Psych Neuro Exam 3: Lasilla Schizophrenia/Psychosis (p1-69)

Schizophrenia Symptoms

-delusions

-hallucinations

-disorganized ___

-grossly disorganized or ___ behavior

-____ behaviors

speech, catatonic, negative

Schizophrenia

-___ or more symptoms for a significant amount of time during a __ month period

2, 1

Schizophrenia

-significant ___ or ____ dysfunction

social, occupational

Schizophrenia

-continuous signs of symptoms for __ months

6

Schizophrenia

-is a "___ ___ diagnosis"

-exclude mood disorder, medical condition, substance use

-exclude depression with psychotic feature

-exclude schizoaffective disorder

-exclude ICU delirium and sepsis

rule out

Schizophrenia Positive Symptoms

1) ____ -disturbances in perceptions

hallucinations

types of hallucinations

-____ (hear)

-____ (touch)

-____ (taste)

-_____ (smell)

auditory, tactile, gustatory, olfactory

Schizophrenia Positive Symptoms

2) ____- irrational beliefs or thoughts not based in reality

delusions

Schizophrenia Positive Symptoms

3) ____, guarding

4) ____ behavior (lack of self-care, illogical behavior)

suspiciousness, disorganized

Schizophrenia Positive Symptoms- Cognitive Changes

1) deficits in learning, memory, concentration

2) inability to stay on ___

3) disorganized speech and thought

4) inability to ____ abstract or nuanced concepts

topic, comprehend

Patients with schizophrenia may exhibit ____, where part of their story is true and part is a lie

confabulation

Schizophrenia Negative Symptoms

1) ___ (lethargy)

2) affective ____ (decreased range of emotion)

anergia, flattening

Schizophrenia Negative Symptoms

3) ___ (loss of interest)

4) ____ (decreased goal-oriented behavior)

anhedonia, avolition

Schizophrenia Negative Symptoms

5) ___ (social withdrawal)

asociality

Schizophrenia Negative Symptoms-Mood Symptoms

1) Mood may be in ___ to the circumstances surrounding the scenario (mood incongurence)

2) Most often, patients have ___ symptoms

contrast, depressive

DSM-5 "Schizophrenia Spectrum"

1) ___

2) ___

3) ___

4) ____

5) ___ (often in patients who are over 50 years old who have had schizophrenia for a long time)

paranoid, disorganized, catatonic, undifferentiated, residual

ALL schizophrenia includes ____

psychosis

ALL schizophrenia includes psychosis, but NOT ALL psychosis is ____

schizophrenia

With psychosis, symptoms will ___ with treatment (may be caused by medical condition, substance abuse, etc)

resolve

D2 receptor antagonism = ___ symptom alleviation, but causes __ and __ effects

positive, EPS, endocrine

5HT2A antagonism = ___ symptom alleviation, causes LESS EPS

negative

Remember Antipsychotic Agents

1st Gen= mainly ___ antagonists

D2

Remember Antipsychotic Agents

2nd Gen =___ + ___ antagonists

D2, 5HT2A

Antipsychotics with a high 5HT2A: D2 receptor binding ratio (2nd gen) tend to have better antipsychotic ___ and less ___

activity, EPS

5HT1a agonism/5HT1D antagonism/5HT2C antagonism= enhances __ improvement OR causes __ __

symptom, side effects

α₁, H1, and M1 receptor antagonism = ___ effects

adverse

mixed 5HT/NE reuptake inhibition = add on for ___ or to improve ___ symptoms

depression, negative

Initial Patient Assessment

-___ exam to detect comorbid disease or illnesses

-laboratory evaluation

-___ history (to rule out drug induced psychosis, to learn of previous response to antipsychotics, to identify potential drug interaction etiology)

-___ status exam

physical, medication, mental

2 Classifications of Antipsychotic Drug Classes

1. ___ antipsychotics (1st gen)

2. ___ antipsychotics (2nd gen)

typical, atypical

What makes an antipsychotic typical?

-predominant mechanism is ___ receptor antagonism

D2

Nigrostriatal Pathway

-related to ___ and ___

-lower than normal levels of dopamine in this pathway in schizophrenic patient

movement, EPS

Mesolimbic Pathway

-related to ___ symptoms (delusions and hallucinations)

-excess dopamine in this pathway

positive

Neocortical Pathway

-related to ___ and ___ symptoms

-lower than normal levels of dopamine in this pathway in schizophrenic patient

cognitive, negative

Tuberoinfundibular Pathway

-related to ____ and cortisol, prolactin secretion

HPA

Dopamine normally inhibits prolactin release; so blocking the tuberinfundibular pathway with antipsychotics can cause ____ prolactin levels

increased

Typical Antipsychotics-Low Potency Agents

1. _____ (Thorazine)

2. ____ (Mellaril)

chlorpromazine, thioridazine

Typical Antipsychotics-High Potency Agents

1. _____ (Stelazine)

2. _____ (Prolixin)

3. _____ (Navane)

4. ______ (Haldol)

5. ______ (Loxitane)

6. _____ (Trilafon)

trifluoperazine, fluphenazine, thiothixene, haloperidol, loxapine, perphenazine

Typical Antipsychotics Therapeutic Issues

-effective on positive

-ineffective on ___ and ___ symptoms

cognitive, negative

Typical Antipsychotics Therapeutic Issues

-Note that the patient may have slower cognition but the cognition is more ___ because no hallucinations

logical

Typical Antipsychotics Therapeutic Issues

-Note that since there are sparse D2 receptors in the frontal cortex, antipsychotics may cause mild ___ of negative symptoms

worsening

Typical Antipsychotics Therapeutic Issues

-High potency agents are more commonly prescribed BUT are also associated with more ___ (___-dependent)

EPS, dose

Typical Antipsychotics

-block ___ in all 4 dopamine pathways (so decreased positive symptoms, but also decreased pleasure, EPS, some cognitive decreases, increased prolactin)

D2

Loxapine is technically a first-generation antipsychotic, but its potent ___ and ___ antagonism gives it some atypical, second-generation–like effects

D2, 5HT2

___-potency antipsychotics tend to cause more sedation (H1), anticholinergic (M1) side effects, and hypotension (alpha-1)

Low

___-potency antipsychotics tend to cause more EPS (D2)

High

EPS can happen with both 1st gen and 2nd gen agents but is MUCH MORE PREVALENT with ____ gen

1st

EPS 3 Etiologies

1. Excessive dopamine ___

antagonism

EPS 3 Etiologies

2. Imbalance between dopamine blockade and ____

acetylcholine

EPS 3 Etiologies

3. Reflexive release of ____

norepinephrine

D2 receptor blockade of ___% produces positive symptom response

60

D2 receptor blockade of ___-___% produces the optimal symptom response

68-70

D2 receptor blockade of >___% produces positive symptom response PLUS dystonia or NMS response

80

What are the 4 movement disorders?

peuedoparkinsonism, acute dystonia, akasthisia, tardive dyskinesia

Which movement disorder is life-threatening if not quickly intervened upon?

dystonia

Neuroleptic Malignant Syndrome (NMS)

-can happen with either 1st or 2nd gen antipsychotics

-more prevalent with ___ gen antipsychotics

-may happen at any time and at any dose (unlike dystonia)

1st

Neuroleptic Malignant Syndrome (NMS)

-dangerous and ___-threatening

life

Neuroleptic Malignant Syndrome (NMS)

-D2 blockade and imbalanced with acetylcholine

-___, generalized onset

-symptoms similar to serotonin syndrome, include muscle rigidity, tremor, hyperthermia, diaphoresis, etc

rapid

1st Gen Low Potency Agents- Side Effects

-___ prolongation (seen with thioridazine)

-____ (seen with thioridazine)

QTc, opthalmic

1st Gen Low Potency Agents- Side Effects

-____ (bc H1 antagonism)

-___ effect (bc M1 antagonism-dry mouth, urinary retention, constipation, confusion)

-_____ (rapid drop in bp)

-_____ (usually only at high doses)

sedation, anticholinergic, orthostasis, NMS

1st Gen High Potency Agents- Side Effects

-______ prolongation (mostly seen with haloperidol)

-____ disorders (psuedoparkinsonism, TD, akasthisia, dystonia)

-___ (at any dose)

QTc, movement, NMS

What defines "atypicality?"

-more potent ___ antagonism than D2 antagonism

-"rapid on-off" theory- refers to ability of D2 receptor to ___ between molecular hits

5HT2A, recover

The optimal "atypical" ratio isn't established, so each atypical antipsychotic has a ___ profile depending on its specific receptor interactions.

different

2nd Gen Antipsychotics

1. ____ (Clozaril)

2. ____ (Zyprexa)

3. ____ (Seroquel)

4. ____ (Risperdal)

5. _____ (Invega)

6. _____ (Fanapt)

7. ______ (Saphris, Secuado)

8. ______ (Geodon)

clozapine, olanzapine, quetiapine, risperidone, paliperidone, iloperidone, asenapine, ziprasidone

3rd Gen Antipsychotics

1. _____ (Abilify)

2. ____ (Rexulti)

3. _____ (Latuda)

4. _____ (Vraylar)

5. ____ (Caplyta)

aripiprazole, brexpiprazole, lurasidone, cariprazine, lumateperone

As you move from 2nd toward 3rd generation antipsychotics, there’s generally ____ weight gain, but sometimes at the cost of slightly ___ efficacy.

less, lower

Atypical Antipsychotic Therapeutic Issues

-effective in improving positive and cognitive symptoms, but only marginally effective on ___ symptoms

negative

Atypical Antipsychotic Therapeutic Issues

-relatively low risk of ____ if within therapeutic range, but can induce TD if doses exceed therapeutic ranges

EPS

Atypical Antipsychotics are considered ___ line for schizophrenia

1st