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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 10July2012. Dx criteria. Q. What are the dx criteria for schizophrenia?. Dx criteria. Ans. Two or more of five: 1] delusions

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psychotic disorders

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 10July2012

dx criteria
Dx criteria

Q. What are the dx criteria for schizophrenia?

dx criteria1
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].

delusions exception
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?

delusions exception1
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.”]

hallucinations exception
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?

hallucinations exceptions
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.

catatonia v paranoid
Catatonia v. paranoid

Q. Your pt has the signs of catatonic type and has the signs of the paranoid type, what is the dx?

catatonic v paranoid
Catatonic v. paranoid

Ans. Catatonic Type. The catatonic type trumps all the other types. Disorganized type also trumps paranoid type.

deficit signs
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.”]

deficit signs1
Deficit signs

Ans. While the list could be long, two will probably reach the exam question:

  • -- Parkinsonian signs from the meds.
  • -- Depression
schizoaffective disorder
Schizoaffective Disorder
  • Q. Criteria for schizoaffective disorder?
schizoaffective disorder1
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. [note, not “schizophrenia,” but “delusions or hallucinations.”]
structural neuroimaging studies
Structural Neuroimaging studies

Q. Most consistent structural neuro-imaging finding of these pts with schizophrenia in comparison to general population?

structural neuroimaging studies1
Structural Neuroimaging studies

Ans. Enlargement of lateral ventricles.

functional neuroimaging studies
Functional neuroimaging studies

Q. What has been the most consistent finding as to functional neuroimaging studies in pts with schizophrenia?

functional neuroimaging studies1
Functional neuroimaging studies

Ans. Hypofrontality.

schizophrenia death
Schizophrenia - death
  • Q. People with schizophrenia death rate compared with the general population is?
schizophrenia death1
Schizophrenia - death

Ans. Die a decade or more earlier. [since 2007, “25 years” has become a common figure.]

death rate why
Death rate - why

Q. List the three reasons why the death rate is higher.

death rate why1
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.]
suicide
Suicide

Q. What is rate of suicides?

suicides
Suicides

Ans. DSM-IV says 10%. More recent studies say 5%.

suicide risks
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.
suicide risk factors
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.]
proven to reduce suicide in people with schizophrenia
Proven to reduce suicide in people with schizophrenia
  • Q. Med/meds proven to reduce suicide rate?
proven to reduce suicide rate
Proven to reduce suicide rate

Ans. Clozapine

  • [Lithium’s use might be an acceptable answer too, but clozapine has a specific FDA approval for suicidal risk in pts with schizophrenia. Li does not.]
suicide prediction
Suicide - prediction
  • Q. Status of clinicians ability to predict suicide?
suicide prediction1
Suicide - prediction

Ans. Not able to predict.

[This will be correct answer to almost any question as to ability to predict suicide, not just the psychotic disorders.]

aggressive behavior
Aggressive behavior
  • Q. List three co-morbid disorders that increase risk of aggressive behavior in pts with schizophrenia.
aggressive behavior1
Aggressive behavior

Ans.

  • 1. Substance abuse/dependence [especially PCP, but alcohol, cocaine, and sedatives]
  • 2. Neurological disorders
  • 3. Antisocial personality
prognosis family hx
Prognosis – family hx
  • Q. Does a hx of mood disorders in the family hx suggest a poorer prognosis for your pt with schizophrenia?
prognosis family hx1
Prognosis – family hx

Ans. A family hx that has a mood disorder has a better prognosis.

prognosis gender
Prognosis - gender
  • Q. Does gender make a difference as to prognosis?
gender
Gender

Ans. Women have a better prognosis.

prognosis age of onset
Prognosis – age of onset
  • Q. What about prognosis and age of onset?
prognosis age
Prognosis - age

Ans. The later the onset of the illness, the better the prognosis.

prognosis mental status
Prognosis – Mental Status
  • Q. What two mental status findings have a good prognosis?
prognosis mental status1
Prognosis – mental status
  • A. Good prognostic signs are:
  • -- Lack of anosognosia
  • -- Signs of mood disorder

[If neither of the above two are among the choices, seems confused may be the correct answer.]

prognosis course of illness
Prognosis – Course of illness
  • Q. What course of illness suggests a good prognosis?

List two as to onset.

List one as inter-episode functioning.

prognosis course
Prognosis - course

Ans. The following suggest a relatively good prognosis:

  • -- acute onset
  • -- precipitating, traumatic, event
  • -- good prior-episode or good inter-episode functioning
stages
Stages
  • Q. APA Practice Guideline has what stages for schizophrenia?
schizophrenia stages
Schizophrenia - stages
  • Ans.
  • -- Acute
  • -- Stabilization
  • -- Stable [“maintenance” also used]
acute phase
Acute phase
  • Q. Definition of acute phase?
acute phase1
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.

course
Course
  • Q. You are treating a pt during his first break, age 21. What are the chances he will never have another schizophrenic episode?
course1
Course

Ans. 10-20%

maintenance
Maintenance
  • Q. Indefinite maintenance of antipsychotic meds is recommended when?
maintenance1
Maintenance
  • Ans. If the pt has had two psychotic episodes within five years.
stable phase relapse rate
Stable phase – relapse rate
  • Q. Within one year, in a pt who responds adequately to meds in the acute phase, what percentage will relapse if continued on meds? What percentage if meds are discontinued?
stable phase relapse
Stable phase - relapse

Ans.

  • 1/3 with meds within one year
  • 2/3 without meds within one year
predicting who doesn t need meds
Predicting who doesn’t need meds
  • Q. Is there a very reliable way to predict which of your pts with schizophrenia will never need meds again after stable stage is reached?
predicting who will not need meds
Predicting who will not need meds
  • Ans. No reliable way to identify this minority.
poor prognosis
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

poor prognosis 1
Poor prognosis - 1
  • Ans. Any of the following ten factors decreases the chances of a good prognosis:
  • 1. male
  • 2. pre-natal injury
  • 3. peri-natal injury
  • 4. severe hallucinations
  • 5. [see next slide]
poor prognosis 2
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.
schizophrenia treatment deficit signs
Schizophrenia – treatmentdeficit signs
  • Q. Proven treatment in controlled studies for deficit [“negative”] signs?
treatment deficit signs
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.
treatment psychosocial
Treatment - psychosocial
  • Q. What are the psychosocial approaches to the psychiatric management of schizophrenia?
treatment psychosocial1
Treatment - psychosocial

Ans.

  • -- supportive psychotherapy
  • -- CBT
  • -- group therapy
  • -- family therapy
  • -- social skills training
  • -- supportive employment
  • -- ACT/PACT
treatment family therapy
Treatment – family therapy
  • Q. During which phase should family therapy begin?
act pact
ACT/PACT
  • Q. What is ACT/PACT?
act pact1
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, there home, their bar, whatever.
act pact2
ACT/PACT
  • Q. For what pts is ACT/PACT indicated?
act pact3
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.
treatment benzodiazepines
Treatment - benzodiazepines
  • Q. Role of benzodiazepines in the management of acute phase of schizophrenia
treatment benzodiazepines1
Treatment - benzodiazepines
  • Ans. Signs of:
  • -- Agitation
  • -- Anxiety
  • -- Catatonia
treatment benzodiazepines2
Treatment - benzodiazepines
  • Q. Role of benzodiazepines in management of stable phase?
schizophrenia benzodiazepines
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.]
schizophrenia beta blockers
Schizophrenia – beta-blockers
  • Q. In pts with schizophrenia, beta-blockers are used for?
schizophrenia beta blockers1
Schizophrenia – beta-blockers
  • Ans. Recurrent signs listed below in the face of antipsychotic failure
  • -- Hostility
  • -- Aggression
mood stabilizers
Mood stabilizers
  • Q. When are mood stabilizers used in this disorder?
mood stabilizers1
Mood stabilizers
  • Ans. In the face of antipsychotic medications failure to prevent RECURRENT:
  • -- Aggression
  • -- Hostility
schizophrenia ect
Schizophrenia - ECT
  • Q. Indications for ECT?
schizophrenia ect1
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

relapse
Relapse

Q. List four causes of relapse in schizophrenia?

relapse1
Relapse

Ans. Causes include:

  • 1. non-compliant with treatment
  • 2. stressful event
  • 3. use of substance or alcohol
  • 4. natural course of illness
substance abuse
Substance Abuse
  • Q. Excluding smoking, what percentage of people with schizophrenia have a substance-related disorder?
dual dxed pts
Dual dxed pts
  • Q. Best psychiatric management of pt with schizophrenia and a substance dependence?
dual dxed pt
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.]

treatment of first episode meds
Treatment of first episode - meds
  • Q. What meds are indicated for the first episode?
treatment of first episode meds1
Treatment of first episode - meds

Ans. All atypicals except clozapine.

[This answer is pre-CATIE. Would be hard to justify this post-CATIE if someone preferred perphenazine.]

medication effects on second episode
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?
medications impact on first episode
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.

clozapine as initial medication
Clozapine as initial medication

Q. How does clozapine compare with other antipsychotics for naïve-medication patient? Will it perform better, for example, than chlorpromazine?

clozapine as initial medication1
Clozapine as initial medication

Ans. Will not do better. So, in addition to the usual side effect concerns, there is no evidence that clozapine is superior in pts in their first acute episode. Clozapine might be the correct answer in highly suicidal pt.

hx of weight gain hyperglycemia or hyperlipidemia
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?
weight gain
Weight gain
  • Q. Weight gain is hypothesized to be associated with which two receptor site?
weight gain1
Weight gain

Ans. Meds blocking

  • H1
  • OR
  • 5-HT2C
weight gain med discontinuance
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?
weight gain med discontinuance1
Weight gain & med discontinuance

Ans. Usually, no further weight gain, but what has been gained will not be automatically loss. If pt 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.

action of typicals
Action of typicals

Q. What is action site of typical antipsychotics?

action of typicals1
Action of typicals
  • Ans. D2 antagonist
atypicals dopamine pathways
Atypicals & dopamine pathways
  • Q. Which dopamine pathway do most atypicals block?
atypicals dopamine pathways1
Atypicals & dopamine pathways
  • Ans. Mesolimbic.
  • [exception: aripiprazole]
qtc interval
QTc interval
  • Q. What is the QTc interval?
qtc interval1
QTc interval
  • Ans. Time from beginning of ventricular depolarization through repolarization.
  • c = correction for heart rate
torsades de pointes
Torsades de Pointes
  • Q. What is torsades de pointes?
torsades de pointes1
Torsades de pointes

Ans. Prolonged QTc leading to malignant ventricular arrhythmia. Sometimes fatal.

qtc black box
QTc black box
  • Q. Which antipsychotics have QTc black box?
qtc black box1
QTc black box
  • Ans. Thioridazine and mesoridazine. [mesoridazine no longer is available]
qtc prolongation
QTc prolongation
  • Q. QTc prolongation can result from which receptor being blocked?
qtc prolongation1
QTc prolongation
  • Ans. Alpha1-adrenergic receptor
action of atypicals
Action of atypicals
  • Q. What is action of atypicals?
action of atypicals1
Action of atypicals
  • Ans. D2 and 5-HT2 antagonists.
blocking d2
Blocking D2
  • Q. What does blocking D2 produce as to side effects? List the two major headings.
blocking d21
Blocking D2
  • Ans.
  • 1. EPS
  • 2. Increased prolactin.
slide111
EPS
  • Q. What are the signs of EPS? List three that can occur soon after use of typical antipsychotics.
slide112
EPS

Ans. Signs include:

  • -- Parkinsonism
  • -- Akathisia
  • -- Dystonia

[TD, of course, would be the answer as to long-term use.]

increased prolactin
Increased prolactin
  • Q. Increased prolactin causes?
increased prolactin1
Increased prolactin

Ans.

  • -- decreased sex drive
  • -- amenorrhea
  • -- increased breast size
slide115
EPS
  • Q. Which antipsychotic med has the highest rate of EPS?
slide116
EPS

Ans. Haloperidol.

slide117
TD

Q. Which antipsychotic has the highest rate of TD?

slide118
TD

Ans. Haloperidol.

prolactin elevation
Prolactin elevation
  • Q. Which two antipsychotics have a high level of prolactin elevation?
prolactin elevation1
Prolactin elevation
  • A. Haloperidol and risperidone.

[There are others, but these two probably reach the answers.]

lipids
Lipids
  • Q. Aripiprazole and ziprasidone’s effect on lipids?
lipids1
Lipids

Ans. All to the good:

  • Decrease LDL
  • Increase HDL
  • Decrease triglycerides
weight gain and dosage
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?
weight gain and dosage1
Weight gain and dosage
  • Ans. Not related.
schizophrenia diabetes
Schizophrenia & diabetes
  • Q. In medication-naïve people with schizophrenia, what is rate of diabetes?
schizophrenia and diabetes
Schizophrenia and diabetes
  • Ans. Even in medication-naïve, people with schizophrenia are more likely to have elevated glucose levels
diabetes risk factors
Diabetes risk factors
  • Q. What are the five risk factors of a pt with schizophrenia developing diabetes?
diabetes risk factors1
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
anticholinergic side effects
Anticholinergic side effects
  • Q. Which antipsychotic has most anticholinergic side effects?
slide131
AIMS = ?

Q. What does AIMS = ?

slide132
AIMS = ?

Ans. Abnormal Involuntary Movement Scale.

slide133
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.

slide134
AIMS
  • Ans.
  • Typical, q 6 months
  • Atypical, q 12 months
aims elderly
AIMS – elderly

Q. How often to do an AIMS in the elderly?

aims elderly1
AIMS - Elderly

Ans.

Typical: every 3 months

Atypical: every 6 months.

sedation
Sedation
  • Q. Which antipsychotic is most sedating?
sedation1
Sedation
  • Ans. Clozapine.
hypotension
Hypotension
  • Q. Which atypical antipsychotic has highest incidence of hypotension?
hypotension1
Hypotension
  • Ans. Clozapine
ssris
SSRIs
  • Q. When using SSRIs with antipsychotics, what do you need to watch for?
ssris1
SSRIs
  • Ans. SSRIs [fluoxetine, paroxetine, fluvoxamine] can inhibit P450 enzymes which can, in turn, elevate antipsychotic blood levels.
slide143
BMI
  • Q. If your pt’s BMI > 25, for what do you want to monitor besides the pt’s weight?
slide144
BMI
  • Ans. BP, serum lipids and blood glucose. You can also mentioned waist-hip ratio despite overlap with BMI.
monitoring for diabetes
Monitoring for diabetes
  • Q. How often to monitor for diabetes of people with schizophrenia who are on an atypical? What to monitor?
diabetes monitor
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.

renal failure
Renal failure
  • Q. If renal failure is a concern, for what to test?
renal failure1
Renal failure
  • Ans. Microalbuminuria in urine.
acute phase environmental
Acute phase - environmental
  • Q. During acute phase, environmental interventions are aimed at?
acute phase environmental1
Acute phase – environmental

Ans. Reducing over-stimulation and reducing stress.

stabilization phase
Stabilization phase
  • Q. Your pt has completed acute phase. What is the strategy to medicating the stable phase?
stabilization phase meds
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.
antipsychotics general
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.
antipsychotics general1
Antipsychotics - general
  • Ans. Work well for psychotic* signs, poorly for deficit** and poorly for cognitive signs.

*Psychotic = “positive”

**Deficit = “negative”

clozapine use
Clozapine use
  • Q. When is clozapine indicated? List three major situations.
clozapine use1
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
prolactin elevation2
Prolactin elevation

Q. Pt has hx of untoward sensitivity to prolactin elevation with typical antipsychotics. Atypical antipsychotic choices for such a pt ?

prolactin elevation3
Prolactin elevation

Ans. Any atypical except risperidone.

weight gain2
Weight gain
  • Q. Among antipsychotics, which two have greatest weight gain?
weight gain3
Weight gain
  • Ans. Clozapine and olanzapine.
glucose abnormalities
Glucose abnormalities
  • Q. Which two antipsychotics have the greatest tendency to have glucose abnormalities?
glucose abnormalities1
Glucose abnormalities
  • Ans. Clozapine and olanzapine.
lipid abnormalities
Lipid abnormalities
  • Q. Which two antipsychotics have the highest incidence of lipid abnormalities?
lipid abnormalities1
Lipid abnormalities
  • Ans. Clozapine and olanzapine.
qtc prolongation2
QTc prolongation
  • Q. Which antipsychotics, still on the market, have QTc prolongation. List three in order of severity.
qtc prolongation3
QTc prolongation

Ans.

Thioridazine

MORE than

ziprasidone

MORE than

risperidone

time to clarify status
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?
time to clarify status1
Time to clarify status
  • Ans. 2 – 4 weeks.
not responding
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?
not responding1
Not responding
  • Ans. Three:
  • -- non-adherence [most likely possibility]
  • -- rapid medication metabolism
  • -- poor gastrointestinal absorption
stable phase psychosocial
Stable phase - psychosocial
  • Q. List 5 psychosocial treatments that have demonstrated effectiveness in stable phase.
stable phase psychosocial1
Stable phase - psychosocial
  • Ans.
  • 1. family interventions: stress-free and stable setting
  • 2. assertive community treatment
  • 3. skills training
  • 4. supportive employment
  • 5. CBT
slide173
CBT
  • Q. CBT focuses on?
slide174
CBT
  • Ans. Residual psychotic signs, i.e., delusions and hallucinations that remain.
supported employment
Supported employment
  • Q. Supportive employment includes? List 5 characteristics of successful supportive employment programs for people with schizophrenia.
supportive employment
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.
social skills training
Social skills training
  • Q. Social skills training consists of? List four characteristics of successful social skills programs?
social skills training1
Social skills training

Ans.

  • -- behavioral based instruction
  • -- modeling
  • -- corrective feedback
  • -- contingent social reinforcement
half life short
Half-life -- short
  • Q. Among antipsychotics, which has shortest half-life?
half life short1
Half-life -- short

Ans.

Shortest, loxapine, 4 hours.

half life long
Half-life -- long

Q. Which antipsychotic has the longest half-life?

half life long1
Half-life -- long

Ans. Aripiprazole, 75 hours.

informed consent
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?
informed consent1
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.]
droperidol
droperidol
  • Q. Droperidol has a black box for?
droperidol1
droperidol
  • Ans. QTc interval.
blood levels
Blood levels
  • Q. For which antipsychotics can blood levels be of clinical use?
blood levels1
Blood levels
  • Ans. clozapine and haloperidol
akathisia
Akathisia

Q. Treatment for akathisia? Practice Guideline lists 6.

akathisia1
Akathisia

Ans.

  • -- benztropine
  • -- trihexyphenidyl
  • -- diphenhydramine
  • -- amantadine
  • -- propranolol
  • -- lorazepam
dystonia
Dystonia
  • Q. Treat dystonia with? Practice Guideline lists 3.
dystonia1
Dystonia

Ans.

  • -- benztropine
  • -- trihexyphenidyl
  • -- diphenhydramine
parkinsonism
Parkinsonism

Q. Treat parkinsonism reaction to an antipsychotic with? Practice Guideline list 4.

parkinsonism1
Parkinsonism
  • Ans.
  • -- benztropine
  • -- trihexyphenidyl
  • -- amantadine
  • -- diphenhydramine
targeted intermittent medicating
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?
targeted intermittent treatment
Targeted intermittent treatment

Ans. Not recommended because results 1] in more relapses and 2] more TD.

discontinuing meds
Discontinuing meds
  • Q. If you do decide to discontinue the antipsychotic medication, what is the recommended dosing rate of discontinuing the meds?
discontinue meds
Discontinue meds
  • Ans. Decrease 10% a month.
depression
depression
  • Q. What is the management of signs of depression in pts with schizophrenia?
depression1
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.
obsessive compulsive signs
Obsessive-compulsive signs
  • Q. What about medicating for obsessive-compulsive signs?
obsessive compulsive signs1
Obsessive-compulsive signs

Ans. Consider an antidepressant if obsessions and compulsions are still present after antipsychotics have failed to improve these signs.

insomnia
Insomnia
  • Q. What meds for insomnia?
insomnia1
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 being too active. Quetiapine is common HS choice in addition to the three meds listed above.
agitation
Agitation
  • Q. You are called to the ward to prescribe something for a very agitated pt. What to consider? Practice Guideline lists four.
agitation1
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.
delusional disorders criteria
Delusional disorders - criteria

Q. Key aspects to DSM-IV criteria for delusional disorder?

delusional disorders criteria1
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.

subtypes
Subtypes

Q. Which is most common subtype of delusional disorder?

subtypes1
Subtypes

Ans. Persecutory.

onset
Onset

Q. Mean age of onset of delusional disorders?

onset1
Onset

Ans. About 40 y/o

Ref: Kaplan & Sadock Synopsis

delusional disorders gender
Delusional disorders - gender

Q. Which gender is more common?

delusional disorders gender1
Delusional disorders - gender

Ans. Females.

[First & Tasman, p 716]

delusional disorder confrontation
Delusional disorder - confrontation

Q. Place of confrontation to the delusion within the physician-patient relationship?

delusional disorder confrontation1
Delusional disorder - confrontation

Ans. Is not helpful at best and destroys physician-pt relationship at worst.

[First & Tasman, 717]

delusional disorder meds
Delusional disorder - meds

Q. Name meds for this disorder.

delusional disorder meds1
Delusional disorder - meds

Ans. While antipsychotics and antidepressants have anecdotal support, exam question may be looking for pimozide.

[First and Tasman, p 717]

shared psychotic disorder criteria
Shared psychotic disorder – criteria

Q. Basic criteria for shared psychotic disorder?

shared psychotic disorder criteria1
Shared psychotic disordercriteria

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.

shared psychotic disorder treatment
Shared psychotic disordertreatment

Q. What is the treatment plan for this disorder?

shared psychotic disorder treatment1
Shared psychotic disordertreatment

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]

slide223
Name

Q. Another name for Shared Psychotic Disorder?

slide224
Name

Ans. Folie a Deux.