- Chronic use: 5% of patients per year of antipsychotic exposure
- Worsen with anticholinergic drugs
78
* The patient presents with Galactorrhea, Amenorrhea, reduced libido and Gynecomastia (males).
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?
1. Hyperprolactinemia
2. Lower FGA dose
Add Dopamine agonist (e.g. amantadine, bromocriptine)
Switch to Aripiprazole
79
What are the risk factors for Tardive dyskinesia (EPSE) in a patient using antipsychotics?
FGAs, Paliperidone => Risperidone > other SGAs
| FPRS
80
*How can antipsychotic induced weight gain be managed?
Switch to lower risk agents
Lifestyle modification: diet, exercise
Treat diabetes (e.g. with metformin), hyperlipidemia
(SLT)
81
*How can orthostatic hypotension be managed in schizophrenia patients?
1. Get up slowly from a sitting/lying position
| 2. Switch to lower risk agents i.e. Aripriprazole, Sulpiride, Olanzapine, Ziprasidone (ASOZ)
82
*How should we manage QTC prolongation in schizophrenia patients?
1. if >500ms refer
| 2. Switch to lower risk agents i.e. Quetiapine > Risperidone> Olanzapine (QRO)
83
*How should we manage DVT/PE in schizophrenia patients?
1. Anticoagulation
| 2. Prefer high potency drugs
84
* The patient presents with Muscle rigidity, fever, autonomic dysfunction, increased HR, labile BP, diaphoresis), altered consciousness, increased CK. Onset: hours to 3 days (within 30 days)
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?
1. Neuroleptic malignant syndrome (NMS)
2. IV Dantrolene 50mg TDS
Oral dopamine agonist (e.g. amantadine, bromocriptine), supportive measures.
Switch to SGA
85
What are the risk factors for Neuroleptic malignant syndrome (NMS) in a patient using antipsychotics?
High potency antipsychotics (i.e. fast acting IM Haloperidol)
86
*How should we manage lowered WBC, Absolute neutrophil count (ANC) and agranulocytosis in schizophrenia patients?
Discontinue antipsychotic if severe (WBC < 3 x10^9/L or ANC < 1.5 x10^9 /L)
87
What are the risk factors for agranulocytosis in a patient using antipsychotics?
```
Clozapine use (1%)
- very rare for other antipsychotics < 1 in 10,000
```
88
*How often should we monitor the BMI of a patient initially started on antipsychotics?
Weekly for 1st 6 weeks OR
at least monthly x 3 months for SGA
x 6 months
- or every visit
89
*How often should we monitor the BMI of a patient who antipsychotic dose is stabilized?
q3 months
90
*How often should we monitor the fasting blood sugar of a patient on antipsychotics, if the patient has low risk for DM?
Annually
91
*How often should we monitor the fasting blood sugar of a patient on antipsychotics, if the patient has high risk for DM?
4 months after initiating new antipsychotic (or 3 months after initiating SGA) --> then annually
92
*How often should we monitor the lipid panel of a patient on antipsychotics, if the patient has low risk for hyperlipidemia?
q2-5 years
93
*How often should we monitor the lipid panel of a patient on antipsychotics, if the patient has high risk for hyperlipidemia?
3 months after initiating SGA --> then q6 months
94
*How often should we monitor the blood pressure of a patient on antipsychotics?
3 months after initiating SGA --> then annually
95
*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a patient initially started on antipsychotics?
Weekly for 1st 2 weeks after initiation or until dose stabilized
96
*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a low-risk patient dose stabilized on antipsychotics?
FGA q6 months
| SGA q12 months
97
*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a high-risk patient dose stabilized on antipsychotics?
FGA q3 months
| SGA q12 months
98
*How often should we monitor the WBC and ANC of a patient on Clozapine?
Weekly for first 18 weeks --> then monthly.
99
*What should we note for elderly schizophrenia patients when initiating pharmacological treatment?
1. Avoid Orthostatic hypotension --> Prefer ASOZ
2. Avoid Anticholinergic SEs --> prefer SGAs (except clozapine)
3. Simplify regime
AAS
100
What should we note when using antipsychotics in patients with parkinson's disease?
Disease interactions: antipsychotics worsen Parkinson’s Disease Symptoms
101
What are some antipsychotics that have interaction with CYP1A2 inducers i.e. smoking, Rifampicin, Phenobarbitone, Phenytoin?
Ziprasidone, Clozapine*, Haloperidol, Olanzapine, Phenothiazines
(ZCHOP)
*Seizures and death
102
What are some antipsychotics that have interaction with CYP1A2 inhibitors?
Ziprasidone, Clozapine, Haloperidol, Olanzapine, Phenothiazines
(ZCHOP)
103
What are some CYP1A2 inhibitors?
Quinolones, Macrolides, Fluvoxamine
| QMF
104
What drug can worsen Clozapine's agranulocytosis SE?
Carbamazepine
105
Common DDIs with antipsychotics based on their side effects?
```
Additive effects based on:
- Anticholinergic
- Antihistamine
- Alpha-1 adrenergic blockade
- Dopamine blockade
- CNS depressant effects
(AAADC)
```
106
How is efficacy monitored in Schizophrenia?
Mental State Examinations (non-specific)
| Psychiatric rating scales
107
How is toxicity monitored in Schizophrenia?
Metabolic parameters
| EPSE: presence of symptoms
108
How is Drug induced pseudo parkinsonism (EPSE) monitored in Schizophrenia?
Simpson Angus Rating Scale
109
How is Akathisia (EPSE) monitored in Schizophrenia?
Barnes Akathisia Scale
110
How is Tardive Dyskinesia (EPSE) monitored in Schizophrenia?
AIMS (Abnormal Involuntary Movement Scale)
| DISCUS (Dyskinesia Identification System: Condensed User Scale)
111
When a patient is newly initiated on antipsychotics, what kind of benefits can they expect in the 1st week?
Lowered: agitation, aggression, hostility
| *Patients will feel sleepy
112
When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 2nd-4th week?
Lowered: paranoia, hallucinations, bizarre behaviors
Improved: organization in thinking
113
When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 6th week?
Lowered: delusions
Improved: Negative Symptoms
114
When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 3rd-6th month?
Improved: maybe Cognitive Symptoms (with SGAs)
115
What kind of benefits can a Schizophrenic patient expect if they are on FGAs only?
Improvement in positive symptoms
116
What kind of benefits can a Schizophrenic patient expect if they are on SGAs only?
Improvement in both positive and mood symptoms
117
What is the main difference between FGAs and SGAs in terms of their side effects?
FGAs: More 'muscle' SEs
SGAs: More metabolic SEs
118
Which SGAs have the least metabolic side effects?
Lurasidone, Aripiprazole, Brexpiprazole, Ziprasidone
| LABZ
119
What can we generally observe for SGAs ending with '-ines'? (e.g. Cloza pine , Olanza pine , Quetia pine
Relatively more sedating and more weight gain
120
What can we generally observe for SGAs ending with '-ones' or '-piprazoles'? (e.g. Risperidone, Lurasidone, Ziprasidone, Aripiprazole)
Relatively less sedating and less weight gain
