Topic 8 Schizophrenia Spectrum Disorders Part 2

• What are signs of extrapyramidal syndrome in someone currently taking Perphenazine?

  Drooling and involuntary arm movements an continual pacing.
• Risks when taking antipsychotics would be weight gain.
• Antipsychotics are used to treat psychotic disorders like schizophrenia.
• First generation antipsychotics are considered typical and are dopamine receptor antagonists.
• First generation antipsychotic examples are Haloperidol and Chlorpromazine.
• Second generation antipsychotics are considered atypical and are serotonin and dopamine receptor antagonists.
• Second generation antipsychotic medication examples are Clozapine and Risperidone.
• First generation antipsychotics work by reducing positive symptoms but have little effect on negative symptoms.
• Second generation antipsychotics treat positive symptoms and negative symptoms but improvement in negative and cognitive symptoms are are usually less.
• Second generation antipsychotic drugs also produce fewer and better tolerated side effects.
• It usually takes 2 - 6 weeks for antipsychotics to become effective.
• Dosages have to be patient specific to find a good balance between side effects and effectiveness.
• Monotherapy is recommended for antipsychotics but if there is failure after two monotherapy trials, Clozapine trials are justified.
• If after 2 monotherapy trials and a Clozapine trials fail, a second antipsychotic may be used to improve the response of another.
• Antipsychotics are not addictive but should be tapered off to reduce risk of discontinuation syndrome.
• What are symptoms of discontinuation syndrome?

  Dizziness, nausea, tremors, insomnia, electric shock like pains, and anxiety.
• A less known risk of all antipsychotics due to dopamine blockage or sedation is impaired swallowing which can cause drooling and risk of choking.
• Antipsychotic medications also run the risk of increased falls due to orthostatic hypotension, sedation, and gait impairment.
• Liquid or fast dissolving forms for antipsychotics can make it harder for patients to hide their medications but some are available in short acting injectable forms for emergencies.
• When antipsychotics are injected, the side effects can be intensified and less easily managed.
• Long acting injectable formulations of antipsychotics need to be administered only every 2 weeks or even months.
• Less frequent administrations with long acting injectables can reduce conflict and adherence is improved.
• First generation antipsychotics are used less due to minimal impact on negative symptoms and higher level of challenging side effects.
• First generation antipsychotics are cheaper, still effective against positive symptoms and have less of a chance of developing metabolic syndrome compared to second generation antipsychotics.
• Blocking dopamine in first generation antipsychotics can cause EPS or extrapyramidal side effects.
• What are extrapyramidal side effects?

  Acute dystonia, akathisia, pseudoparkinsonism.
• Higher potency first generation antipsychotics like Haloperidol have higher chances of giving EPS.
• Clozapine and Risperidone are second generation antipsychotics.
• Other first generation antipsychotic side effects are sedation, orthostatic hypotension, lowered seizure threshold (higher chance of seizures), photosensitivity, cataracts, or other visual changes.
• Release of prolactin from first generation antipsychotics can cause sexual dysfunction while other abnormalities can be galactorrhea (milk nipple discharge), amenorrhea, gynecomastia.
• Weight gain from antipsychotics can increase risk of cardiovascular disorder, diabetes, and psychological distress.
• Sedation as a side effect with first generation antipsychotics can occur initially but improve later.
• Abnormal Involuntary Movement Scale (AIMS) is a scale used to measure the severity of involuntary movements
• Potentially dangerous side effects of first generation antipsychotics can be anticholinergic toxicity, neuroleptic malignant syndrome, and QT interval prolongation.
• What is akathisia, an EPS?

  Restlessness that causes pacing or inability to stay still in one place. This has the highest risk for suicidality.
• What is tardive dyskinesia, an EPS?

  Involuntary rhythmic movements starting at the mouth, to face, then to fingers and below.
• What medication can be given to treat akathisia?

  Antiparkinsonians, propranolol, lorazepam, diazepam.
• Screening for abnormal movements with antipsychotics should be done every 3 months minimum.
• Discontinuing the antipsychotic rarely relieves tardive dyskinesia.
• What medication can be given to treat tardive diskinesia?

  Valbenazine or Deutetrabenazine.