Psychotic Disorders

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Psychotic Disorders

  1. 1. Psychotic Disorders Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February, 2004. As of 28Jul07
  2. 2. Dx criteria Q. What are the dx criteria for schizophrenia?
  3. 3. Dx criteria Ans. Two or more of five: 1] delusions 2] hallucinations 3] disorganized speech 4] disorganized behavior or catatonia 5] deficit signs of flat affect, apathy, alogia, and so on [“negative” signs].
  4. 4. Delusions - exception Q. Under what circumstances can you give a person a dx of schizophrenia when delusions is the only one of the five supra that the pt has?
  5. 5. Delusions -exception Ans. When the delusions are “bizarre.” By bizarre, DSM means that the idea could not be true. It could be true, for example, that someone is poisoned, but it could not be true that the pt’s father lives on the planet Jupiter. [Thus, one does not need to dx psychotic disorder NOS when faced with a six month illness that only has bizarre delusions, but can dx “schizophrenia.”]
  6. 6. Hallucinations - exception Q. What characteristics of hallucination allows one to dx a person with schizophrenia even when the individual lacks any of the other four signs of schizophrenia listed supra?
  7. 7. Hallucinations -- exceptions Ans. Two exceptions: 1] “Hearing” a voice constantly reflecting on the pt’s behavior or thoughts. 2] “Hearing two voices conversing with each other.
  8. 8. Catatonia v. paranoid Q. Your pt has the signs of catatonic type and has the signs of the paranoid type, what is the dx?
  9. 9. Catatonic v. paranoid Ans. Catatonic Type. The catatonic type trumps all the other types. Disorganized type also trumps paranoid type.
  10. 10. Deficit signs • Q. Your pt has developed deficit [negative] signs. Besides being part of schizophrenia, what are two other possibilities common in psychiatric practice? [These slides avoid the terms “positive” and “negative” and instead use “psychotic” and “deficit.”]
  11. 11. Deficit signs • A. While the list could be long, two will probably reach the exam question: • -- Parkinsonian signs from the meds. • -- Depression
  12. 12. Schizoaffective Disorder • Q. Criteria for schizoaffective disorder?
  13. 13. Schizoaffective Disorder Ans. Someone who has: • -- signs of a mood disorder • AND • -- delusions or hallucinations for at least two weeks when mood disorder is not present.
  14. 14. Structural Neuroimaging studies Q. Most consistent structural neuro- imaging finding of these pts with schizophrenia in comparison to general population?
  15. 15. Structural Neuroimaging studies Ans. Enlargement of lateral ventricles.
  16. 16. Functional neuroimaging studies Q. What has been the most consistent finding as to functional neuroimaging studies in pts with schizophrenia?
  17. 17. Functional neuroimaging studies Ans. Hypofrontality.
  18. 18. Schizophrenia - death • Q. People with schizophrenia death rate compared with the general population is?
  19. 19. Schizophrenia - death Ans. Die a decade or more earlier. [In 2007, “25 years” has become a common figure.]
  20. 20. Death rate - why Q. List the three reasons why the death rate is higher.
  21. 21. Death rate - why • Suicide rate is much higher • Accidents are much more common • Medical care is more inadequate. • [Side effects of meds that are used to treat the mentally ill may become the fourth.]
  22. 22. Suicide Q. What is rate of suicides?
  23. 23. Suicides Ans. DSM-IV says 10%. More recent studies say 5%.
  24. 24. Suicide risks • Q. What five suicide risk factors DIFFER from the suicide risk factors of the general populations? That is, if you are doing a risk assessment on a pt with schizophrenia, what findings would increase the suicide risk chances with pt with schizophrenia, findings that would not increase the suicide risk in the general population.
  25. 25. Suicide – risk factors Ans. Risk factors that are different from the general population include: • 1. Young • 2. High socioeconomic status • 3. High IQ • 4. Good scholastic record • 5. High aspirations • [This is a pretty common question on Boards, consistent with the focus on passing a safe psychiatrist.]
  26. 26. Proven to reduce suicide in people with schizophrenia • Q. Med/meds proven to reduce suicide rate?
  27. 27. Proven to reduce suicide rate Ans. Clozapine • [lithium’s use probably would be an acceptable answer too, but clozapine has a specific FDA approval for suicidal risk in pts with schizophrenia.]
  28. 28. Suicide - prediction • Q. Status of clinicians ability to predict suicide?
  29. 29. Suicide - prediction Ans. Not able to predict. [This will be correct answer to any question as to ability to predict suicide.]
  30. 30. Aggressive behavior • Q. List three co-morbid disorders that increase risk of aggressive behavior in pts with schizophrenia.
  31. 31. Aggressive behavior Ans. • 1. Substance abuse/dependence [especially PCP, but alcohol, cocaine, and sedatives] • 2. Neurological disorders • 3. Antisocial personality
  32. 32. Prognosis – family hx • Q. Does a hx of mood disorders in the family hx suggest a poorer prognosis for your pt with schizophrenia?
  33. 33. Prognosis – family hx Ans. A family hx that has a mood disorder has a better prognosis.
  34. 34. Prognosis - gender • Q. Does gender make a difference as to prognosis?
  35. 35. Gender Ans. Women have a better prognosis.
  36. 36. Prognosis – age of onset • Q. What about prognosis and age of onset?
  37. 37. Prognosis - age Ans. The later the onset of the illness, the better the prognosis.
  38. 38. Prognosis – Mental Status • Q. What two mental status findings have a good prognosis?
  39. 39. Prognosis – mental status • A. Good prognostic signs are: • -- Lack of anosognosia • -- Signs of mood disorder [Some examiners might accept “seems confused on admission.”]
  40. 40. Prognosis – Course of illness • Q. What course of illness suggests a good prognosis? List two as to onset. List one as inter-episode functioning.
  41. 41. Prognosis - course Ans. The following suggest a relatively good prognosis: • -- acute onset • -- precipitating, traumatic, event • -- good inter-episode functioning
  42. 42. Stages • Q. APA Practice Guideline has what stages for schizophrenia?
  43. 43. Schizophrenia - stages • Ans. • -- Acute • -- Stabilization • -- Stable [“maintenance” also used]
  44. 44. Acute phase • Q. Definition of acute phase?
  45. 45. Acute phase Ans. Beginning with the onset of the episode until the pt reaches what the clinician believes is to be the pt’s baseline.
  46. 46. Course • Q. You are treating a pt during his first break, age 21. What are the chances he will never have another schizophrenic episode?
  47. 47. Course Ans. 10-20%
  48. 48. Maintenance • Q. Indefinite maintenance of antipsychotic meds is recommended when?
  49. 49. Maintenance • Ans. If the pt has had two psychotic episodes within five years.
  50. 50. Stable phase – relapse rate • Q. Within one year, in a pt whose responds adequately to meds in the acute phase, what percentage will relapse if continued on meds? What percentage if meds are discontinued?
  51. 51. Stable phase - relapse Ans. • 1/3 with meds • 2/3 without meds
  52. 52. Predicting who doesn’t need meds • Q. What is a very reliable way to predict which of your pts with schizophrenia will never need meds again after stable stage is reached?
  53. 53. Predicting who will not need meds • Ans. No reliable way to identify this minority.
  54. 54. Poor prognosis • Q. What factors suggest a poor prognosis as to treatment response? Use the following outline. Gender Pre-natal factors Peri-natal factors Pre-morbid functioning Severity of signs of delusion and hallucinations Duration of untreated psychosis EPS side effects Family setting
  55. 55. Poor prognosis - 1 • Ans. Any of the following ten factors decrease the chances of a good prognosis: • 1. male • 2. pre-natal injury • 3. peri-natal injury • 4. severe hallucinations • 5. [see next slide]
  56. 56. Poor prognosis - 2 • 5. Severe delusions • 6. Attentional impairment • 7. Poor premorbid functioning • 8. Long duration of untreated psychosis • 9. Prominent EPS side effects to meds • 10. High levels of expressed emotions in family setting.
  57. 57. Schizophrenia – treatment deficit signs • Q. Proven treatment in controlled studies for deficit [“negative”] signs?
  58. 58. Treatment – deficit signs • Ans. None proven for deficit [negative] signs. When pt does dramatically improve as to deficit signs, may be a function of the switch of meds as to less side effects, not an improvement in the schizophrenia per se.
  59. 59. Treatment - psychosocial • Q. What are the psychosocial approaches to the psychiatric management of schizophrenia?
  60. 60. Treatment - psychosocial Ans. • -- supportive psychotherapy • -- CBT • -- group therapy • -- family therapy • -- social skills training • -- supportive employment • -- ACT/PACT [Might add: encourage the family to join NAMI.]
  61. 61. Treatment – family therapy • Q. During which phase should family therapy begin?
  62. 62. Treatment – family therapy • Ans. Acute phase.
  63. 63. Family therapy • Q. Length of time needed for family therapy to be effective?
  64. 64. Family therapy • Ans. One major study found that less than 9 months was ineffective. [need reference]
  65. 65. ACT/PACT • Q. What is ACT/PACT?
  66. 66. ACT/PACT Ans. • ACT = Assertive Community Treatment • PACT = Program for Assertive Community Treatment. • Above is community based, 7x24, in which the team goes to where each pt is.
  67. 67. ACT/PACT • Q. For what pts is ACT/PACT indicated?
  68. 68. ACT/PACT • Ans. two conditions: • 1] Pt has high risk of hospital readmission. • AND • 2] Unable to use usual community-based [e.g., clinic] resources.
  69. 69. Treatment - benzodiazepines • Q. Role of benzodiazepines in the management of acute phase of schizophrenia
  70. 70. Treatment - benzodiazepines • Ans. Signs of: • -- Agitation • -- Anxiety • -- Catatonia
  71. 71. Treatment - benzodiazepines • Q. Role of benzodiazepines in management of stable phase?
  72. 72. Schizophrenia - benzodiazepines • Ans. In stable phase: • -- Anxiety • -- Insomnia • [while not in Guideline, one can probably assume that if lorazepam was a major success in abolishing catatonia in acute phase, it would be continued.]
  73. 73. Schizophrenia – beta-blockers • Q. In pts with schizophrenia, beta-blockers are used for?
  74. 74. Schizophrenia – beta-blockers • Ans. Recurrent signs listed below in the face of antipsychotic failure • -- Hostility • -- Aggression
  75. 75. Mood stabilizers • Q. When are mood stabilizers used in this disorder?
  76. 76. Mood stabilizers • Ans. In the face of antipsychotic medications failure to prevent RECURRENT: • -- Aggression • -- Hostility
  77. 77. Schizophrenia - ECT • Q. Indications for ECT?
  78. 78. Schizophrenia - ECT • Ans. Indications are: • 1. Catatonia [some might say, catatonia after benzodiazepine failure] • 2. Clozapine failures that have: a. persistent, severe psychosis b. suicidal
  79. 79. Relapse Q. List four causes of relapse in schizophrenia?
  80. 80. Relapse Ans. Causes include: • 1. non-compliant with treatment • 2. stressful event • 3. use of substance or alcohol • 4. natural course of illness
  81. 81. Substance Abuse • Q. Excluding smoking, what percentage of people with schizophrenia have a substance-related disorder?
  82. 82. Substance abuse • Ans. 50%
  83. 83. Dual dxed pts • Q. Best psychiatric management of pt with schizophrenia and a substance dependence?
  84. 84. Dual dxed pt • Ans. Integrated, comprehensive and carried out by the same team. [This is politically correct answer for all dual dx pts, not just those with schizophrenia.]
  85. 85. Treatment of first episode - meds • Q. What meds are indicated for the first episode?
  86. 86. Treatment of first episode - meds Ans. All atypicals except clozapine. [These answers are pre-CATIE. Not yet clear that CATIE will change this in major guidelines.]
  87. 87. Medication effects on second episode • Q. How do medications during the first episode differ from latter episodes as to impact on the pt? For example, your pt had good response to risperidone on 1 mg BID during first episode with side effects of dizziness and dry mouth in his first hospitalization. He failed to take meds after your hospital discharge and was readmitted with another episode of schizophrenia. What would you expect if you use risperidone again?
  88. 88. Medications impact on first episode Ans. Pt is less sensitive as to the therapeutic effects AND less sensitive as to the side effects. You will probably need to use higher dose that 1 mg BID for the second hospitalization and the side effects might be less prominent.
  89. 89. Clozapine as initial medication Q. How does clozapine compare with other antipsychotics for naïve-medication patient? Will it perform better, for example, than chlorpromazine?
  90. 90. Clozapine as initial medication Ans. Will not do better. So, in addition to the usual side effect concerns, you can also point out to the examiners that there is no evidence that clozapine is superior in pts in their first acute episode.
  91. 91. Hx of weight gain, hyperglycemia, or hyperlipidemia • Q. With the hx of weight gain, hyperglycemia or hyperlipidemia with prior antipsychotics, what meds would now likely become first choice if they have not already been used and found wanting?
  92. 92. Hx of weight gain, hyperglycemia or hyperlipidemia • Ans. aripiprazole or ziprasidone.
  93. 93. Weight gain • Q. Weight gain is hypothesized to be associated with which two receptor site?
  94. 94. Weight gain Ans. Meds blocking • H1 • OR • 5-HT2C
  95. 95. Weight gain & med discontinuance • Q. When one discontinues an antipsychotic that apparently was related to gaining weight, what is the impact of discontinuance of that medication on the pt’s weight? Rapidly return to pre-med weight?
  96. 96. Weight gain & med discontinuance Ans. Usually, no further weight gain, but what has been gained will not be automatically loss. If he has gained 25 pounds, losing that weight is not going to take place simply because the med has been discontinued. Still, some pts have had dramatic weight loss on ziprasidone and aripiprazole after being switched from olanzapine.
  97. 97. Action of typicals Q. What is action site of typical antipsychotics?
  98. 98. Action of typicals • Ans. D2 antagonist
  99. 99. Atypicals & dopamine pathways • Q. Which dopamine pathway do most atypicals block?
  100. 100. Atypicals & dopamine pathways • Ans. Mesolimbic. • [exception: aripiprazole]
  101. 101. QTc interval • Q. What is the QTc interval?
  102. 102. QTc interval • Ans. Time from beginning of ventricular depolarization through repolarization. • c = correction for heart rate
  103. 103. EPS & atypicals • Q. Rank the six atypicals in order of EPS tendencies. First list the one with the most EPS, then select the three that have the next most EPS, then one with the next most EPS, and then the one of the six with the least of all.
  104. 104. EPS & Atypicals Ans. • 1. Risperidone MORE than • 2. Aripiprazole = olanzapine = ziprasidone MORE that • 3. Quetiapine MORE than • 4. Clozapine
  105. 105. Torsades de Pointes • Q. What is torsades de pointes?
  106. 106. Torsades de pointes Ans. Prolonged QTc leading to malignant ventricular arrhythmia. Sometimes fatal.
  107. 107. QTc black box • Q. Which antipsychotics have QTc black box? If can only think of one, fine.
  108. 108. QTc black box • Ans. Thioridazine and mesoridazine. [mesoridazine no longer is available]
  109. 109. QTc prolongation • Q. QTc prolongation can result from which receptor being blocked?
  110. 110. QTc prolongation • Ans. Alpha1-adrenergic receptor
  111. 111. D2 occupancy • Q. Two antipsychotics have a wide range as to D2 occupancy depending on doses. Which two?
  112. 112. D2 occupancy • Ans. Olanzapine and quetiapine. • [-- At 6 mg, olanzapine has a 65% occupancy and at 16 mg, an 85% occupancy • -- at 400 mg, quetiapine has a 65% occupancy and at > 800 mg, an 85% occupancy]
  113. 113. Action of atypicals • Q. What is action of atypicals?
  114. 114. Action of atypicals • Ans. D2 and 5-HT2 antagonists.
  115. 115. Blocking D2 • Q. What does blocking D2 produce as to side effects? List the two major headings.
  116. 116. Blocking D2 • Ans. • 1. EPS • 2. Increased prolactin.
  117. 117. EPS • Q. What are the signs of EPS? List three that can occur soon after use of typical antipsychotics.
  118. 118. EPS Ans. Signs include: • -- Parkinsonism • -- Akathisia • -- Dystonia [TD, of course, would be the answer as to long-term use.]
  119. 119. Increased prolactin • Q. Increased prolactin causes?
  120. 120. Increased prolactin Ans. • -- decreased sex drive • -- amenorrhea • -- increased breast size
  121. 121. EPS • Q. Which antipsychotic med has the highest rate of EPS?
  122. 122. EPS Ans. Haloperidol.
  123. 123. TD Q. Which antipsychotic has the highest rate of TD?
  124. 124. TD Ans. Haloperidol.
  125. 125. Prolactin elevation • Q. Which two antipsychotics have a high level of prolactin elevation?
  126. 126. Prolactin elevation • A. Haloperidol and risperidone. [There are others, but these two probably reach the exam’s answers.]
  127. 127. Lipids • Q. Aripiprazole and ziprasidone’s effect on lipids?
  128. 128. Lipids Ans. All to the good: • Decrease LDL • Increase HDL • Decrease triglycerides
  129. 129. Weight gain and dosage • Q. For the pt who seems to gain weight on an antipsychotic med, what is the relationship to med dosage? Does it make a difference if the pt is on 20 mg of olanzapine rather than 10?
  130. 130. Weight gain and dosage • Ans. Not related.
  131. 131. Schizophrenia & diabetes • Q. In medication-naïve people with schizophrenia, what is rate of diabetes?
  132. 132. Schizophrenia and diabetes • Ans. Even in medication-naïve, people with schizophrenia are more likely to have elevated glucose levels
  133. 133. Diabetes risk factors • Q. What are the five risk factors of a pt with schizophrenia developing diabetes?
  134. 134. Diabetes risk factors Ans. Like all of us: • 1. Weight gain • 2. Family hx of diabetes • 3. co-occurring substance abuse/dependence • 4. Inactivity • 5. Lack of access to health care
  135. 135. Anticholinergic side effects • Q. Which antipsychotic has most anticholinergic side effects?
  136. 136. Anticholinergic side effects • Ans. Clozapine
  137. 137. AIMS = ? Q. What does AIMS = ?
  138. 138. AIMS = ? Ans. Abnormal Involuntary Movement Scale.
  139. 139. AIMS Q. In using antipsychotic meds, how often should you do the AIMS? Two answers: 1] If your pt is on typical. 2] If on atypical.
  140. 140. AIMS • Ans. • Typical, q 6 months • Atypical, q 12 months
  141. 141. AIMS – elderly Q. How often to do an AIMS in the elderly?
  142. 142. AIMS - Elderly Ans. Typical: every 3 months Atypical: every 6 months.
  143. 143. Sedation • Q. Which antipsychotic is most sedating?
  144. 144. Sedation • Ans. Clozapine.
  145. 145. Hypotension • Q. Which atypical antipsychotic has highest incidence of hypotension?
  146. 146. Hypotension • Ans. Clozapine • [If examiner is elderly and the question is all antipsychotics, thioridazine also can be mentioned. Thioridazine was frequently associated with fainting in the 1960s.]
  147. 147. SSRIs • Q. When using SSRIs with antipsychotics, what do you need to watch for?
  148. 148. SSRIs • Ans. SSRIs [fluoxetine, paroxetine, fluvoxamine] can inhibit P450 enzymes which can, in turn, elevate antipsychotic blood levels.
  149. 149. BMI • Q. If your pt’s BMI > 25, for what do you want to monitor besides the pt’s weight?
  150. 150. BMI • Ans. BP, serum lipids and blood glucose. You can also mentioned waist-hip ratio despite overlap with BMI. [Some would say do with all people with schizophrenia since people with schizophrenia are prone to metabolic syndrome regardless of meds.]
  151. 151. Monitoring for diabetes • Q. How often to monitor for diabetes of people with schizophrenia who are on an atypical? What to monitor?
  152. 152. Diabetes - monitor • Ans. Monitor 1] fasting blood sugar* or hemoglobin A1c q 4 months for a year [i.e., three times the first year], then annually. *In 2007, some began championing 2 hour post-prandial blood sugar as more meaningful.
  153. 153. Renal failure • Q. If renal failure is a concern, for what to test?
  154. 154. Renal failure • Ans. Microalbuminuria in urine.
  155. 155. Acute phase - environmental • Q. During acute phase, environmental interventions are aimed at?
  156. 156. Acute phase – environmental Ans. Reducing over-stimulation and reducing stress.
  157. 157. Stabilization phase • Q. Your pt has completed acute phase. What is the strategy to medicating the stable phase?
  158. 158. Stabilization phase - meds • Ans. Continue with what worked in acute phase for at least 6 months, except for changes needed to address any side effects.
  159. 159. Antipsychotics - general • Q. In general, antipsychotics meds work relatively well for what symptoms and poorly if at all for what symptoms? Answer as to the major breakdown of symptomotology in schizophrenia.
  160. 160. Antipsychotics - general • Ans. Work well for psychotic* signs, poorly for deficit** and cognitive signs. *Psychotic = “positive” **Deficit = “negative”
  161. 161. Clozapine use • Q. When is clozapine indicated? List three major situations.
  162. 162. Clozapine use • A. Useful for: • -- Suboptimal response with at least two antipsychotic meds [at least one of which is an atypical] • Or • -- persistently suicidal • OR • -- has TD
  163. 163. EPS threshold • Q. Role of EPS threshold concept? This is an historic question as to the use of typicals – no longer an accepted concept.
  164. 164. EPS threshold • Ans. Used as a goal in determining dose level of 1st generation antipsychotics, that is, you would increase the dose level until one achieved max clinical affect or reached EPS signs. Questionable approach. • EPS has no such concept in prescribing in 2nd generation.
  165. 165. Long-acting IMs • Q. List the available long-acting IMs.
  166. 166. Long-acting IMs • Ans. • -- fluphenazine • -- haloperidol • -- risperidone
  167. 167. Prolactin elevation Q. Pt has hx of untoward sensitivity to prolactin elevation with typical antipsychotics. Atypical antipsychotic choices for such a pt ?
  168. 168. Prolactin elevation Ans. Any atypical except risperidone.
  169. 169. Weight gain • Q. Among antipsychotics, which two have greatest weight gain?
  170. 170. Weight gain • Ans. Clozapine and olanzapine.
  171. 171. Glucose abnormalities • Q. Which two antipsychotics have the greatest tendency to have glucose abnormalities?
  172. 172. Glucose abnormalities • Ans. Clozapine and olanzapine.
  173. 173. Lipid abnormalities • Q. Which two antipsychotics have the highest incidence of lipid abnormalities?
  174. 174. Lipid abnormalities • Ans. Clozapine and olanzapine.
  175. 175. QTc prolongation • Q. Which antipsychotics, still on the market, have QTc prolongation. List three in order of severity.
  176. 176. QTc prolongation Ans. Thioridazine MORE than ziprasidone MORE than risperidone
  177. 177. Rapid dissolving forms • Q. Which antipsychotic meds come in rapid dissolving form?
  178. 178. Rapid dissolving form • Ans. Olanzapine and risperidone.
  179. 179. Time to clarify status • Q. When using an antipsychotic, about how long does it take to clarify its clinical usefulness, how many weeks before deciding that it is not efficacious?
  180. 180. Time to clarify status • Ans. 2 – 4 weeks.
  181. 181. Not responding • Q. If a pt is not responding, in addition to the possibility that you selected a medication with no efficaciousness for that pt, what are some other possibilities?
  182. 182. Not responding • Ans. Three: • -- non-adherence [most likely possibility] • -- rapid medication metabolism • -- poor gastrointestinal absorption
  183. 183. Stable phase - psychosocial • Q. List 5 psychosocial treatments that have demonstrated effectiveness in stable phase.
  184. 184. Stable phase - psychosocial • Ans. • 1. family interventions: stress-free and stable setting • 2. assertive community treatment • 3. skills training • 4. supportive employment • 5. CBT
  185. 185. CBT • Q. CBT focuses on?
  186. 186. CBT • Ans. Residual psychotic signs, i.e., delusions and hallucinations that remain.
  187. 187. Supported employment • Q. Supportive employment includes? List 5 characteristics of successful supportive employment programs for people with schizophrenia.
  188. 188. Supportive employment Ans. • -- focus on competitive employment • -- pt’s choice • -- rapid job search • -- integration of rehabilitation and mental health programs • -- unlimited time of job support, i.e., indefinite.
  189. 189. Social skills training • Q. Social skills training consists of? List four characteristics of successful social skills programs?
  190. 190. Social skills training Ans. • -- behavioral based instruction • -- modeling • -- corrective feedback • -- contingent social reinforcement
  191. 191. Half-life -- short • Q. Among antipsychotics, which has shortest half-life?
  192. 192. Half-life -- short Ans. Shortest, loxapine, 4 hours.
  193. 193. Half-life -- long Q. Which antipsychotic has the longest half- life?
  194. 194. Half-life -- long Ans. Aripiprazole, 75 hours.
  195. 195. Informed consent • Q. Usually, of what does informed consent consist relative to your choice of an antipsychotic in a pt hospitalized for the first time?
  196. 196. Informed consent • Ans. • -- nausea • -- orthostatic hypotension • -- dizziness • -- dystonic reactions • -- insomnia • -- sedation • [usually leave longer-term effects, like diabetes and TD, until later as the important immediate goal is to prepare for the immediate untoward events.]
  197. 197. droperidol • Q. Droperidol has a black box for?
  198. 198. droperidol • Ans. QTc interval.
  199. 199. Blood levels • Q. For which antipsychotics can blood levels be of clinical use?
  200. 200. Blood levels • Ans. clozapine and haloperidol
  201. 201. Cheeking • Q. You have a pt who you suspect is cheeking. What meds can be used to address cheeking?
  202. 202. Cheeking • Ans. • Liquid: – Haloperidol – Risperidone Quick dissolving: -- Olanzapine -- Risperidone
  203. 203. Akathisia Q. Treatment for akathisia? Practice Guideline lists 6.
  204. 204. Akathisia Ans. • -- benztropine • -- trihexyphenidyl • -- diphenhydramine • -- amantadine • -- propranolol • -- lorazepam
  205. 205. Dystonia • Q. Treat dystonia with? Practice Guideline lists 3.
  206. 206. Dystonia Ans. • -- benztropine • -- trihexyphenidyl • -- diphenhydramine
  207. 207. Parkinsonism Q. Treat parkinsonism reaction to an antipsychotic with? Practice Guideline list 4.
  208. 208. Parkinsonism • Ans. • -- benztropine • -- trihexyphenidyl • -- amantadine • -- diphenhydramine
  209. 209. Targeted intermittent medicating • Q. Targeted intermittent medicating means slowly tapering the antipsychotic and awaiting signs of illness before re- medicating. Is this a recommended approach to people with schizophrenia?
  210. 210. Targeted intermittent treatment Ans. Not recommended because results 1] in more relapses and 2] more TD.
  211. 211. Discontinuing meds • Q. If you do decide to discontinue the antipsychotic medication, what is the recommended dosing rate of discontinuing the meds?
  212. 212. Discontinue meds • Ans. Decrease 10% a month.
  213. 213. depression • Q. What is the management of signs of depression?
  214. 214. depression • Ans. Depressive signs are common is all three phases. Antipsychotics themselves may improve the depressive signs. If the pt fully meets the DSM-IV criteria for “depressive event,” then you should prescribe an antidepressant.
  215. 215. Obsessive-compulsive signs • Q. What about medicating for obsessive- compulsive signs?
  216. 216. Obsessive-compulsive signs Ans. Consider an antidepressant if obsessions and compulsions are still present after antipsychotics have failed to improve these signs.
  217. 217. Insomnia • Q. What meds for insomnia?
  218. 218. Insomnia • Ans. If antipsychotic is not reaching the insomnia, trazodone, mirtazapine or a benzodiazepine. But first review the dosing schedule of meds already prescribed as there may one about which the pt takes in the AM and is complaining of sedation – or pt takes in the PM and is complaining of very too active. Quetiapine is common HS choice in addition to the three meds listed above.
  219. 219. Agitation • Q. You are called to the ward to prescribe something for a very agitated pt. What to consider? Practice Guideline lists four.
  220. 220. Agitation • Ans. Practice Guideline list four – haloperidol, ziprasidone, olanzapine and lorazepam. There are probably others that are acceptable. Ziprasidone has a specific FDA approval for agitation in schizophrenia.
  221. 221. Delusional disorders - criteria Q. Key aspects to DSM-IV criteria for delusional disorder?
  222. 222. Delusional disorders – criteria Ans. 1. Nonbizarre delusions. 2. Not part of another disorder, especially doesn’t meet criteria for schizophrenia. 3. Distressing to the pt or has led to pt’s becoming socially, educationally or occupationally dysfunctional.
  223. 223. Subtypes Q. Which is most common subtype of delusional disorder?
  224. 224. Subtypes Ans. Persecutory.
  225. 225. Prevalence Q. What is prevalence of delusional disorders?
  226. 226. Prevalence Ans. 0.03% [This DSM-IV-TR percent is lower percentage than some texts.]
  227. 227. Onset Q. Mean age of onset?
  228. 228. Onset Ans. About 40 y/o Ref: Kaplan & Sadock Synopsis
  229. 229. Delusional disorders - gender Q. Which gender is more common?
  230. 230. Delusional disorders - gender Ans. Females. [First & Tasman, p 716]
  231. 231. Delusional disorder - confrontation Q. Place of confrontation to the delusion within the physician-patient relationship?
  232. 232. Delusional disorder - confrontation Ans. Is not helpful at best and destroys physician-pt relationship at worst. [First & Tasman, 717]
  233. 233. Delusional disorder - meds Q. Name meds for this disorder.
  234. 234. Delusional disorder - meds Ans. While antipsychotics and antidepressants have anecdotal support, the examiner’s is probably expecting pimozide. [First and Tasman, p 717]
  235. 235. Shared psychotic disorder – criteria Q. Basic criteria for shared psychotic disorder?
  236. 236. Shared psychotic disorder criteria Ans. Delusion develops in an individual who has a close relationship with another person who already had that delusion – and not part of another disorder. Commonly, parent and child.
  237. 237. Shared delusional disorder gender Q. More common in females?
  238. 238. Shared delusional disorder - gender Ans. Yes, more common in females.
  239. 239. Shared psychotic disorder treatment Q. What is the treatment plan for this disorder?
  240. 240. Shared psychotic disorder treatment Ans. 1. Separate the two people. 2. If the second person is still delusional after a week of separation, begin an antipsychotic. 3. Supportive psychotherapy 4. Steps to avoid social isolation may help prevent reemergence. Treating the first person is obviously a need and family therapy may be important if within a family. [First & Tasman, p 719]
  241. 241. Name Q. Another name for Shared Psychotic Disorder?
  242. 242. Name Ans. Folie a Deux.

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