Chief Complaint: I want to see my lawyer.

SUBJECTIVE:
HPI: AG is a 32 year old female brought to the state hospital by the polie for her
first admission. !he had reated a disturbane at a loal fast"food restaurant# the
polie were alled# and she was brought to the hospital on an order of proteti$e
ustody. %he patient e&hibits numerous delusions# inluding belie$ing that people
snea' into her room at night and plae a thousand worms inside her body# she is
being raped by passing men on the street# her ideas ha$e been gi$en to a (uban
ommunist who is pretending to be her# her feet were ut off and were reattahed
after they were sent ba' from (entral Ameria# eggs were ta'en from her body#
she used to ha$e transmitters in her ba'bone# and sna'es were in her stomah.
!he also demonstrates some grandiose ideations# inluding belie$ing she used to
be a surgeon# she owns gold# she owns the fast"food restaurant# and she has great
wealth. !he also has rambling speeh.
Past Psych History: )enies any prior hospitali*ations
Family Psych History: laims her family is not really her family and she is not
sure who is her family
PMH: Gallbladder surgery 2 months ago# no doumentation of bro'en hip#
no
doumentation of rape
SH: + tobao ,2 ppd-# denies drug or alohol use. di$ored# li$es in an apartment
alone
Meds: /n'nown
ll: Peniillin " rash
!"S: 0eports oasional GI upset# omplains that worms are inside her stomah
"BJECTIVE:
1!2: Appearane: wf of Hispani ethniity# morbidly obese# modestly dressed
w3some disarray. Hair unwashed
!peeh: lear# onstant# pressured# rambling# flight of ideas# hyper$erbal
1ood: euphori# mar'ed grandiosity
Affet: mood"ongruent
%hought proess: illogial# delusional# grandiose
%hought ontent: no auditory3$isual halluinations# no suiidal3homiidal ideation#
mar'ed delusions with paranoid ideation prominent
1emory: immediate# reent# and remote are fair
(onentration: ade4uate
Intelletual funtion: a$erage
5udgment: mar'edly impaired
Insight: mar'edly impaired
PE: VS: 6P 7893:;# P :9# 00 7<# % 3<.7# =t >< 'g# Ht ;?3# 61I: 3<.> ,@besity
lass II-# (r(l >7 mA3min. !'in: srathes on both hands. 0emainder wnl
Aabs: Beutrophils CCD# Aymphoytes 28D# 1onoytes :D# GG% 3:# %otal
holesterol 29:# Phosphate ;.7# remainder wnl. /rine pregnany negati$e
Complete Pro#lem $ist: Schi%ophrenia& paranoid type& "#esity
Pro#lem ': Schi%ophrenia& paranoid type
Assessment:
%he patient endorses at least 3 of the ; harateristi symptoms of shi*ophrenia
,riterion A from )!1"IE"%0-# inluding delusions# disorgani*ed speeh# and
grossly disorgani*ed beha$ior. 6ased on the information pro$ided in the HPI and
the 1!2# it is diffiult to disern if the patient has any negati$e symptoms
,affeti$e flattening# a$olition# anhedonia# et-. %he patient was disarrayed with
unwashed hair# indiating she may ha$e some impairment in self"are. It is
diffiult to disern if she has demonstrated impairments in other areas of funtion#
suh as wor' or interpersonal relationships. %here is no information pro$ided
regarding duration of symptoms in this patient. In order to warrant a diagnosis of
shi*ophrenia# the patient must ha$e ontinuous signs of disturbane for at least C
months with at least 7 month of symptoms ,less if patient is treated-. Although we
ha$e no information regarding duration of symptoms# the patient does ha$e
harateristi symptoms of shi*ophrenia and would warrant a diagnosis of
shi*ophrenia. !ine the patient has prominent delusions# partiularly perseutory
and grandiose delusions# she would further be lassified as ha$ing paranoid type
shi*ophrenia.
=hile any antipsyhoti ould be used to treat the patient# it is preferred to use a
seond generation antipsyhoti for initial treatment
(TMP Schi%ophrenia al)orithm& accessi#le at
http:**+++,dshs,state,t-,.s*mhpro)rams*disclaimer,shtm/# e&luding
lo*apine whih is reser$ed for treatment resistant ases. @ptions within the
atypial antipsyhoti lass inlude risperidone# 4uetiapine# olan*apine#
aripipra*ole# *iprasidone# paliperidone# and the reently appro$ed# but not yet
a$ailable# iloperidone. %here is no linial e$idene demonstrating that any
atypial agent is more effiaious than another atypial agent. As suh# the
ad$erse effet profile should be ta'en into aount# partiularly for this obese
female. %he propensity for weight gain in the reommended and a$ailable atypial
antipsyhotis is as follows: olan*apine F 4uetiapine F risperidone G paliperidone
F *iprasidone HG aripipra*ole. %he patient?s un'nown employment status and
un'nown insurane status should also be onsidered.
It is important to note that this patient?s primary symptoms are delusions# and
delusions are the last symptom of shi*ophrenia to resol$e# if they do resol$e. %he
possibility of these delusions being fi&ed delusions and unresponsi$e to
mediations should always be onsidered. If the delusions do resol$e with the use
of mediation# it may ta'e from 8 to 72 wee's to resol$e.
Plan:
Goals of therapy: 0esolution of target symptoms I ultimate goal is remission of
symptoms. 1inimi*e ad$erse effets from mediations. Impro$ed 4uality of
life
Bon"pharmaologial plan:
2duate patient about shi*ophrenia and mediations. !tress importane of
adherene with mediation regimen. 0e$iew the onset of effet of mediation
sine effiay is not seen for many wee's and patient should be aware to not
disontinue mediation belie$ing it is ineffeti$e
Pharmaologial plan: Any of the following
0isperidone 7 mg 6I)# titrate up daily by 7"2 mg3day. 1)) per PI: 7C
mg3day# usual dose range 2": mg3day.
Aripipra*ole 79 mg 4A1# titrate up 42wee's to response. 1)) per PI: 39
mg3day# linial trials ha$e used up to 8; mg3day
Juetiapine 2; mg 6I) & 7 day# ;9"<; mg 6I) & 2 days# 7;9"299 mg 6I)#
ontinue to titrate to response. 1)) per PI: :99 mg3day# linial trials
ha$e used up to 7C99 mg3day
@lan*apine 79 mg 4day ,preferentially H!-# titrate up by ; mg3d wee'ly to
response. 1)) per PI: 29 mg3day# linial trials ha$e used up to C9
mg3day. Bo e$idene showing inreased effiay F29 mg3day in treatment
naK$e pts. 1ay be greater effiay with high dose in treatment refratory
patients.
Liprasidone 29 mg 6I) with food ,full meal-# titrate up no more fre4uently
than 2 day inter$als. 1)) per PI: 799 mg 6I)
Paliperidone C mg 4day# titrate up no more fre4uently than ; day inter$als.
1)) per PI: 72 mg
01otes for facilitators
Any atypial antipsyhoti agent# e&ept for lo*apine# would be
appropriate for initial treatment for this patient. Alternati$ely# a typial agent
ould be used# pro$ided that the students pro$ide rationale for hoosing a typial
agent o$er an atypial agent. %he only absolutely wrong answer is lo*apine.
All recommended Max Daily Doses for atypical antipsychotic agents are per
package insert recommendations and based on doses for FDA approvals. All
agents have been used clinically in higher than recommended doses and higher
than recommended doses may be required in order to stabilize patients.
Specific medication notes:
!isperidone: doses F C mg3day onfers greater )2 binding and funtions
similarly to a typial agent. Higher doses are assoiated with a greater ris'
of de$elopment of 2P! and ele$ated prolatin
Paliperidone: the ati$e metabolite of risperidone ,>"hydro&yrisperidone-.
Bo e$idene e&ists indiating that this mediation has any greater effiay than
risperidone. %here are no fewer ad$erse effets# should not be used in patients
with se$ere GI issues ,I6!# stritures# et- beause of the e&tended release @0@!
formulation
and must be dose adMusted in patients with renal dysfuntion. %his ould play a
role in patients with ati$e hepati disease as it does not undergo e&tensi$e hepati
metabolism. @f note# risperidone is a$ailable generially while paliperidone is not.
2.etiapine: has reently beome a$ailable as an N0 formulation.
Pharmao'ineti studies indiate that the pharmao'inetis are not highly
different between the two formulations. Juetiapine I0 an be dosed one daily if
tolerated by the patient. %here is no differene in effiay or ad$erse effets
between the two formulations. %he only differene is prie ,N0 being more
e&pensi$e-.
ripipra%ole: essential that titration is done slowly. Appro&imately 33D of
patients e&periene a'athisia# and this perentage is inreased by 2& if you inlude
those patients who e&periene an&iety. Aow initial doses and slow titrations help
to minimi*e ris' of de$elopment of a'athisia. !hould not be used in ombination
with typial antipsyhoti agents or atypial agents with tight )2 biding ,e.g.
risperidone- beause of the no$el pharmao'inetis of a partial )2
agonism3antagonism
"lan%apine: may ause substantial weight gain in relati$ely short periods of time.
Ha$e been reports of weight gain F39 lbs in 7"2 months with use of olan*apine.
(aution should be ta'en using this mediation in this already obese female. Also
of note: if ben*odia*epines are used to manage agitation3aggression initially in the
patient# are should be ta'en with ombining lora*epam with olan*apine.
@lan*apine I1 and lora*epam I1 should not be used within 7 hour of eah other
as the ombination has been shown to result in se$ere hypotension leading to ases
of oma and death. Although there are no speified reommendations regarding
ombining one oral agent with one I1 agent or both oral agents ombined# aution
should be used and it may be best to separate doses by a minimum of 7 hour. Also
important to note patient?s smo'ing status. )epending on referene# smo'ing may
derease olan*apine serum onentrations anywhere from C9">9D. %his is a
funtion of the aromati hydroarbons in igarette smo'e# not a funtion of
niotine# so this only plays a role if the patient is smo'ing# not if the patient is
reei$ing B0%. Although there are no reommendations regarding dose
adMustments in smo'ers# this should be 'ept in mind if the patient is reei$ing B0%
while inpatient ,when she is disharged if she begins smo'ing again# will ha$e
dereased olan*apine le$els# potentially resulting in readmission-. %his should also
be 'ept in mind in the e$ent that she is stabili*ed on a dose outpatient O deides to
4uit smo'ing
,4uitting smo'ing will result in an inrease in serum olan*apine le$els I may need
to derease dose if patient deides to 4uit-.
Patient may also re4uire an immediate ating agent for management of
agitation3aggression. @lan*apine# *iprasidone# and aripipra*ole are a$ailable in I1
inMetions# whih may help to alle$iate this. @ther options inlude short"term
ben*odia*epine use ,generally lora*epam as it is a$ailable both P@ and I1-.
@ther onsiderations that may be brought up inlude use of orally"disintegrating
agents# inluding 0isperdal 1"tabs# Lypre&a Lydis# and Abilify )is1elts. It is
important to note that there are no pharmao'ineti differenes between @)%s and
regular tablets. %here is no faster onset of ation with @)%s as ompared with
tablets. =hile patients ha$e reported a subMeti$e faster onset of ation with @)%s#
this is a plaebo effet. %he greatest ad$antage for @)%s is to failitate adherene
with mediations initially and is of use in patients who ha$e diffiulty swallowing
tablets.
If long"term adherene is a onern# risperidone is a$ailable as a long"ating
inMetion ,0isperdal (onsta- gi$en I1 42wee's. If onsideration is gi$en to
starting patient on (onsta inMetions for long"term adherene# patient should be
stabili*ed on oral dose first prior to on$ersion. @ral risperidone supplementation
is re4uired for the first three wee's after the first (onsta shot as it ta'es 3 wee's
for the mirospheres in the I1 inMetion to release the drug.
Monitorin):
2ffiay: resolution of symptoms3delusions# may monitor with regular
assessments with 6P0!
(Por all atypial agents-:
6aseline: 61I# PPG3HbA7# fasting lipids# 2P! e$aluation# %) assessment
@ngoing: 61I monthly for C months then 4uarterly
PPG3HbA7 yearly if no diabetes ris' or weight gain
PPG3HbA7 at 8 months then yearly if diabetes ris' or weight gain
Pasting lipids e$ery 2 years if lipid le$els are at goal
Pasting lipids e$ery C months if A)A F 739
Assess for symptoms of ele$ated prolatin ,galatorrhea# amenorrhea#
et- yearly
If symptoms of ele$ated prolatin# prolatin le$el yearly
2P! e$aluation wee'ly after initiation and dose inreases# ontinue & 2
wee's after last dose inrease
%) assessment e$ery 72 months
Eision 4uestionnaire yearly and oular e$aluation 42years
For specific atypical a)ents:
Liprasidone: baseline 2QG# follow"up 2QGs indiated if patient has symptoms of
J% prolongation ,e.g. synope-
Juetiapine: although not speified in PI# baseline O follow"up 2QGs ould be
onsidered. (linially J% prolongation has been reported in greater
inidene with 4uetiapine# partiularly high dose 4uetiapine# than has been
reported with *iprasidone. 1onitor for hypotension O synope.
0isperidone: assess for symptoms of ele$ated prolatin 4uarterly during the first
year of treatment
Pro#lem 3: "#esity
Assessment:
Patient is lassified as ategory II obesity per BH6AI riteria. 0e4uires eduation
regarding weight loss# appropriate dietary hanges# and regular e&erise.
Sample Presenter 2.estions
', Briefly descri#e the 4 -is system
A&is I: linial disorders ,psyhiatri diagnoses-
A&is II: personality disorders and mental retardation
A&is III: general medial onditions
A&is IE: psyhosoial and en$ironmental problems
A&is E: Global assessment of funtioning ,9"799 soring-
3, ccordin) to 5SM6IV& +hat are the dia)nostic criteria for schi%ophrenia7
a. At least two of the following harateristis# eah present for at least
one month
)elusions
Halluinations
)isorgani*ed speeh,e.g. fre4uent derailment or inoherene-
Grossly disorgani*ed or atatoni beha$ior
Begati$e symptoms ,i.e affeti$e flattening# alogia# or a$olition-
b. !oial3oupational dysfuntion
. Any of abo$e symptoms lasting at least si& months
d. !hi*oaffeti$e disorder and 1ood disorder e&lusion
e. Illness not due substane3general medial ondition
f. Illness not due to autism or a per$asi$e de$elopment disorder
8, 9hat does a )lo#al assessment of f.nctionin) score of 83 mean7
!ome impairment in reality testing or ommuniation @0 maMor
impairment in se$eral areas ,suh as wor' or shool# family relations#
Mudgment# thin'ing or mood-.
:, 9hat are the classes of antipsychotics7
Typicals (conventional, dopamine antagonists): haloperidol# fluphena*ine#
thiothi&ene# hlorproma*ine# triflupera*ine and thiorida*ine
Atypicals (second generation, serotonin-dopamine antagonists-:lo*apine#
risperidone# olan*apine# 4uitiapine# *iprassidone# aripripra*ole# and
paliperidone
4, 9hat are some )eneral side effects of typical antipsychotics7
2&trapyrimidal symptoms# sedation# antiolnergi and ardio$asular
effets
;, 9hat are some )eneral feat.res that distin).ish atypical from typical
antipsychotics7
)ereased inidene of 2P! and tardi$e dsy'inesia ,%)-
Aa' of effet on serum prolatin
Greater effiay for refratory shi*ophrenia
Greater ati$ity against negati$e symptoms
<, 9hat is the mechanism of action of antipsychotics7
Postsynapti blo'ade of )
2
and serotonin ;"H%
2A
reeptor sites
Pour dopamine trats in$ol$ed: ,blo'ade leads to-
1esolimbi: redution of positi$e symptoms
1esoortial: redution of negati$e symptoms
Bigrostriatal: e&trapyramidal symptoms ,2P!-
%uberonfundibular: hyperprolatinemia
=, In )eneral& +hat ad>erse effects are associated +ith antipsychotics7
!edation
2P!
Antiholinergi effets
@rthostasis
!ei*ures
Prolatin ele$ation
=eight gain
?, 9hat are e-trapyramidal symptoms
%hey are neurologial ompliations of aused by neurolepti blo'ade of
the )2 reeptors in the basal ganglia and inlude: aute dystoni reations.
a'athisia. pseudo"par'insonism. and tardi$e dys'inesia
'@, In +hat order +o.ld yo. e-pect the EPS to present7
2arly onset:
Aute dystonia ,>9D within 3 days-
A'athisia ,appro& ; days onwards-
Pseudopar'insonism ,: days onwards-
Aate onset:
%ardi$e dys'inesia ,tardi$e dystonia and tardi$e a'athisia-: may present
after 799days or years of treatment
'', 5efine*descri#e dystonia
6rief or proloned musle ontratures ,usually of the head# ne'# and
tongue# oulogyri risis# spasm of the Maw- ourring within a few hours or
days. Aaryngeal dystonias are the most serious and are potentially fatal.
'3, 5escri#e*define aAathisia
%his is a syndrome onsisting of subMeti$e feelings of restlessness or the
urge to mo$e# and an obMeti$e motor omponent e&pressed as
semipurposeful mo$ement most often in$ol$ing the lower e&tremities. It is
hareatei*ed by paing# ro'ing# and inability to sit or stand in one plae
for e&tended periods of time. @bser$ed in up to ;9D of patients treated
with typial and ranges from ;D to 7;D in patients treated with atypial.
(an produe dysphoria and possibly aggressi$e or suiidal beha$ior.
Patients paing around and unable to sit should be assessed for this.

'8, 5escri#e*define pse.do6parAinsonism
%his is harateri*ed by resting tremor# rigidity and brady'inesia. %he
symptoms are $irtually indistinguishable from Par'inson?s )isease. It
ours after a few wee's or more of therapy. A'inesia?s should be
differentiated from primary depression and blunted affet.
':, 9hat is tardi>e dysAinesia7
In$oluntary mo$ements# espeially of the lower fae ,tongue thrusting#
repetiti$e hewing# Maw swinging# and3or faial grimaing- but an inlude
in$oluntary mo$ements of the ne' and trun' or fle&ion of the an'les.
'4, Ho+ do yo. treat T57
If patient is on typial antipsyhoti swith to (lo*apine or other atypial.
@ther agents that ha$e been used with minimal suess inlude dia*epam#
lona*epam# $alproate# propranolol# lonidine# and $itamin 2.
';, Ho+ +o.ld yo. monitor this patient for T57
=ith the )ys'inesia Identifiation !ystem (ondensed /ser !ale
,)I!(/!- or
Abnormal In$oluntary 1o$ement !ale ,AI1!-at the beginning of
treatment and then 4uarterly.
Because it is believed that the risk of T is much less !ith atypicals, this is
only done every "-#$ months in patients on these% &uarterly is the
recommendation for the typicals% A'() is the most commonly administered
and is very easy to use.
'<, 5escri#e IMS,
Interati$e and obser$ational e&amination of in$oluntary mo$ements
Paial and @ral mo$ements " musles of faial e&pression# lips3perioral
area# Maw# and tongue
2&tremity mo$ements I upper ,arms# wrists# hands# fingers- and lower
,legs# 'nees# an'les# toes-
%run' mo$ements I ne'# shoulders# and hips
Global Mudgments I se$erity of abnormal mo$ements# inapaitation due to
abnormal mo$ements# and patient?s awareness of abnormal mo$ements
)ental !tatus I urrent problems with teeth3dentures# does pt wear dentures
Higher sores indiate greater se$erity of impairment
'=, 9hat are the risA factors for EPS7
Rounger age ,S3;-. I1 route of administration# male gender# pre$ious
dystoni reation.
'?, Ho+ +ill I treat ac.te dystonia7
6en*tropine 2mg I13IE or diphenhydramine ;9mg I 799mg I13IE#
resolution within 39 minutes. If no response in 39 minutes# repeat. If no
response after 2 trials# gi$e lora*epam 7mg to 2mg I13IE. If symptoms
return# derease dose# swith to a lower poteny neurolepti or swith to
AAP
3@, Ho+ do I treat Pse.do6ParAinsonism7
In mild ases# immediate inter$ention may not be re4uired if the mo$ement
disorder is not bothersome to the patient
Por troublesome ases# the antipsyhoti an be redued to the lowest
effeti$e dose or swith to a low poteny antipsyhoti or an AAP.
If abo$e does not resol$e par'insonian symptoms# add antipar'insonian
agents: ben*tropine 9.; to 2mg po bid and3or diphenhydramine 2;";9mg po
bid or amantadine 799mg po bid or tid
3', Ho+ lon) sho.ld anticholiner)ic therapy #e7
%hey should be stopped after 78days if asymptomati beause of the
potential to inrease the ris' if tardi$e dys'inesia
33, Ho+ do I treat aAathisia7
A'athisia is less responsi$e to treatment than are antipsyhoti"indued
par'insonism and dystonia. Pirst step is to lower dose. If symptoms persist
then following is attempted
If no 2P!: first hoie is propranolol 79mg to 39mg tid ,ma& 729mg daily-.
!eond option is lora*epam 7mg pot id
If other 2P! is present: ben*tropine 2mg po bid
38, 9hat la# tests +ill #e reB.ired to monitor therapy +ith olan%apine7
Plasting blood gluose. holesterol. speifially %Gs and weight
3:, Ho+ lon) does it taAe for olan%apine to +orA7
%he full effet may ta'e se$eral months. If patient has not responded to a
therapeuti dose by wee' :"72# mo$e on to the ne&t drug.
34, 9hat are the maCor (serio.s/ side effects of clo%apine7
(lo*apine has fi$e bla'bo& warnings from the P)A: agranuloytosis#
sei*ures# myoarditis# inreased mortality in elderly patients with dementia"
related psyhosis# and other ad$erse ardio$asular ,hypotension- and
respiratory effets.
Agranuloytosis ,7D of patients-: re4uires baseline and wee'ly omplete
blood ount ,(6(- and granuloyte ount during early therapy initiation.
Pre4ueny of tests derease with time.
1ay also ause sialorrhea# or hypersali$ation ,inidene ranges from 37D
to :9D-. 1ost often worst at night# and may lead to soial withdrawal#
ho'ing# or aspiration pneumonia.
3;, 5o atypical antipsychotics ha>e any effect on the hypothalamic6pit.itary
system7
0isperidone is the only one really thought to potentially inrease prolatin
le$els. @lan*apine temporarily inrease prolatin.
3<, 9hich of the atypical a)ents is most liAely to ca.se +ei)ht )ain7
(lo*apineFolan*apineF4uitiapineGrisperidoneFaripripra*oleG*iprasidone
3=, 9hat is the mechanism of +ei)ht )ain +ith the atypical a)ents7
%he mehanism of antipsyhoti"indued weight gain is unlear# but
antagonism of histamine H
7
and serotonin ;"H%
2(
reeptors has been
impliated. A geneti predisposition e&ists for weight gain. a mutation in
the ;"H%
2(
reeptor gene may inrease the ris' for weight gain from
atypial.
3?, Somnolence seems to #e a common occ.rrence +ith atypicals, Tell me
a#o.t this side effect7
!omnolene is $ery ommon with olan*apine# lo*apine and 4uetiapine. It
ours in dose"related fashion. Aess ommonly it may our with
risperidone.
8@, 5escri#e the 1e.roleptic Mali)nant Syndrome (1MS/
B1! is rare but potentially lethal ad$erse effet of antipsyhoti therapy.
%he ris' seems to be lower for atypial than for typial.
B1! an our hours to months after the initial drug e&posure# and the
mortality rate is reported to be high as 29D. Inidene is between 9.92D
and 3.23D of patients ta'ing typial antipsyhoti drugs. (ardinal features:
musular rigidity# hyperthermia# autonomi dysfuntion# and altered
onsiousness.
B1! is self"limiting and usually lasts 2 to 78 days after the oral
antipsyhoti is disontinued or longer after disontinuation of depot
inMetions.
8', 5escri#e the mechanism #y +hich antipsychotics can ca.se sei%.res
Antipsyhoti drugs an lower sei*ure threshold. !ei*ures are most
ommon with low" poteny typial antipsyhotis ,hlorproma*ine and
thiorida*ine- and lo*apine.
83, 9hat is the a>aila#le e>idence for appropriateness or inappropriateness of
antipsychotic .se in pre)nancy7
/se of antipsyhotis during the first trimester should be minimi*ed or
a$oided if possible# espeially between wee's C and 79. If neessary during
this period# high poteny typial antipsyhotis ,e.g. haloperidol#
fluphena*ine# lo&apine# triflupera*ine- may be safer.
88, Ho+ are yo. )oin) to monitor patient response to medication7
CDI I (linial Global Impression: a three"item sale ommonly used in
studies on shi*ophrenia that enables liniians to 4uantify se$erity of
illness and o$erall linial impro$ement. %he items are: se$erity of illness.
global impro$ement and effiay inde&. A se$en"point soring system is
usually used with low sores indiating dereased se$erity and3or greater
reo$ery
BP!S I 6rief Psyhiatri 0atings !ale: an 7:"item sale measuring
positi$e symptoms# general psyhopathology and affeti$e ,negati$e-
symptoms. %he original sale has si&teen items# but a re$ised eighteen"item
sale is ommonly used. !ores an range from 9"72C. 2ah item is rated
on a se$en"point sale# with high sores indiating more se$ere symptoms
P1SS I Positi$e and Begati$e !ymptoms !ale: a 39"item

sale with 7C
general psyhopathology

symptom items# se$en positi$e"symptom

items#
and se$en negati$e symptom

items. Also ompleted by the

physiian# eah
item is sored

on the same se$en point se$erity

sale as the PAB!!#
resulting

in a range of possible sores

from 39 to 279
S1S I !ale for the Assessment of Begati$e !ymptoms: a global rating of
the following negati$e symptoms: alogia ,impo$erished thin'ing-# affeti$e
blunting# a$olition"apathy# anhedonia"asoiality and attention impairment.
Assessments are made on a si&"point sale ,9Gnot at all to ;Gse$ere-.
Higher sores indiate more symptoms
8:, Ho+ lon) +o.ld yo. treat this patient for7
!hi*ophrenia is typially a life"long disease harateri*ed by multiple
relapses. Aong term maintenane therapy is reommended. In the absene
of ontinuing prophyla&is up to <;D of patients will relapse with an aute
psyhoti episode within C"28 months.
84, Ho+ liAely is it that this patient +ill e-perience complete resol.tion of her
symptoms on treatment7
=ith treatment# appro&imately 39D of patients ahie$e a partial but good
response to treatment# 39D a partial but inade4uate response with the
remainder e&periening hroni deterioration. Appro&imately 79D of
patients e&periene ontinuous psyhoti symptoms.
8;, 9hat is the pre>alence of schi%ophrenia7
6etween 9.;"7D of the adult /! population.
8<, Is this a typical a)e of onset for schi%ophrenia7
Res. 1edian age of onset for women is late twenties and for men is early to mid"
twenties. It rarely presents before adolesene or after the age of 89 years.
8=, 9hat are Epositi>eF and Ene)ati>eF symptoms7
Positi$e symptoms inlude delusions# halluinations# disorgani*ed thought#
bi*arre beha$ior and insomnia. Begati$e symptoms inlude soial
withdrawal# po$erty of speeh ,alogia- and inability to e&periene pleasure
,anhedonia-.
8?, 9hat symptoms of schi%ophrenia does this patient manifest7
)elusions# paranoid ideations# grandiose ideations# disorgani*ed speeh.
:@, Ho+ +o.ld yo. confirm a dia)nosis of schi%ophrenia7
%here are no lab tests to diagnose or assess the se$erity of shi*ophrenia.
%o onfirm the diagnosis the patient must ha$e two or more symptoms
,delusions. halluinations. disorgani*ed speeh. grossly disorgani*ed or
atatoni beha$ior negati$e symptoms- for at least one month# with some of
the symptoms persisting for up to C months.
:', 9hat differential dia)noses did yo. consider7
Patient may ha$e another psyhoti disorder inluding the possibility of a
psyhoti disorder due to a general medial ondition or a drug"indued
psyhosis. A to&iology sreen should be performed. A diagnosis of
shi*ophrenia ,$s. shi*ophreniform disorder et- may typially only be
made after e&lusion of other diagnoses o$er time.
:3, !isperidone recently )ot a E#lacA #o-F +arnin) from the F5, 9hat for7
It has been assoiated with inreased mortality in elderly patients treated for
dementia"related psyhosis. %hese primarily appear to be ardio$asular in
nature. It is not appro$ed for this indiation.
:8, !isperidone recently )ot a E#lacA #o-F +arnin) from the F5, Is this a
class effect7
All of the atypial agents ha$e reei$ed the same warning. 6ased on
analysis of 7< plaebo"ontrolled trials ,modal duration 79 wee's- there
was a 7.C to 7.<"fold inrease in ris' of death $s. plaebo"treated patients
,i.e. a death"rate of 8.;D $s 2.CD-.
Sample 1on6Presenter 2.estions
9hat is the mechanism of action of the second6)eneration antipsychotics7
%hey at primarily by inhibition of dopamine )
2
and serotonin ;"H%2
a
reeptors. %hey
also ,$ariably- inhibit dopamine )
7
and )
8
# histamine H
7
# serotonin ;"H%2

# holinergi
and T
7
"adrenergi reeptors.
Aripipra*ole: high affinity for )2 ,partial agonist-# )3# ;"H%7A ,partial agonist-# ;"
H%2A ,antagonist-. moderate affinity for )8# ;"H%2(# ;"H%<# alpha"7# histamine"7.
moderate affinity for serotonin reupta'e
@lan*apine: seleti$e monoaminergi antagonist with high affinity for ;"H%2A3(# ;"
H%C# )7# )2# )3# )8# histamine"7# and adrenergi alpha"7. antagonist with moderate
affinity for ;"H%3# musarini 17";. also wea'ly binds to GA6A"a# 6L)# and beta"
adrenergi reeptors
Paliperidone: )2 antagonist with ;"H%2a ati$ity. some alpha"7# alpha"2# and histamine"
7 antagonism. no affinity for holinergi musarini or beta reeptors
Juetiapine: antagonist at ;"H%7a# ;"H%2# )7# )2# histamine"7# alpha"7 O 2. no affinity
for musarini or 6L) reeptors
0isperidone: seleti$e monoaminergi antagonist with high affinity for ;"H%2# )2#
alpha"73alpha"2 adrenergi# and histamine"7 reeptors. low"to"moderate affinity ;"
H%7A3(3). wea' affinity for )7. no affinity for musarini or beta reeptors
Liprasidone: high affinity for )2 ,antagonist-# )3# ;"H%2a ,antagonist-# ;"H%7a
,agonist-# ;"H%7d ,antagonist-# and alpha"7. also inhibits synapti re"upta'e of serotonin
and norepinephrine. no affinity for other reeptor sites
Can yo. name other dr.)s in this therape.tic class7
(lo*apine ,(lo*arilU-# @lan*apine ,Lypre&aU-# 0isperidone ,0isperdalU-# Liprasidone
,GeodonU-# Aripipra*ole ,AbilifyU-# Juetiapine ,!ero4uelU3!ero4uel N0-#
Paliperidone ,In$egaU-
9hat +o.ld a month of treatment +ith this a)ent cost7
!ee table. %he atypial agents are generally far more e&pensi$e than the typial agents.
re )enerics a>aila#le for these a)ents7
@f the atypial antipsyhotis risperidone and lo*apine are a$ailable as generis
9hat are the most common side6effects of the antipsychotic a)ents7
A)0s of these agents an be split into antihistamini ,sedation-# antidopaminergi ,2P!
and hyperprolatinemia-. antiholinergi ,dry mouth# blurred $ision# onstipation# urinary
retention# sinus tahyardia# ognition and memory effets-. and anti"adrenergi effets
,refle& tahyardia and orthostasis-. %hese inlude drowsiness# di**iness# an&iety#
onstipation and nausea. Generally# the atypial antipsyhotis are more tolerable than
the typial antipsyhotis and ha$e a lower propensity ,with the e&eption of risperidone-
to ause 2P!. 0isperidone at a dose of FCmg 4d has a similar ris' of 2P! as haloperidol.
%he ris' of metaboli side"effets suh as weight gain# gluose dysregulation and
dyslipidemia appears to be greater with the atypial agents.
Freedman, R. NEJM. 10/30/2003.
Are there any significant drug-drug interactins !et"een the medicatins yu ha#e
$rescri!ed%
Answer will depend on the medications prescribed. If the students elect to prescribe
lorazepam or another benzodiazepine in addition to an antipsychotic then an increase in
sedation may be noted. The students could also be asked about significant interactions
between the agent they have prescribed and other medications in general Alcohol should
typically be avoided with all of these agents.
&" "u'd yu cunse' a $atient a!ut h" t ta(e this medicatin%
Note: Counseling this patient about her medication would most likely be deferred until
she is stabilized. The usual advice should be given with regard to storage missed doses
pregnancy taking other new prescription!nonprescription medications taking as
prescribed and the avoidance of alcohol. "arn patient of the possibility of drowsiness
dizziness an#iety constipation and nausea. $atient should be alerted with regard to
orthostatic hypotension and the management of same. $atient will need to be e#amined
at %&'( month intervals for the development of movement disorders and periodically for
weight gain and development of hyperglycemia.
&" effecti#e is this anti$sychtic agent%
)verall antipsychotics have only a moderate effect in the management of schizophrenia
*mean effect size +,.(-..
"hen compared to the typical antipsychotics the atypical agents appear to be as effective
in the treating the positive symptoms and more effective in treating the negative
symptoms of schizophrenia. It is argued that in clinical practice they are more effective
in the management of positive symptoms due to a lower propensity to be discontinued
because of poor tolerance ! adverse effects.
) any f the AA*s need t !e dse-ad+usted in rena' r he$atic fai'ure%
Aripiprazole & no
)lanzapine / no
$aliperidone& hepatic no renal yes
0uetiapine / hepatic yes renal no
1isperidone & reduce dose in both renal and hepatic dysfunction
2iprasidone & hepatic yes renal no
Ma, dse infrmatin
Aripiprazole / 3,mg 045 though not shown to be more effective than doses of ',&'-mg
045 if solution used / match tablet dose on a mg&mg basis to a ma# of (- mg dose of oral
solution
)lanzapine / (, mg 04
$aliperidone / '( mg 04
0uetiapine / 6,,mg daily in divided doses
1isperidone & '%mg daily though 7$8!A41s worsen at doses 96mg daily5 ma#imal
efficacy seen with doses :&6mg daily
2iprasidone & 6,mg ;I4
Are there any -./ r a'ternati#e thera$ies "hich are effecti#e in the treatment f
schi0$hrenia%
8hort answer / N)<< There is some evidence of the use of gingko biloba in addition to
A$ but patients should be cautioned to avoid the use of herbals!)TC=s without
>4!pharmacist supervision.
A$$r,imate /st f )rug .reatment
)rug /1trength 2mg3 *rice 230 ta!s/ca$s3 /mments
)lanzapine *2ypre#a. (.- (,?.@3 2ydis ',mg A3, B3?-.(,
CDsual daily dose ',&(,mg
i.e. B3%,&B@(,!month
)lanzapine *2ypre#a. - (:,.%'
)lanzapine *2ypre#a. @.- 3''.-'
)lanzapine *2ypre#a. ', 3-?.@:
)lanzapine *2ypre#a. '- --6.33
1isperidone *1isperdal. ' '(@.(: >&Tab (mg A(6 B(''.@(
Consta -,mg A' B-%@.??
CDsual daily dose :&%mg
i.e. B33,&B-,,!month
1isperidone *1isperdal. ( (,@.(?
1isperidone *1isperdal. 3 (:(.-6
1isperidone *1isperdal. : 3(:.,6
Aripiprazole *Abilify.( 3@@.@%
CDsual daily dose '-mg i.e.
B3-,!month
Aripiprazole *Abilify.- 3:%.:'
Aripiprazole *Abilify.', 3-3.36
Aripiprazole *Abilify.'- 3-3.36
Aripiprazole *Abilify. (, :6@.@6
Aripiprazole *Abilify. 3, :6@.@6
2iprasidone *Eeodon. (, '%3.:'
CDsual daily dose '%,mg
i.e. B3%,!month
2iprasidone *Eeodon. :, '%3.:'
2iprasidone *Eeodon. %, '@:.,-
2iprasidone *Eeodon. 6, '@@.-,
0uetiapine *8eroFuel. (- A%, '3'.%(
CDsual daily dose %,,&
6,,mg i.e. B--,&%%,!month
0uetiapine *8eroFuel. -, A%, (('.?:
0uetiapine *8eroFuel. ',, A%, (((.('
0uetiapine *8eroFuel. (,, A%, :':.%@
0uetiapine *8eroFuel. 3,, A%, -:(.'(
0uetiapine *8eroFuel. :,, A%, %%3.3-
$aliperidone *Invega. 3 3%%.-3 CDsual daily dose is %mg
i.e.B:,,!month $aliperidone *Invega. % 3%%.-3
$aliperidone *Invega. ? -:6.:@
Note: Older antipsychotic agents are significantly less expensive. Alternative dosage
forms are typically more expensive than oral tablets (injectables, oral solutions).