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Chapter 6: Psychiatry 207
Give temporary relief
OCD Sx in 20%
https://t.me/med1917
1. Obsessions: thoughts, impulses, images e.g. need for symmetry
2. AND/OR compulsive acts/rituals: physical behaviours e.g. washing hands
• Present most days for at least 2w
• Cause distress and interference with activities → results in functional
impairment (not seen in simple over-valued ideas)
Obsessions/compulsions often present in:
Schizophrenia, Tourette’s, eating disorders, anankastic PD, depression, other
anxiety disorders
Endocrine
• Thyroid dysfunction
• Phaeochromocytoma
• Acidosis
• Hyper-/hypothermia
Cardiac/hypoxia
• Arrhythmias
• CHF/angina
• COPD
Drug withdrawal/
intoxication
Psychiatric
• Depression
• Personality disorders
• ASD/Asperger’s
• Delusional disorder
• Hoarding
• Alcohol
• Seizures
• Vestibular dysfunction
• Opiates
• Amphetamine/cocaine
Originate in the mind of the patient
• Acknowledged as excessive/unreasonable
• Repetitive, intrusive, ego-dystonic
OCD is common in kids (average onset = 9y)
& it is considered normal at this age
Step 1
• Psychoeducation
• Active monitoring
For all cases
Step 2
• Guided self-help
• Low intensity
psychological
interventions
Step 3
• High intensity psychological
interventions e.g. CBT,
psychodynamic psychotherapy
• AND drug treatment
PSYCHOLOGICAL INTERVENTIONS: mild/moderate anxiety
1. Psychoeducation: improve patient and carer understanding of illness
e.g. process, causes, treatment, prognosis
2. Guided self-help / low intensity: use few resources/less time-consuming
e.g. books, computer, self-help apps
3. CBT
• Phobias: systematic desensitisation / graded exposure
• OCD: exposure & response prevention
• PTSD: eye movement desensitisation & reprocessing (EMDR)
PHARMACOLOGICAL INTERVENTIONS: severe anxiety / psychological
treatment failed
1. Antidepressants (SSRIs) – proven efficacy long-term (especially combined
with psychological treatments)
2. Beta-blockers – symptom control (reduce HR & autonomic arousal)
→ caution in asthmatics
3. BZDs – acute management only (max 4w as addictive potential / sedative effect)
SOCIAL INTERVENTIONS: alongside other interventions
to promote long-term recovery by improving functioning e.g. help with work,
access to benefits etc.
5
NICE (2011, updated 2020) Generalised anxiety disorder and panic disorder in adults [CG113]
Step 4
Refer to 2° care (MDT)
• Complex therapies
• Complex drug regimes
AIM: STOP AVOIDANCE
(prolongs/reinforces problem)
Other Tx options: counselling, relaxation
techniques, breathing exercises, social skills
training
For SSRIs counsel patients:
• Cause short-term anxiety
• Common SEs: GI upset, insomnia, sexual
dysfunction
CBT (cognitive behavioural therapy)
= attempts to change thoughts which
affect feelings, which in turn affect
behaviour
Pros: strong evidence base
Cons: patient must confront anxieties →
can increase agitation
208 Chapter 6: Psychiatry
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Reactions to stress and trauma
A brief response (<1m) to a severely stressful event e.g. motor accident, violent
↳
Coping strategies seen with acute stress
reaction
• Avoid thinking/speaking of event
• Denial / cannot remember event
• Alcohol/substance misuse
crime
SYMPTOMS: (overlap with anxiety/depression symptoms)
• Numbness, detachment, concentration, derealisation
• Insomnia, agitation, restlessness, anger
• Autonomic symptoms
MANAGEMENT
• Talking to friends/family/
professionals to relieve anxiety
• Encouraging recall
A psychological reaction to a stressful life event / major change e.g. new job/
home, divorce, bereavement
→ starts within 3m (more gradual than acute stress reaction)
• Learning effective coping strategies
• Anxiolytics (if severe anxiety)
• Hypnotics (if insomnia)
Coping strategies seen with adjustment
disorder
Alcohol/drug abuse
Normal bereavement process: DABDA
Denial→ Anger → Bargaining → Depression →
Acceptance
Coping strategies for PTSD
Coping: alcohol/drug abuse
Prognosis: 50% recover in 1st year
Poor if: comorbid mental illness, long duration,
poor support & coping strategies
SYMPTOMS: (overlap with anxiety/depression symptoms)
• Autonomic symptoms e.g. palpitations, shortness of breath
• Sleep disturbance
• Irritability / aggressive outbursts
• Social functioning impaired
MANAGEMENT
• Talking to friends/family/professionals: avoid denial/avoidance, encourage
problem-solving behaviour
• Psychological interventions + medication (SSRIs) if severe
Symptoms of normal grief persisting >6m
SYMPTOMS
• Low mood, guilt, worthlessness, disturbed sleep & appetite, suicidal thoughts
• Significant psychomotor retardation – very slow
• Prolonged, serious functional impairment
• Hallucinatory experiences other than those relating to the deceased person
Abnormal grief that is not severe enough to meet depression criteria = ‘adjustment
reaction’
Delayed (often few months) response to a stressful event of an exceptionally
threatening/catastrophic nature → symptoms persist >6m after event
SYMPTOMS: (overlap with depressive symptoms)
• Hyperarousal – persistent anxiety, irritability, insomnia, poor concentration,
autonomic Sx
• Re-experiencing – ‘flashbacks’, recurrent dreams/nightmares, cannot recall
event by will
• Avoidance – of reminders, detachment, numbness, anhedonia
Complex PTSD: overlaps PDs
Added emotional element – often resulting
from ongoing/multiple experiences of ‘trauma’
e.g. abuse
MANAGEMENT
1. Psychological – psychoeducation, CBT, EMDR
2. Biological – antidepressants (SSRIs = 1st line) ± antipsychotic
3. Social – educate family, social reintegration, alcohol & illicit substance avoidance
6
NICE (2018) Post-traumatic stress disorder [NG116]
Chapter 6: Psychiatry 209
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Health anxiety & somatisation
Health anxiety is an umbrella term encompassing:
• Excessive/unrealistic health-related concerns
• Somatic perceptions – preoccupied with bodily sensations e.g. pain
• Behaviours – reassurance seeking, repeated symptom checking, avoid
medications/doctors
‘Health anxiety’ itself is not a diagnosis, but it is linked to other diagnosable disorders (see below)
HYPOCHONDRIACAL DISORDER
At least 6m of:
• belief of 1 or 2 serious physical diseases (worried about a specific diagnosis
e.g. cancer)
• OR preoccupation with presumed deformity/disfigurement
(bodydysmorphic disorder)
FACTITIOUS DISORDER (MUNCHAUSEN’S)
• Feigns/exaggerates symptoms for no obvious reason
• May inflict self-harm to produce signs/symptoms
MALINGERING
• Feigns/exaggerates symptoms for secondary gain
DISSOCIATIVE (CONVERSION) DISORDER
• Traumatic event disrupts consciousness, memory, identity or perception
• Patient converts anxiety into more tolerable symptoms to attract benefits
of sick role
• Variable presentation: amnesia, stupor, trance, motor disorders, anaesthesia,
convulsions
→ Internal motivation to
adopt the sick role
→ e.g. benefits / monetary
gain or emotional
gain / attention
Possible predisposing factors/precipitants:
• Personal experience of a previous illness
• Significant illness of a loved one
• Early life trauma
• Family members with health anxiety
La belle indifférence: Absence of distress despite
symptoms of serious illness being relayed by the
patient
↳ also known as medically unexplained symptoms (MUS)
= expression of psychological distress through physical symptoms
SOMATISATION DISORDER
• Complaints for at least 2y of multiple & variable physical symptoms from at
least 2 body systems
• Symptoms are real to patient but cannot be explained by a detectable
physical disorder or investigations
• Causes persistent distress, significant functional impairment & refusal to
accept medical reassurance
MANAGEMENT
• General: build rapport (acknowledge suffering, regular appointments),
minimise investigations
• Psychological therapy: CBT, psychoeducation, self-help
• Social: encourage normal functioning, normal ADLs/hobbies, involve social
network/support
• Biological: antidepressants → evidence of long-term efficacy is weak
IMPORTANT: Don’t just assume all in patient’s mind → ensure suitable
investigations done
: involves MDT*
↳
↳
• Assess impact on function/ADLs
• Assess insight & explore their expectations
Differential diagnoses of health anxiety
disorders / somatisation
• Depression/anxiety
• Personality disorder
• Over-valued ideas
• Schizophrenia/psychosis: hypochondriacal
delusions
• Organic causes with vague symptoms: MS,
lupus, porphyrias
especially with relationships
Explaining to patient is key!
Suggest link between physical symptoms
and psychological factors
May reinforce idea there is a
physical problem
7
NICE (2011, updated 2020) Generalised anxiety disorder and panic disorder in adults [CG113]
210 Chapter 6: Psychiatry
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Personality disorders
Personality = combination of consistent thoughts, feelings & behaviours
shown over time & in a variety of settings
and adolescence
*PDs are enduring: unlike other mental
health illnesses which may occur in
discrete episodes
Attachment problems with PRIMARY CAREGIVER
Patients find it
people → intense
Personality disorder = when unhelpful personality traits cause functional
difficulties/distress & interpersonal difficulties
Problems caused by personality disorders are usually:
1. Pervasive – occur in all/most areas of life
2. Persistent* – evident from adolescence and into adulthood
3. Pathological – cause distress to self/others and impair function (occupation,
relationships etc.)
• Genetics / neurochemical imbalance: e.g. impulsive behaviour / aggression &
serotonin
• Childhood temperament: innate/biological disposition to an emotional
response
• Childhood experience: neglect, trauma, abuse (upbringing & parenting style
play a big role)
↱
Common comorbid conditions/DDx:
• Anxiety disorder
• PTSD, OCD
• Adjustment disorder / stress reaction
↳ Comorbidities often missed as assumed to be due
to difficult behaviours caused by the personality
disorder OR comorbidities cause delayed diagnosis
of the personality disorder itself
PDs (especially cluster B) are linked to higher
rate of suicide
• Depression
• ASD/ADHD
DSM-5 CLUSTERS: clusters overlap
Cluster A ‘mad’ Cluster B ‘bad’ Cluster C ‘sad’
• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Histrionic
• Borderline
• Narcissistic
• Obsessive–compulsive (anankastic)
• Anxious/avoidant
• Dependent
↳
ICD-10 CLASSIFICATION
Paranoid Suspicious, Unforgiving, Sensitive, Possessive/jealous, Excessive self-importance,
Conspiracy theories, Tenacious sense of self-rights
Schizoid Anhedonic, Lack relationships, Only small emotion range, Normal conventions
ignored, Excess fantasy world
Dissocial Social disregard, Irresponsible, No concern for others, Guiltless, Loses temper
easily, Egocentric
Emotionally
unstable
Histrionic Attention-seeking, Concerned about self, Theatrical, Open to suggestion,
Anankastic Perfectionist, Excessive detail, Rigid, Full of doubt, Excludes pleasure/people,
Anxious/
avoidant
Dependent Submissive/Subordinate, Unable to make decisions, Pessimism, Poor confidence,
Borderline: Self-image unclear, Chronic emptiness, Abandonment fear,
Relationships unstable/intense, Self-harm/suicide, Labile emotions, Impulsive,
Emotions very intense
Impulsive: No Plans, Lacks impulse control, Aggressive outbursts, No thought of
consequences
Racy/seductive, Shallow
Conscientious, Thoughts are intrusive
Avoids social contact, Fears rejection/criticism, Restricts lifestyle, Apprehensive,
feels Inferior/Inadequate, Desires acceptance
Oversensitive, Rely on others,
Terror of abandonment
‘SUSPECT’
‘ALONE’
‘SINGLE’
‘SCARS LIE’
‘No PLAN’
‘ACTORS’
‘PERFECT’
‘AFRAID’
‘SUPPORT’
Chapter 6: Psychiatry 211
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Avoid admission where possible: fosters dependence & prevents adoption
ofcoping strategies
→ RISK ASSESSMENT – consider admission if acute risk to self/others
→ CONSIDER COMORBIDITIES – admission may be needed to treat underlying
mental illness
LONG-TERM MANAGEMENT
• Psychoeducation: especially for carers/family/friends
• Self-help: mood diary, coping behaviours, mindfulness, meditation, maintain
physical health, sleep hygiene
• Talking therapies: CBT, DBT, MBT, CAT (cognitive analytical therapy)
• Social support: finance, housing, inclusion activities / activity scheduling,
support with stigma
Most important
MEDICATION*
• Antipsychotics: for transient psychosis, reducing impulsivity/agitation
• Antidepressants: for comorbid anxiety/depression
• Mood stabilisers
• Short-term sedative/anxiolytic – in crisis situations
↳
GENERAL
Set clear boundaries, demonstrate you are reliable/consistent, beware
of splitting/transference
Risks of personality disorder
• Impulsive behaviour
• Self-harm/suicide
• Substance abuse
• Self-neglect
Inclusion & involvement in their own care
plan = key
*
Medication is only
indicated for related symptoms/comorbidities
Transference: how patient feels about you
They subconsciously associate a feeling of the
past in the present situation
(Don’t take it personally!)
8
NICE (2009) Borderline personality disorder [CG78]
9
NICE (2009, updated 2013) Antisocial personality disorder [CG77]
212 Chapter 6: Psychiatry
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Psychosis & schizophrenia
PSYCHOSIS = a syndrome characterised by a loss of contact with reality
Persecutory: being stalked/spied on etc.
Grandiose: elevated self-importance, special
power or ability
Somatic: think something physically wrong
with themselves
• Delusions = fixed, false, unshakable beliefs, despite conflicting evidence
– cannot be rationalised away
• Hallucinations = perception of something in the absence of external stimuli
– auditory/visual/touch, smell, taste
• Formal thought disorder = pattern of disordered language reflecting
disordered thoughts
– tangential/circumstantial speech, derailment / thought disconnection (switch
from one topic to another)
Acute transient psychosis: sudden onset
psychotic symptoms lasting <28d with no
identifiable organic cause → linked to stress
Epidemiology of schizophrenia
Annual incidence: 1 in 500, M=F
Peak age males: 23–29y + 55–64y
Peak age females: 15–24y
Summary of 1st rank Sx
Auditory hallucinations
Broadcasting of thought
Control delusions (passivity)
Delusional perception
Organic:
• Delirium
• Medication-induced – DA agonists,
corticosteroids, stimulants
• Endocrine disorders – Cushing’s,
hyperthyroidism
• Epilepsy
Psychiatric disorders:
• Schizophrenia
• Depression with psychotic features
• Schizotypal disorder – distorted
thoughts but hallucinations/
delusions not prominent
SCHIZOPHRENIA = a psychotic disorder diagnosed if ≥28d of ≥2 of the following
symptoms, with no organic cause found
• Schizoaffective disorder – 1st rank
symptoms congruent to mood
symptoms (mood & psychosis
present at same time)
• Delusional disorder – delusions not
so bizarre and no hallucinations
Other:
• Substance-induced – cannabis,
hallucinogens, alcohol, cocaine
• Systemic – MS, SLE, HIV, syphilis,
hypoglycaemia, Wilson’s
SCHNEIDER’S FIRST RANK SYMPTOMS
Hallucinations (auditory) Delusions
3rd person (‘he’ or ‘she’)
Being talked about
Thought echo / thoughts spoken aloud Delusion of control
Running commentary Delusions of thought interference
Delusional perception
Attribute false meaning to a true perception
↳ e.g. red traffic light means aliens are landing
Believe thoughts/feelings/actions are being controlled
by external force
Insertion, withdrawal, broadcasting
PANSS (Positive & Negative Severity Scale)
can be used to assess severity of symptoms
motivation
OTHER SYMPTOMS
Positive: delusions, hallucinations, thought disorder
Negative: blunted/flat affect, social withdrawal, poverty of speech, anhedonia,
avolition
Cognitive: poor attention, learning & problem solving (autism), disorganised
behaviour
Motor: catatonic movements, waxy flexibility, stupor, posturing, negativism
Chapter 6: Psychiatry 213
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→ mixture of genetics (80%) and environment
Genetic Developmental Psychosocial
• Family history
(likely polygenic)
50% chance in MZ twins
10% chance in 1st° relative
1. Prodrome: period of more subtle changes prior to obvious psychosis
(not everyone experiences prodromal period)
• non-specific negative symptoms
• transient psychotic symptoms
2. Acute phase: relapsing & remitting positive and negative symptoms
Good prognostic factors Poor prognostic factors
Female Male & unmarried
Married FHx of schizophrenia
Acute onset Early/insidious onset
Prominent mood symptoms Prominent negative symptoms
Good premorbid personality Substance abuse
Clear precipitating event Long duration untreated
Early Tx with good response
To r/o organic cause & assess suitability for antipsychotics
• History (+ collateral) and MSE
• Physical examination: BMI,
neurological
• Bloods: FBC, RFT, LFT, TFT, glucose,
lipids, cholesterol
BIOLOGICAL
• Antipsychotics
• Annual physical health R/V: smoking, alcohol, BP, BMI, bloods, ECG
PSYCHOLOGICAL
• CBT
• Psychoeducation: signs of relapse, prevent relapse, crisis plans
• Family Intervention Therapy (FIT): education and support for carers
• Low birth weight
• Obstetric complications
• Maternal illness in pregnancy
e.g. influenza, malnutrition
Lack of insight / non- compliance
• Urine: drug screen
• ECG
• ± brain scan ± EEG if specifically
BIOPSYCHOSOCIAL APPROACH
• Urban living, migration (Afro-Caribbean minority)
• Adverse life event (childhood abuse / parental death)
• Poor premorbid personality
• Abnormal family processes
(e.g. overprotective/intrusive, arguing parents)
distress/agitation
•
indicated
Key to ask in
history
SOCIAL
• OT assessment of functioning: ADLs, occupation, hobbies
• Social assessment for housing, benefits, finances, education/career
• Carer assessment: carer stress
ACUTE EPISODES: → All patients need follow-up and monitoring
• May need admission OR
• May prevent admission with community input from EIP (early intervention
psychosis) team & CRHT (crisis resolution and home treatment team)
10
NICE (2014) Psychosis and schizophrenia in adults [CG178]
Illicit substance use may age
of onset & relapses
Outcomes
• 20% have only 1 episode
• 50% recover but relapse in future
• 30% develop chronic
schizophrenia
• 10–15% die by suicide
Other risks: T2DM, CVD, life
expectancy
Diagnosis consists of:
• Comprehensive psychiatric history
• Comprehensive medical history
• Risk assessment (to self & others)
Treatment-resistant schizophrenia
= no response to TWO different antipsychotics
Management:
1. Check Dx, compliance & substance misuse
2. CLOZAPINE: register with monitoring
service for side-effects, including weekly
FBC (SEs: agranulocytosis, neutropenia,
cardiomyopathy)
Recovery isn’t necessarily completely
stopping symptoms BUT:
• Learning how to deal/cope with them
• Providing social support (financial,
educational, housing etc.)
• Reducing stigma
• Reducing risk to self and others
Reasons for non-compliance with treatment:
• Side-effects
• Lack of insight
• Delusions about medication/prescriber
• Gains remission & thinks medication no longer
needed
• Feels better when ‘ill’
Treat acute episode then continue
maintenance treatment for:
1y after 1st episode
2y if 2nd episode
5y if ≥3 episodes
214 Chapter 6: Psychiatry
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Mania & bipolar aective disorder
Acute mania: 1 episode of mania
Bipolar affective disorder: 2 episodes of mania OR ≥1 episode of mania + 1
episode of depression
Cyclothymia: persistent mood instability with numerous subthreshold manic &
depressive periods
Dysthymia: chronically low mood but with no episode justifying a diagnosis
of depression
Overinflated self-esteem & grandiosity are
common
Prognosis of BPAD
• Avg. episode: 6m
• Recurrence = 90%
• 10% die by suicide
Differential diagnosis
• Substance misuse
• Hyperthyroidism, Cushing’s
• Space-occupying lesion
• Metabolic disturbance
• Epilepsy
Mania = syndrome characterised by abnormally elevated arousal, affect
(incongruent) and energy levels
Hypomania = symptoms for 4d Mania = symptoms for 1w
Mildly elevated or unstable mood Elevated, expansive or irritable mood
Increased energy Increased activity (often goal-directed)
Mild overspending and risk-taking Reckless behaviour (overspending, sexual)
Increased sociability and overfamiliarity Disinhibition
Distractibility Marked distractibility
Increased sexual energy Marked increased sexual energy
Decreased need for sleep
EPIDEMIOLOGY
→ 1–2% of population
→ peak onset = early 20s
→ F=M
4th most common mental health illness
but often initially misdiagnosed as recurrent
depression
Sleep severely impaired / absent
Flight of ideas & pressured speech
Grandiose/persecutory delusions
Auditory hallucinations (2nd person)
RISK FACTORS: cause is unknown (mix of social & environmental factors)
Genetics: FHx of bipolar disorder (neurotransmitter imbalance – NA, DA, 5-HT)
Life events: prolonged stress, childbirth, physical illness, sleep disturbance
Substance misuse: amphetamines, cocaine, steroids, antidepressants
INVESTIGATIONS: to r/o organic cause
• Physical exam
• Bloods (FBC, TFTs, U&Es, glucose, Ca)
• Drug screen
• CT/MRI
REASONS FOR RELAPSES
• Non-compliance with medication
• Life events / stress
• Substance misuse
• Childbirth (puerperal)
• Disrupted circadian rhythm
MANAGEMENT
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1. Pharmacological Mx
Chapter 6: Psychiatry 215
haloperidol,
risperidone,
quetiapine,
olanzapine
lorazepam
Psychological Mx
2.
• Psychoeducation: recognising
• CBT
1. Antipsychotic
2. ± 2nd antipsychotic
3. + Mood stabilisers
→ valproate (acute episode)
→ lithium (long-term/prophylaxis)
4. May consider BZDs
STOP routine antidepressants
relapses
1. Antipsychotic (2nd generation)
2. + lamotrigine / other mood
stabiliser
No evidence for routine
antidepressants → risk of rapid
cycling – if prescribed, must be
alongside anti-manic agents
3. Social Mx
• Support for education, training,
employment
• Support for carers and family
1. Lithium OR continued treatment
2. Valproate or olanzapine
(if lithium intolerable)
• CPN visits: monitor mood, mental
state, symptoms
LITHIUM
Indications: Tx & prophylaxis of acute hypo-/mania & BPAD, Tx of refractory
depression / aggressive self-harming
Side-effects
Acute mania Bipolar depression Long-term Tx of bipolar disorder
Common:
• GI upset
• Fine tremor
• Polyuria/polydipsia
• Metallic taste
• Weight gain
• Oedema
• Cognitive slowing
• Hyperparathyroidism
In lithium toxicity (>1.2mmol/L):
• Diarrhoea/vomiting/dehydration
• Coarse tremor
• Ataxia (fasciculations, jerks, stiff)
• Dysarthria
• Nystagmus / visual disturbance
• Confusion/convulsions/seizures
• Drowsiness/lethargy
• Renal failure
• Cardiac dysrhythmia
for mania
In acute manic phase consider use of MHA &
inpatient admission
→ no serious decisions while unwell
→ psychotherapy not useful in the acute stage
Physical health monitoring:
• Eating/exercise programme
• Weight and cardiovascular/metabolic
parameters monitored annually
• Monitoring for medication effects e.g. lithium
Monitoring of lithium
Narrow therapeutic window: 0.4–1.2mmol/L
• Take sample 12h post-dose
• After dose change monitor levels weekly, then
3-monthly for 1y, then 6-monthly
• Monitor U&Es, LFTs & TFTs, calcium every 6m
Mx of lithium toxicity: STOP LITHIUM
IMMEDIATELY
• Rehydration
• If severe: diuresis/haemodialysis
Cautions: cardiac disease, epilepsy, elderly
significant renal impairment, Na
Lithium metabolised by kidneys:
• Check eGFR before prescribing • Counsel patient to stay hydrated
VALPROATE
Indications: acute hypo-/mania, BPAD, anti-epileptic
liver failure & cirrhosis
LAMOTRIGINE
Indications: BPAD, treatment-resistant depression, anti-epileptic
Side-effects: risk of Stevens–Johnson syndrome
CARBAMAZEPINE
Indications: prophylaxis of BPAD if unresponsive to lithium, trigeminal neuralgia,
anti-epileptic
11
NICE (2014) Bipolar disorder [CG185]
Lithium in pregnancy = risk of cardiac defects
e.g. Ebstein anomaly
Must counsel women of child-bearing age on
contraception & co-prescribe folate if pregnant
Monitoring of valproate
• LFTs – hepatotoxic
• Bone profile – supplement vit D
→
216 Chapter 6: Psychiatry
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Antipsychotics
Antipsychotics (APs) work by blocking postsynaptic receptors in dopaminergic
pathways, therefore decreasing dopamine activity
Nigrostriatal
Meso-cortic pathway
Meso-limbic pathway
Nigrostriatal pathway
Fig. 6.3
Examples: chlorpromazine, haloperidol, sulpiride, flupentixol, trifluoperazine
Mechanism: D2 receptor antagonists
Side-effects
psychotic symptoms
hyperprolactinaemia
AIM = reduce positive and negative
symptoms with minimal SEs
(target mesolimbic pathway)
Prescribing antipsychotics:
• Start low & go slow
• Monitor for side-effects
• May take 2–3w for effects
• If non-compliance, consider long-acting
DEPOT INJECTION
Stepwise progression of AP Tx
Initially: atypical AP
No response 4–6w:
switch to another atypical AP
Still no response: clozapine
(consider compliance first)
Clozapine = for Tx-resistant schizophrenia
(no response to 2 antipsychotics)
Side-effects: agranulocytosis, neutropenia,
cardiomyopathies
*Metabolic syndrome
• Central obesity
• Insulin resistance
• Impaired glucose regulation (T2DM)
• HTN
• LDL and triglycerides
Neurological
Psychiatric Apathy, confusion, depression
Anti-muscarinic Dry mouth, blurred vision, constipation,
Other Arrhythmias, hyperprolactinaemia,
Extrapyramidal side-effects (EPSEs): due to dopamine blockage in nigrostriatal
pathways
DAYS–WEEKS
Respond to anticholinergics: PROCYCLIDINE
Examples: aripiprazole, olanzapine, risperidone, clozapine
Mechanism: D2 receptor antagonists ± 5-HT receptor antagonists (except
aripiprazole, which is a partial D2 agonist)
Side-effects
• Nausea, constipation, dizziness (postural hypotension)
• Weight gain & metabolic syndrome*
• Sedation
• QTc prolongation (not aripiprazole)
• ± insomnia, ± prolactin
Generally, atypicals are 1st line as SAME EFFICACY but FEWER EPSEs than
1st generation medications
Weight gain Aripiprazole Olanzapine & clozapine
Sedation Aripiprazole Clozapine
Metabolic complications Aripiprazole Olanzapine & clozapine
EPSEs, seizure threshold, sedation,
neuroleptic malignant syndrome (NMS)
urine retention
hypotension, weight gain
>48 HOURS
Akathisia: uncontrollable urge to fidget e.g. pacing,
crossing and uncrossing legs
Acute dystonia: involuntary muscle spasms causing
abnormal movements/postures
Parkinsonism: tremor, rigidity, bradykinesia
Tardive dyskinesia: involuntary hyperkinetic movements
e.g. lip-smacking, chewing
AP with least effect AP with most effect
EMERGENCY!
• hyperthermia
• muscle rigidity
• tremor
• acidosis
• tachycardia
• confusion
NB Risperidone is somewhere in the middle with causing the above side-effects,
BUT causes the most EPSEs of 2nd generation APs
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