2. CASE SCENARIO
A 45 year old male patient was brought to the
casualty in agitated state .His wife complains
that he is agitated, talkative and keeps on
mumbling to himself and does not sleep well
at night. When asked about his mumbling, he
says that his wife and children are trying to
poison him. He has been talking to his
mother about this & believes that only she
can save him.( according to his wife , the
mother passed away 20 yrs ago)
3. Family h/o father & mother not alive.3 siblings.
One brother is admitted to mental asylum.
others normal. 2 children - both normal.
Past h/o he had similar symptoms and was on
treatment, but discontinued as soon as his
symptoms disappeared.
O/E—Well built, but poorly nourished. Poor
hygiene. Weight- 50 kg. He is anxious, worried
and suspicious of the interviewer. He is well
oriented, but keeps on talking to himself. All
systems within normal limits.
Biochemical parameters – normal, ECG- normal
4. 1) What is your diagnosis?
Schizophrenia- paranoid (DSM-V-TR)
DSM-V-TR Diagnostic Criteria for Schizophrenia
Two (or more) of the following, each present for a significant
portion of time during a 1-month period
delusions
hallucinations
disorganized speech grossly
disorganized or catatonic behaviour
negative symptoms, i.e., affective flattening, alogia, avolition,
anhedonia
5.
6. Treatment was started and within 2 weeks he
became less agitated and started taking interest in
himself & surroundings & became more co-
operative. Sleeps well at night. After 4 weeks of
treatment, he began to socialise with his family and
neighbours but still continues to have auditory
hallucinations. Adequate dose adjustment was
done.
After 6 months of treatment , all his symptoms
subsided. O/E – adequately nourished. Wt 63 kg.
Very co-operative. Answering to all questions.
Biochemistry :RBS- 180 mg %. Urine sugar +ve
others –normal, ECG – normal
7. PSYCHIATRIC DISORDERS
2 Types - PSYCHOSIS / NEUROSIS
PSYCHOSIS - Insight is absent
Refuses to take treatment
Schizophrenia & Mood disorders…
NEUROSIS – Less serious ,insight is present
Anxiety, OCD, PTSD, Phobias …
12. 4. How will you treat his present agitated state?
Treatment during the acute phase focuses on
alleviating the most severe psychotic symptoms. This
phase usually lasts from 4 to 8 weeks. Antipsychotics
and benzodiazepines can result in relatively rapid
calming of patients.
Haloperidol
Fluphenazine
Olanzapine
Ziprasidone
Less EPS
13. BZD
Lorazepam (Ativan) has the advantage of reliable
absorption when it is administered either orally or
intramuscularly.
The use of benzodiazepines may also reduce the
amount of antipsychotic that is needed to control
psychotic patients.
14. 5) Name a drug that can be used immediately to control
his symptoms. Mention its route and onset of action?
Parenteral short acting drugs
Haloperidol- 5-10 mg intramuscular
Onset of action- 30-60 mts
repeated at 4-8 hrs for the first 24-72 hrs.
Other drugs- fluphenazine
olanzapine
ziprasidone
Other option- BZD
15. 6) Will you use injectable long acting depot
preparation to control his symptoms in acute
phase? Why?
NO
take months to reach a steady-state concentration and are
eliminated very slowly
difficult to correlate clinical effect with dosage, and it is
extremely difficult to make dosage adjustments to manage
side effects.
16. 7) Name the drugs which are available as
long acting preparations. Mention its
indications?
Fluphenazine
Haloperidol long-acting decanoate injections
Risperidone
17. 8) Once his agitation & other symptoms are
controlled, which drug can we use to stabilize
him?
Any atypical agent to control symptoms
acute stage
stabilization stage
stable stage
18. 9) How long should you continue the treatment
for stabilisation?
6 months
19. 10) How does this drug act?
Mesolimbic-mesocortical- behaviour, cognition
Nigrostriatal- vol movement coordination
Tuberoinfundibular – suppresses prolactin secretion
Medullary periventricular – eating
Incertohypothalamic – copulatory behaviour
D2, 5HT2A,D4,D1 - Antagonism
Dopamine Psychosis
20.
21. 11) What are its adverse effects?
1. Cardiovascular
2. Cerebrovascular
3. Neurological – EPS
4. Metabolic
5. Blood
6. Skin eruptions
7. Ocular
8. GI & hepatic S/E
22. 12) What is meant by SDA?
Serotonin Dopamine Antagonist- second generation
antipsychotics.
23. 13) Comment on the efficacy and potency of
antipsychotics.
Efficacy
Positive symptoms- new drugs equal to old drugs
Negative symptoms- newer ones are superior
Potency
high (e.g., haloperidol)
low (e.g., chlorpromazine),
intermediate (e.g., loxapine)
affinity for D2 receptor
24. 14) What are the extrapyramidal side effects
likely to occur?
25. REACTION FEATURES TIME OF MAXIMAL
RISK
TREATMENT
Acute dystonia Spasm of muscles of tongue,
face, neck, back; may mimic
seizures; not hysteria
1 to 5 days Antiparkinsonian agents are
diagnostic and curative
Akathisia Motor restlessness; not
anxiety or "agitation"
5 to 60 days Reduce dose or change
drug; antiparkinsonian
agents,a benzodiazepines or
propranolol b may help
Parkinsonism Bradykinesia, rigidity,
variable tremor, mask facies,
shuffling gait
5 to 30 days; can
recur even after a
single dose
Antiparkinsonian agents
helpfula
Neuroleptic
malignant
syndrome
Catatonia, stupor, fever,
unstable blood pressure,
myoglobinemia; can be fatal
Weeks; can persist
for days after
stopping neuroleptic
Stop neuroleptic
immediately; dantrolene or
bromocriptine c may help;
antiparkinsonian agents not
effective
Perioral tremor
("rabbit
syndrome")
Perioral tremor (may be a
late variant of parkinsonism)
After months or
years of treatment
Antiparkinsonian agents
often helpa
Tardive
dyskinesia
Oral-facial dyskinesia;
widespread choreoathetosis
or dystonia
After months or
years of treatment
(worse on
Prevention crucial;
treatment unsatisfactory
26. 15) What are the antipsychotics C/I in patients with
heart disease?
Prolonged QT interval-
1. Thioridazine
2. Pimozide
3. High doses of haloperidol
4. Ziprasidone
Myocarditis & cardiomyopathy-
clozapine
27. 16) What are the metabolic adverse effects likely
to occur with antipsychotics?
1. Weight gain- max- clozapine & olanzapine
Risperidone produces intermediate weight gain
Quetiapine and ziprasidone produce the least weight
gain.
2. Hyperglycemia ,hyperlipidemia, exacerbation of
existing type 1 and 2 DM, new-onset type 2 DM, and
diabetic ketoacidosis.
28. 17) Name the antipsychotic causing retinopathy.
Thioridazine
18) What are its other significant adverse effects?
Comment on the extrapyramidal A/E produced by
this drug.
Low incidence of adverse EPS increased central
antimuscarinic activity
Depressant effects on cardiac conduction and repolarization.
Impaired ejaculation- alpha blockade, anticholinergic
29. 19) Name the antipsychotic producing
hypersalivation. Why does it cause that? how
will you treat it?
Clozapine
Muscarnic agonism at M4 receptors.
Clonidine , anticholinergics, amitriptyline,scopolamine
patch, ipratropium sublingual spray ,atropine 1% solution,
botulinum toxin
30. 20) Name the longest acting antipsychotic. What
are its other advantages?
Aripiprazole
Aripiprazole and its active metabolite – t½ 75 and 94 hrs
Adv
Long t ½
partial DA agonist, enhance action at these receptors
when there is a low concentration of dopamine and would
block the actions of high concentrations of dopamine
Min weight gain
Lower EPS
Produces no elevation of prolactin
31. 21) Mention the indications & contraindications
of clozapine?
Treatment of refractory schizophrenia.
Clozapine is the first drug to be FDA approved for an
antisuicide indication in schizophrenia pts.
32. Contraindications to clozapine
H/o myeloproliferative disorder
Uncontrolled epilepsy
Paralytic ileus
Clozapine-induced agranulocytosis or
granulocytopenia
with caution
patients who cannot tolerate anticholinergic
effects.
at risk for drug-induced orthostasis.
significant renal or hepatic disease.
33. 22)How will you monitor a patient on clozapine?
Monitoring of WBC count
Weekly monitoring- 6 months
Every 3 weeks – next 6 months
Monthly there after.
Monitoring of body weight, lipid profile, blood
glucose level also important.
34. 23) Name the antipsychotic with antianxiety &
antidepressant action. What are its advantages and
disadvantages?
Ziprasidone – antianxiety & antidepressant
Adv
im formulation
Min metabolic A/E, EPS, sedation
Disadv
Short t ½
Cardiac depressant action
35. 24)Name the atypical agent preferred in autism?
What are its advantage and disadvantage ?
Risperidone
ADV- similar to other atypical drugs, though EPS more than the
other atypical drugs
DISADV- hyperprolactinemia
36. 25) Name the only antipsychotic given sublingually.
Asenapine
26) Name a 1st generation antipsychotic with
metabolic side effects. ( Wt gain,
Hyperglycemia,Hypertriglyceremia)
Chlorpromazine
Perceptual misinterpretation of a real external stimulus. Compare with hallucination-ILLUSION
long-acting depot medications can be useful for maintenance therapy in patients with a history of nonadherence to their oral medication and in those who prefer the convenience of long-acting or depot injections. In these situations, the oral form of available depot medications should be initiated first. If the oral form has been shown to be safe and effective, the patient can be converted to the depot form
Agranulocytosis (granulocyte count less than 500/mm3)
is a fatal side effect of antipsychotic drugs. The risk of
agranulocytosis with clozapine is 1% and is greatest early in
treatment, usually within the first 8 to 12 weeks of treatment.
It tends to occur slightly more often in women, the elderly,
and young patients (less than 21 years old).
