SKIP AHEAD:
1:01 – Antipsychotic Mechanism
1:58 – Antipsychotics and their Indications
3:30 – Neuroleptic Malignant Syndrome (Typical Antipsychotic Side Effect)
4:18 – Extrapyramidal Symptoms (Typical Antipsychotic Side Effect)
6:19 – Atypical Antipsychotics and their side effects
8:57 – Mood Stabilizers
12:58 – Anxiolytics and Benzodiazepines
We will start with a quick review of some material from my previous video on psychosis. Symptoms of schizophrenia can be broken down into 2 categories, Positive and Negative Symptoms. Positive symptoms include behaviors or sensations that are not normally present. Examples include hallucinations, delusions, and catatonia. These symptoms are thought to be related to an excess of dopamine. I remember this by remembering that “doPamine has a P in it”. So P for Positive and P for Dopamine. Negative symptoms are the absence of normal behavior. Examples include a lack of initiative, diminished speech, disheveled appearance & flat affect. These symptoms are thought to be related to an excess of serotonin. As we will see antipsychotics affect dopamine and serotonin to varying levels.
The indications for this class of drugs includes psychosis (mainly schizophrenia), Mania (mainly bipolar disorder), aggression and Tourette's disease.
Typical Antipsychotics primarily block dopamine receptors in a non-specific manor. Therefore, these drugs work best for positive symptoms, and have little effect on negative symptoms. The non-specific mechanism of the drug also means there are lots of side effects. Some of these medications come in a slow release injectable form so they can be used in non-compliant and aggressive patients. There are a lot of high yield side effects so we will break them down one by one
Neuroleptic Malignant Syndrome (or NMS) is a rare but potentially fatal adverse reaction of typical antipsychotics. It involves fever, altered mental status, rigidity and autonomic instability (such as tachycardia, hypertension, diaphoresis etc.). You may also see elevated myoglobin in blood or urine and elevated Creatine Kinase (CK). One of the ways I think about it is that it looks kinda sorta like Serotinin Syndrome that you can see with antidepressatns. If you see this you have to emergently stop the medication, provide supportive care and consider adding Dantrolene
Extrapyramidal Symptoms (or EPS) are due to blockage of Nigrostriatal dopamine. It can present with a number of different symptoms.
Akasthisia is a general sensation of restlessness
Acute Dystonia is involuntary continuous muscle contractions often of the neck. Another common presentation of acute dystonia is Oculogyris Crisis when your eyes get locked looking upward and you have to lean over to see
Dyskinesia (AKA Pseudoparkinsonism) presents like Parkinson’s Disease with symptoms like a pill rolling tremor, cogwheel rigidity & bradykinesia (or slow movement)
Tardine Dyskinesia (or TD) is uncontrollable facial tics, grimacing & tongue movements
As scary as these symptoms may look, they are generally not medical emergencies. In most cases you will continue to use the drug with perhaps a reduction in the dose or the addition of an anticholinergic mediation like Benzatropine or Diphenhydramine. Tardive Dyskinesia is the exception and requires cessation of the medication as it can be permanent. Usually you would switch a patient with TD to a 2nd gen antipsychotic.
Hyperprolactinemia is a side effect due to Blockage of Tuberoinfundibular dopamine. It presents just like any other disease that increases prolactin. So you can have galactorrhea, gynecomastia, decreased libido and menstrual irregularities.
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