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antipsychotic treatment and pharmacology
is an important topic let's go over the
highlights here so antipsychotics are
medications also known as neuroleptics
and they are categorized in terms of
typical and atypical they work by
blocking dopamine receptors and thereby
reduce psychotic symptoms these are used
to treat psychotic disorders and also
psychosis that goes along with other
disorders so throughout the lecture
series you've learned that psychosis can
actually appear as a symptom of severe
depression it can also come up during
times of dementia so there are a lot of
uses for antipsychotics and they can
occur in other patients who don't only
have a primary psyche psychotic disorder
as well so let's go through the two
types typical and atypical well examples
of typical neuroleptics include
chlorpromazine thyroid is een
haloperidol a typical examples are
things like risperidone and ziprasidone
so the typical neuroleptics these are d2
dopamine - antagonists they have a
pretty high potency now a typical
neuroleptics do antagonize dopamine -
however their lower potency for that and
they actually also will target serotonin
and histamine receptors as well
the typical neuroleptics tend to be
really good at treating positive
symptoms but the atypicals are actually
better at treating the negative symptoms
which we think of as the core of the
psychotic symptoms typical neuroleptics
because of their dopamine blockade they
can really cause a lot of extrapyramidal
side effects that doesn't happen as much
with the atypical neuroleptics however
these are more likely to cause side
effects like sedation and also weight
gain or metabolic problems when it comes
to the typical neuroleptics there are
again two subtypes there's the high
potency typical neuroleptics and also
low potency typical neuroleptics so
we'll talk a little bit more about those
later and for the atypical Nora
as I said before these tend to not only
block dopamine but they also have a
strong affinity for serotonin alpha
receptors histamine receptors as well in
serotonin so the antipsychotics
basically again these target
dopaminergic neurons that's really the
key and there are a few different
dopamine pathways that you should be
familiar with the nigrostriatal the Me's
a limbic and the tubero infundibular now
neuroleptics are highly fat soluble and
therefore there are a lot of options for
giving these intramuscularly or through
an injection we're gonna review that
later but as a teaser it's important to
know that when it comes to taking an
anti-psychotic medication sometimes
patients are very agitated in the
hospital setting and it's really nice to
have the option to do an injection of
medication likewise some people don't
like taking a pill every day and the
long-acting injectable antipsychotics
actually allow for by monthly or monthly
dosing which can be a nice option for
patients so there are a lot of different
uses for antipsychotic medications some
are of course the primary psychotic
disorders also mood disorders like mania
and depression and Tourette's syndrome
they can also be helpful there so let's
talk a little bit more about the typical
antipsychotics and let's start with the
low potency wands so these have a little
bit of a lower affinity for the dopamine
receptor and examples include cor
promazine and thioridazine now there's a
higher incidence of anticholinergic
effects with these medications and a
lower incidence of the extrapyramidal
side effects that can be very upsetting
to patients also a little bit of a lower
incidence of neuroleptic malignant
syndrome which can be a deadly side
effect of antipsychotic medication the
high potency typical antipsychotics have
a very high affinity for dopamine
blockade and these include haloperidol
flu phenazine and some other examples
listed here there's a very high
incidence of EPS or extrapyramidal
symptoms with these medications and also
neuroleptic malignant syndrome
lower incidence of anticholinergic and
antihistamine problems so what are
extrapyramidal side effects you might be
wondering so it's very important to know
for your boards so extrapyramidal side
effects come from dopamine blockade
typically through that nigrostriatal
pathway and the earliest signs of this
can be acute dystonia now this might
manifest in your patient as something
like an oculogyric crisis where their
eyes kind of roll up in their head it
can also be seen as torticollis or next
stiffness and acute dystonia can be very
distressing to a patient and it can
occur immediately or within hours next
another eps symptoms is brady kinesia or
parkinsonian symptoms so this can look
like masked facies where somebody
doesn't have a lot of expression it can
also look like cogwheel rigidity which
you might test for when you're doing
your physical exam on a patient some
patients have this brady kinesia
or slowed movements and they also can
have a gate where they do something
which is called turning on block meaning
that they will make a sudden stop and
then turn their whole body so it's not
very easy for them to shift and maneuver
as it is for the rest of us they may
also get a tremor which can be a
cardinal feature of a parkinsonian side
effect from this medication another
problem that can occur within months of
starting an anti-psychotic medication is
akathisia this is highly distressing to
patients
so what akathisia is is it's an internal
sense of restlessness it will often
manifest as a patient
pacing maybe tapping their foot or their
hand on their leg they'll often describe
to their doctor that they just feel like
they want to crawl out of their skin so
that's a sign of a Cathie's which again
is very distressing and then a really
important side effect of antipsychotics
to know about is tardive dyskinesia now
it can take years and even decades for a
patient to develop tardive dyskinesia a
little pearl for your exam is that
elderly Caucasian women
her hat highest risk for developing
tardive dyskinesia when they're treated
with an anti-psychotic so what this
actually looks like is abnormal
movements for example of somebody's face
you may see someone sticking their
tongue out repeatedly or smacking their
lips together this can also occur less
frequently in extremities or truncal
areas and the really unfortunate thing
about tardive dyskinesia
is that in most cases it's actually not
reversible so it can be very permanent
and a disfiguring side effect both
traditional and atypical neuroleptics
have similar efficacies in terms of
treating positive symptoms of psychosis
now you might remember the positive
symptoms of psychosis or things like
delusions hallucinations bizarre
behaviors however when it comes to
treating the negative symptoms of
psychosis things like having a flat
effect little motivation poor energy
speech alodia that's better treated with
one of the newer antipsychotics or
atypical antipsychotics so the
traditional antipsychotic side effects
to review them are anti dopaminergic
anti ham which we'll go over that in
more detail in a minute
of course tardive dyskinesia and
dystonia or in other words the EPS
symptoms including brady kinesia and
akathisia neuroleptic malignant syndrome
which we'll talk about in more details
also a serious side effect so in terms
of tardive dyskinesia we talked about it
before but another little pearl to know
this is riding movements of the mouth
and tongue when your patient is
described as having that think tardive
dyskinesia the anti dopaminergic
side-effects are of course the
extrapyramidal symptoms also
hyperprolactinemia and this is due to
interference of dopamine in the tubero
infundibular pathway so patients can
actually end up with so much dopamine
blockade that they get a surge in
prolactin and this can manifest is
actually lactation from the breast and
it can occur in women but also in men
and then neuroleptic malignant syndrome
is another very noteworthy side-effect
to look out for so I mention anti ham
side effects before well let's talk
about that means so that H is
antihistamine where patients can become
very sedated the a is anti alpha
adrenergic side effects this can look
like worth a static hypotension cardiac
arrhythmias and sexual dysfunction the
anti muscarinic side effects include dry
mouth tachycardia
urinary retention blurry vision and
constipation all things that are of
course undesirable to your patient they
may also get weight gain elevated liver
enzymes they may have eye problems or
off the malla logic problems
dermatological problems and seizures and
because tardive dyskinesia is so
incredibly important in a potentially
irreversible and disfiguring side
effects we're mentioning it a lot here
it's really important to know about for
your exam and it's really important to
note that it can lead to that permanent
disfiguration if you have a patient
showing signs of tardive dyskinesia you
really want to consider lowering their
dose of anti-psychotic giving them a
drug holiday from their antipsychotic or
switching them to another agent
preferably an atypical antipsychotic
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