PSYT209~ test V (schizophrenia)

The average age of onset is _ in men and _ in women

18; 25

schizophrenia runs in _

families

_ of people are affected by schizophrenia at some point in their life

<1%

_ of people who suffer an episode of schizophrenia will recover completely

25%

What’s does ‘spectrum’ mean?

In the DSM-5, it refers to a group of related mental disorders that share many of the same symptoms

What’s a psychotic disorder?

Psychotic disorders are characterized by psychosis.

Psychosis is a symptom that describes a loss of contact with reality in some way and can include abnormal perceptions, thinking and behavior.

• interferes with the brain’s ability to perceive reality

• can be temporary/acute or chronic and long lasting

Psychosis is a symptom that be demonstrated in many different ways and may look different in each person.

Per the DSM-5 these disorders all have an impairment related to one or more of the following five domains:

1. delusions

2. hallucinations

3. disorganized thinking or speech

4. grossly disorganized or abnormal behavior

5. negative symptoms

delusion

false, fixed belief that is resistant to change when presented with evidence. Delusions can involve any topic but there are few that are more common

delusion of reference

that events in the external environment refer to oneself (may be seen as getting messages from the TV or newspaper)

magical thinking

belief that their thoughts or ideas can cause something to happen

thought withdrawal

that their thoughts have been ‘removed’ by some outside force

persecutory delusion

delusion of persecution

Hallucinations

false, sensory perceptions that occur in the absence of external stimuli.

may occur though any sensory modality (visual, auditory, tactile, olfactory or gustatory)

auditory hallucinations are the most common

• commonly experienced as voices, that may be familiar or unfamiliar

• perceived as separate from the individual’s thoughts

• may be in the form of command hallucinations

Disorganized thinking

thoughts are disorganized and not connected logically. We can assess the degree of disorganization by the individual’s speech

loose associations

ideas shifting quickly from one unrelated topic to another; ideas not connected

flight of ideas

constant shifting from one idea to another; ideas loosely connected.

word salad

words are put together randomly, without any logical connection, may be incoherent

Grossly disorganized or abnormal motor behavior can be demonstrated by:

lack of inhibition and impulse control

unpredictable agitation

purposeless behavior/activities

impaired self care (e.g. poor hygiene or ADLs)

unpredictable or inappropriate emotional responses

regression

catatonic excitement or stupor

echopraxia, posturing or waxy flexibility

Negative symptoms

represent a decrease in motivation, social skills, emotional expression or responsiveness.

Examples include:

flat or blunted affect (absent or limited outward emotional expression)

alogia (poverty of speech)

anhedonia (inability to experience pleasure)

avolition (lack of goal directed behavior)

anergia (abnormal lack of energy)

asociality (lack of interest in social interactions)

flat or blunted affect~ negative symptoms

absent or limited outward emotional expression

alogia~ negative symptoms

poverty of speech

anhedonia~ negative symptoms

inability to experience pleasure

avolition~ negative symptoms

lack of goal directed behavior

anergia~ negative symptoms

abnormal lack of energy

asociality~ negative symptoms

lack of interest in social interactions

Symptoms of schizophrenia have traditionally been placed into these two groups:

positive symptoms (psychosis)

negative symptoms (social and emotional deficits)

There is another group of symptoms, called cognitive symptoms. These are problems that relate to attention, concentration, and memory.

Prevalence~ Schizophrenia Spectrum Disorders

Schizophrenia Spectrum Disorders occur in just under 1% of the general population.

Average age of onset is during late adolescence or in early adulthood.

• average age for men is 18 years of age

• average age for women is 25 years

• slightly more common in males than females

Young adults are at increased risk because of hormonal changes in the brain during puberty.

Schizophrenia may develop at different times of life but is rare.

New onset under the age of 14 years or over 40 years of age is very unusual.

• Onset below the age of 14 correlates with a poor prognosis.

• Onset after 40 years of age is associated with a milder course and better prognosis.

Etiology of Schizophrenia Spectrum Disorders

BRAIN STRUCTURE & CHEMISTRY

GENETIC PREDISPOSITION

ENVIRONMENTAL STRESSORS

Brain Structure & Chemistry

People with schizophrenia have differences in both brain structure and brain chemistry.

Brain structure abnormalities have been identified with neuroimaging studies. They include:

• decrease in brain volume

• changes in gray and white matter

• thinner cerebral cortex

• ventricular enlargement~ the most common finding

Brain chemistry

abnormalities relate to an imbalance of neurotransmitters in the brain.

• Variations in some neurotransmitter levels can lead to positive, negative or cognitive symptoms

The neurotransmitter that is most closely identified with schizophrenia is dopamine

Excessive dopamine activity is believed to be the cause of positive symptoms in schizophrenia.

• Taking drugs like amphetamines or cocaine (dopamine agonists) can briefly cause symptoms of psychosis like hallucinations or delusions.

Antipsychotics, especially the typical or first generation antipsychotics (FGA) work by blocking dopamine receptors to reduce the activity of dopamine.

Genetic Predisposition

There is a strong genetic component associated with the development of a schizophrenia spectrum disorder.

Researchers have been trying to identify genes that could increase a person’s risk.

• several genes have been identified that may increase a person’s risk but only by a small proportion

• there is no one gene capable of causing a schizophrenia spectrum disorder

The risk of developing a schizophrenic disorder does increase in proportion to how closely related the individuals are:

• one parent with schizophrenia ↑ risk 5-8%

• one sibling with schizophrenia ↑ risk up to 10%

• identical twin with schizophrenia ↑ risk up to 50%

The fact that 50% of identical twins don’t develop schizophrenia indicates that genetics are not the only factor involved.

Environmental Stressors

Certain environmental stressors have been statistically associated with an increased risk for developing schizophrenia spectrum disorders.

They include:

• prenatal and birth complications that can harm the developing fetus

• exposure to environmental toxins, infections

• severe childhood stressors (isolation, trauma and abuse)

• substance abuse

• extreme emotional stress

Etiology: Environmental Stressors

Extreme stress can precipitate psychosis in a person who has predisposing factors for schizophrenia.

The onset of schizophrenia is most common during late adolescence and early adulthood.

• leaving home, starting college, living on their own

• starting and ending relationships, heartbreak

• joining the military, going to war

• experimenting with drugs or other risky behaviors

. . . could be the trigger that propels someone at risk into their first episode of psychosis (FEP).

First Episode Psychosis (FEP)

Early or first episode psychosis (FEP) refers to when a person first shows signs of beginning to lose contact with reality.

About 100,000 adolescents and young adults in the US experience FEP each year.

early treatment of psychosis, especially during the first episode, leads to the best outcomes, with the potential to stop or even reverse psychosis.

FEP rarely happens suddenly. Usually, a person has gradual, non-specific changes in thoughts and perceptions.

Early warning signs to watch for include:

• hearing, seeing, believing things that others don’t

• persistent, unusual thoughts or beliefs

• strong, inappropriate emotions or no emotions

• withdrawing from family or friends

• a sudden decline in self-care

• trouble thinking clearly or concentrating

Schizophrenia Spectrum and Other Psychotic Disorders

SCHIZOTYPAL (PERSONALITY) DISORDER

DELUSIONAL DISORDERS

BRIEF PSYCHOTIC DISORDER

SCHIZOPHRENIFORM DISORDER

SCHIZOPHRENIA

SCHIZOAFFECTIVE DISORDER

Schizotypal (Personality) Disorder

Schizotypal Disorder is characterized by a pervasive pattern of social and interpersonal impairments, extreme discomfort in close relationships, cognitive or perceptual distortions and odd or eccentric behaviors.

It is included in the Schizophrenia Spectrum of Disorders and also in the chapter for Personality Disorders.

• may be a precursor to Schizophrenia Spectrum

• symptoms are below the threshold for a psychotic disorder

Delusional Disorders

Delusional Disorders are characterized by the presence of one (or more) delusions with a duration of 1 month or longer.

• no other psychotic symptoms are present

• functioning is not usually impaired

• behavior is not obviously bizarre or odd

Specifier:

• with or without ‘bizarre content’ (clearly not possible)

• specify the type of delusion

erotomanic type~ delusional disorders

belief that someone (often famous or of higher status) is in love with him

grandiose type~ delusional disorders

conviction of having a great (but unrecognized) talent, making an important discovery, being famous or having wealth, power, knowledge

jealous type~ delusional disorders

persistent belief that spouse or lover is unfaithful, searches for evidence to support delusion

somatic type~ delusional disorders

delusion related to their body

persecutory type~ delusional disorders

belief that they are being cheated, followed, harassed, plotted against, maligned, etc.

Brief Psychotic Disorder

Brief Psychotic Disorder is characterized by the sudden onset of at least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized speech, or grossly abnormal psychomotor behavior (including catatonia).

• symptoms last for at least 1 day but less than 1 month

• eventual return to premorbid functioning (e.g. complete recovery)

Schizophreniform Disorder

Schizophreniform Disorder is characterized by symptoms that that meet the same criteria as schizophrenia, except for:

• duration –lasts for at least 1 month but less than 6 months.

• functional impairment is not required for a diagnosis

If the disorder persists, the diagnosis may later be changed to schizophrenia.

• Specifier: with good prognostic features, without good prognostic features

Schizophrenia: DSM-5 Criteria

Acute symptoms (2 or more for at least 1 month):

1. delusions (false, fixed ideas)★

2. hallucinations (false sensory perceptions)★

3. disorganized speech (word salad, echolalia, tangentiality, loose associations, etc.) ★

4. grossly disorganized or catatonic behavior (poor hygiene, regression, agitation, etc.)

5. negative symptoms (diminished emotional expression or avolition)

★at least one of these symptoms must be 1, 2, or 3

Schizophrenia

Less severe symptoms must also be present for at least 6 months as evidenced by the presence of prodromal or residual symptoms:

• prodromal – early symptoms before the onset of acute disease (i.e. changes in perception, cognition, etc.)

• residual – less severe sx that remain after an acute episode (blunted affect, isolation, difficulty communicating, etc.)

Plus the one month of active/acute symptoms

functional ability is significantly impaired in one or more major areas, such as work/school, interpersonal relations, or self-care.

Exclusions – schizophrenia is excluded as a diagnosis if:

• a neurodevelopmental disorder (e.g. Autism Spectrum Disorder, Intellectual Developmental Disorder) is present

• symptoms of a major mood disorder (mania, depression or both) are present

Schizoaffective Disorder

Schizoaffective Disorder is characterized by the psychotic symptoms of schizophrenia (delusions, hallucinations, negative symptoms) in addition to the symptoms of a major mood disorder. The diagnosis will specify type of mood disorder:

• Bipolar Type: with alternating moods that relate to the symptoms of both Manic Episodes and Major Depressive Episodes.

• Depressive Type: with symptoms of Major Depressive Episodes

Substance/Medication Induced Psychotic Disorder

Psychotic symptoms are attributed to the effects of a substance (drugs, toxins, withdrawal, etc.) which cease after removal of the agent.

Specifiers – with onset during intoxication, with onset during withdrawal

Psychotic Disorder Due to another Medical Condition

Psychotic symptoms are attributed to a medical condition (endocrine disorder, metabolic disorder, etc.)

Specifiers – with delusions, with hallucinations

Course of Schizophrenia Spectrum Phases

I. PREMORBID PHASE

II. PRODROMAL PHASE

III. ACTIVE PHASE

IV. RESIDUAL PHASE

Premorbid Phase

The term ‘premorbid’ literally means “before disease”

During the Premorbid Phase, certain personality traits or behaviors may be present even though schizophrenia symptoms are not yet apparent. These can include:

• social impairment, limited emotional expression

• decrease in motivation/goal directed behavior

• initial cognitive symptoms (problems focusing, paying attention)

The more normal the premorbid behavior, the better the prognosis.

Prodromal Phase

‘Prodrome’ or ‘prodromal’ refers to the signs and symptoms that can signal the onset of a disease before more definitive diagnostic criteria have developed.

This phase begins when the premorbid phase ends and lasts until the Active Phase starts.

The time frame is variable:

• may be as short as 2 weeks or may last for years

• the average length of the prodromal period is from 2 to 5 years

Prodromal Phase

The Prodromal Phase is characterized by a significant deterioration in overall abilities.

substantial impairment in role functioning (family, social, occupational, self care).

prominent negative symptoms:

• social withdrawal

• blunted or inappropriate affect

• disorganized behavior, regression

increase in cognitive symptoms

disturbances in perception, thought, belief, mood and/or affect

Active Phase

The Active Phase is the acute schizophrenia episode when psychotic symptoms are most active.

The time between the onset of psychotic symptoms until the start of effective treatment is called the duration of untreated psychosis (DUP).

• Studies show that a longer DUP can increase damage to the brain and worsen the amount of functional decline.

• The average DUP in the US is about 74 weeks.

Residual Phase

In most cases, a Residual Phase follows the Active Phase.

• active psychotic symptoms are gone

• negative and cognitive symptoms continue

• functional impairment is common

As the individual with schizophrenia ages, becoming an elder adult, the severity of their psychotic symptoms tends to decrease which correlates to age related decreases in dopamine activity.

Course of Schizophrenia Spectrum

For most individuals, schizophrenia tends to be a chronic disorder with periods of psychosis (active phase) and periods of remission (residual phase).

• With every episode of psychosis, the individual is less likely to return to as high a level of functioning as he was before the episode.

• Repeated psychotic episodes can result in clinical deterioration, treatment resistance and functional disability.

• Early treatment and fewer episodes of psychosis is associated with a better prognosis.

our goal is to promote remission and prevent psychosis.

Factors that promote remission:

• early dx and treatment

• effective medication

• stable structure and environment

• support system (friends, family, peers)

Factors that promote psychosis:

• longer DUP

• noncompliance with medication

• high levels of stress, lack of structure

• absence of support

final outcome can be complete recovery, a mild disorder or a chronic severe illness~ stats

Statistics vary but studies show:

• at least 25% of people with schizophrenia will have a complete recovery

• 25% will continue to have symptoms but with treatment, their symptoms stabilize and they can function independently

• the remaining patients, approximately 50%, develop a chronic condition with moderate to severe symptoms

The most important factor associated with recovery is early diagnosis and treatment. Other factors associated with a better prognosis include

normal premorbid functioning (unimpaired or well-adjusted)

rapid onset of psychosis (compared to a gradual onset over several years)

older age at onset

• early onset (before 14) is associated with a poor outcome

absence of any close relatives with schizophrenia spectrum disorder

Course of the disorder~ Schizophrenia Spectrum Specifiers

First episode: currently in acute episode, currently in partial remission or currently in full remission

Multiple episodes: currently in acute episode, currently in partial remission or currently in full remission

Continuous: virtually no remission of symptoms

Specify severity~ Schizophrenia Spectrum Specifiers

Severity is rated by assessing the primary symptoms of psychosis (delusions, hallucinations, disorganized speech, abnormal psychomotor behavior and negative symptoms).

• Other symptoms often present (impaired cognition, depression, mania) are also rated.

Each of these symptoms is rated for its current severity on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Catatonia Features specifier~ Schizophrenia Spectrum Specifiers

descriptive specifier that can be used with many psychiatric disorders, but is traditionally seen in schizophrenia spectrum disorders

catatonia

a marked decrease in response to the external environment

catatonic stupor

completely unresponsive, without any verbal or motor responses

• extreme psychomotor retardation, mutism, negativism and posturing

catatonic excitement

extreme psychomotor agitation, frenzied, and purposeless behaviors

Catatonia Features specifier requires at least three of the following

stupor

catalepsy

waxy flexibility

negativism

posturing

mannerism

agitation not influenced by external stimuli

grimacing

echolalia

echopraxia

mutism

stereotype

Treatment Modalities~ types

GROUP THERAPY

SOCIAL SKILLS TRAINING

FAMILY THERAPY

RAISE (Recovery After an Initial Schizophrenia Episode)

PSYCHOPHARMACOLOGY

Treatment Modalities

The severity and type of symptoms, the individual’s current level of functioning, any comorbid psychiatric or medical conditions, and potential for danger (to self or others) will vary greatly for each person with a psychotic disorder.

Treatment is individualized to meet each patients’ needs with the goal of:

• reducing symptoms

• promoting safety

• improving role functioning

• supporting independence

Group therapy

for people with schizophrenia generally focuses on real-life plans, problems, and relationships.

• Benefits include social interaction, sense of cohesiveness, identification and reality testing.

Behavior Therapy

uses behavior modification techniques to help patients change undesirable behaviors.

• Targets specific problematic behaviors, like bizarre, disturbing or deviant behaviors.

social skills training

helps patients improve interpersonal skills and communication.

• taught about nonverbal behaviors (e.g., facial expression, eye contact); paralinguistic features, personal space, etc.

• effective in reducing the social dysfunction often seen in schizophrenia

Family therapy

provides education to family members about the illness, ways to promote family interaction, reduce conflict and improve communication.

• Designed to support the family system, prevent or delay relapse, and help to maintain the client in the community.

• These programs treat the family as a resource rather than a stressor, increasing the patient’s support system in order to reduce the likelihood of relapse.

Community-based treatment programs

provide resources, rehabilitation and support for individuals with serious and persistent mental illness, focusing on:

• links with community agencies

• developing a social support network, finding housing

• coordinated education, vocational training, supported employment

• substance abuse treatment

• mobile crisis intervention

Treatment: RA1SE

In 2008, the National Institute of Mental Health (NIMH) launched the Recovery After an Initial Schizophrenia Episode (RAISE) research project.

• Individuals in RAISE studies who received coordinated specialty care stayed in treatment longer and experienced greater improvement in their symptoms, interpersonal relationships, and quality of life.

• Coordinated specialty care is now the standard of care for treating early psychosis. It is

a recovery-oriented, team approach to treating early psychosis.

Coordinated Specialty Care (CSC)

is an evidence-based model of early intervention for individuals during the first 2 to 3 years after FEP.

• Teams of health care professionals provide individualized case management, medication management, psychotherapy, supported employment and education, family education and support, based on the individual’s needs and preferences.

• Shown to be effective in decreasing DUP and reducing subsequent disability.

Typical Antipsychotics~ meds to know

chlorpromazine (Thorazine)

haloperidol (Haldol)

fluphenazine (Prolixin)

Atypical Antipsychotics~ meds to know

clozapine (Clozaril)

olanzapine (Zyprexa)

risperidone (Risperdal)

quetiapine (Seroquel)

aripiprazole (Abilify)

ziprasidone (Geodon)

paliperidone (Invega)

iloperidone (Fanapt)

asenapine (Saphris)

Antipsychotics

Indications:

• treatment of Schizophrenia Spectrum and Other Psychotic Disorders

• Bipolar and Related Disorders

• Depressive Disorders

• prn for acute mania and aggression

• some have medical uses (preop sedation, antiemetic, intractable hiccups, etc.)

Antipsychotics: Available Forms

Most antipsychotics are available in PO forms (tablets and/or capsules and in liquid form)

Some are available in IM parenteral form (Thorazine, Haldol, Geodon, Abilify)

• IM administration produces a faster onset of action compared to PO

• used for patients who are agitated or aggressive (STAT, emergency administration) or as IM backups for patients with involuntary medication orders

• monitor BP before and after IM injections to avoid orthostatic hypotension (VS required pre- and post-IM)

Depot form, or long-acting IM injections

are available for both typical and atypical antipsychotics.

• good choice for patients who have little insight into their mental illness, feel they don’t need meds and demonstrate poor adherence to medication regimen

• serum drug levels remain at a steady state between injections

• because of the very long half life, dosing may be monthly or every couple of weeks

• monitor blood pressure pre-IM

Depot form antipsychotics include:

Typical Antipsychotics

• haloperidol (Haldol) decanoate

• fluphenazine (Prolixin) decanoate

Atypical Antipsychotics

• risperidone (Risperdal Consta)

• paliperidone (Invega Sustenna)

• aripiprazole (Abilify Maintena)

• olanzapine (Zyprexa Relprevv)

Antipsychotics: MOA

Antipsychotics decrease hallucinations and delusions by blocking dopamine receptors and decreasing the activity of dopamine.

People need normal dopamine levels in the brain for other functions such as:

• control of smooth muscle movement

• regulating prolactin levels

• normal cognitive functioning

When dopamine receptors are successfully blocked and dopamine activity is reduced, effectively decreasing the symptoms of psychosis, what kind of side effects will occur?

movement disorders (EPS)

gynecomastia (breast enlargement) or amenorrhea (absence of menstruation)

cognitive deficits

First Generation Antipsychotics (FGA)~ Typical Antipsychotics

chlorpromazine (Thorazine) was the first effective treatment for schizophrenia in 1952

• MOA: blocks dopamine receptors in the CNS

• effective on positive symptoms: delusions, hallucinations, loose associations, disorganized behavior

• most drug therapy has revolved around development of other dopamine antagonists until the past few decades

Second Generation Antipsychotics (SGA)~ Atypical Antipsychotics

clozapine (Clozaril) was the first atypical

• MOA: affects dopamine, but affects other neurotransmitters as well

• a decreased risk of EPS than the typical antipsychotics (FGA)

• effective on negative symptoms: flat affect, social withdrawal, alogia, apathy, anhedonia

• now only used as a 2nd line of treatment for treatment resistant schizophrenia due to several potentially fatal adverse effects

Clozapine (Clozaril) has a Black Box warning for agranulocytosis

(a potentially fatal blood disorder characterized by critically low WBC/ANC).

• symptoms of agranulocytosis include sore throat, fever, malaise, low WBC/ANC count

• if suspected - hold med, notify psychiatrist and treat the symptoms

• requires close monitoring of lab tests (CBC with differential, ANC)

Clozapine monitoring for agranulocytosis

• baseline CBC/ANC tests before treatment is initiated

• weekly CBC/ANC with differential for 6 months

• CBC/ANC bimonthly for the next 6 months

• then monthly throughout treatment after one year

• weekly for four weeks after discontinuation

The FDA monitors the labs for each person on clozapine to ensure that they are done and within normal limits.

Clozapine (Clozaril) also has a Black Box warning for myocarditis

an inflammation of the myocardium (heart muscle).

symptoms are variable and may include fatigue, malaise, SOB, dyspnea, edema and/or arrhythmia

potentially (but rarely) fatal

• most often seen, but not limited to, the first month of treatment

• if suspected, notify psychiatrist

• clozapine treatment will be discontinued

Clozapine has another serous side effect that does not have a Black Box warning: constipation

Patients on clozapine are monitored every shift with the BCFS. In addition, they receive:

• routine fiber supplements

• daily or BID stool softeners, lactulose and prn Mag Citrate

• KUB (or upright abdomen xray) every quarter

• Staff encourage hydration and daily exercise.

All Antipsychotics: Black Box Warning

All antipsychotics, typical and atypical, have a Black Box warning about use in elderly patients with dementia-related psychosis.

All antipsychotics are contraindicated in elderly patients with dementia-related psychosis.

NMS (Neuroleptic Malignant Syndrome)~ All Antipsychotics: Serious Adverse Effect

potentially fatal adverse effect of antipsychotics

may occur at any time during treatment

symptoms can be variable but may include:

• hyperthermia (102-107º)

• diaphoresis

• tachycardia

• muscular rigidity (↑ CPK lab)

• labile BP

• confusion, Δ in LOC, coma

hold med, notify psychiatrist/RN, treat symptoms

if untreated, death can occur within 24 hours

Antipsychotics: Common Side Effects

sedation (usually transitory)

orthostatic hypotension

anticholinergic effects

may decrease seizure threshold

photosensitivity

hormonal effects (decreased libido, amenorrhea, gynecomastia, insulin resistance/hyperglycemia → weight gain, Metabolic Syndrome)

EPS (Extrapyramidal Symptoms)

Antipsychotics: Metabolic Syndrome

Patients taking atypical antipsychotics are more than twice as likely to develop Metabolic Syndrome, a cluster of conditions that include:

• weight gain, ↑ BMI

• ↑ Blood pressure

• insulin resistance, hyperglycemia

• ↑ lipids (triglycerides, cholesterol)

Together these conditions increase the risk of heart disease, stroke and Type II Diabetes.

EPS (Extrapyramidal Symptoms)~ Antipsychotics: Side Effects

Movement disorders associated with dopamine blockers (most typical antipsychotics):

• Pseudoparkinsonism (tremor, drooling, shuffling gait)

• Dystonia (painful muscle spasms)

• Akathisia (continuous restlessness, fidgeting)

• Akinesia (muscle weakness, ↓ movement)

Above may be treated with Antiparkinson medication.

• Tardive dyskinesia - bizarre facial and tongue movements, difficulty swallowing, sx potentially irreversible, hold med, notify Psychiatrist

NEW – Ingrezza (valbenazine) effective for TD

EPS Treatment

If extrapyramidal side effects occur from neuroleptic drugs, the psychiatrist may:

• reduce the dosage to reduce severity of EPS

• change to a drug that has less potential for causing EPS (from FGA to SGA)

• treat the symptoms with an Antiparkinson Agent

Antiparkinson agents may be scheduled (BID, TID) or prn or both.

Antiparkinson Agents

Indications: treatment of parkinsonism of various causes, including drug-induced (EPS)

MOA: work to restore the natural balance of acetylcholine and dopamine in the CNS

Common side effects:

• anticholinergic effects

• orthostatic hypotension

• dizziness

• sedation

• N/V, GI upset

• increased psychosis

Antiparkinson Drugs

Medications used as antiparkinson drugs include:

benztropine (Cogentin) an anticholinergic

• anticholinergic effects

diphenhydramine (Benadryl) an antihistamine

• anticholinergic effects plus sedation

propranolol (Inderal) a beta-blocker

• cardiovascular effects (↓ HR and BP)

amantadine (Symmetrel) a dopamine agonist

• increased psychosis

Consequences of Schizophrenia

LACK OF TREATMENT

HOMELESSNESS

INCREASED MORTALITY

SUICIDE RISK

INCARCERATION

Lack of Treatment~ Consequences of Schizophrenia

Studies show that at least half of people diagnosed with schizophrenia do not receive treatment.

• The reasons for nonadherence to treatment are many (adverse effects, expense of treatment, anosognosia, residential instability, etc.).

• Nonadherence to therapy is the primary reason for ongoing psychosis, worsening symptoms and progressive damage to the brain.