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A 45 year old male patient was brought to the
casualty in agitated state .His wife complains
that he is agitated, talkative and keeps on
mumbling to himself and does not sleep well
at night. When asked about his mumbling, he
says that his wife and children are trying to
poison him. He has been talking to his
mother about this & believes that only she
can save him.( according to his wife , the
mother passed away 20 yrs ago)
Family h/o father & mother not alive.3 siblings.
One brother is admitted to mental asylum.
others normal. 2 children - both normal.
Past h/o he had similar symptoms and was on
treatment, but discontinued as soon as his
O/E—Well built, but poorly nourished. Poor
hygiene. Weight- 50 kg. He is anxious, worried
and suspicious of the interviewer. He is well
oriented, but keeps on talking to himself. All
systems within normal limits.
Biochemical parameters – normal, ECG- normal
1) What is your diagnosis?
Schizophrenia- paranoid (DSM-V-TR)
DSM-V-TR Diagnostic Criteria for Schizophrenia
Two (or more) of the following, each present for a significant
portion of time during a 1-month period
disorganized speech grossly
disorganized or catatonic behaviour
negative symptoms, i.e., affective flattening, alogia, avolition,
Treatment was started and within 2 weeks he
became less agitated and started taking interest in
himself & surroundings & became more co-
operative. Sleeps well at night. After 4 weeks of
treatment, he began to socialise with his family and
neighbours but still continues to have auditory
hallucinations. Adequate dose adjustment was
After 6 months of treatment , all his symptoms
subsided. O/E – adequately nourished. Wt 63 kg.
Very co-operative. Answering to all questions.
Biochemistry :RBS- 180 mg %. Urine sugar +ve
others –normal, ECG – normal
2 Types - PSYCHOSIS / NEUROSIS
PSYCHOSIS - Insight is absent
Refuses to take treatment
Schizophrenia & Mood disorders…
NEUROSIS – Less serious ,insight is present
Anxiety, OCD, PTSD, Phobias …
2) Name the older /classical /typical /1st
generation antipsychotics. (NEUROLEPTICS)
C) Butyrophenone Derivatives
Pimozide ,Loxapine, Molindone
eg .Chlorpromazine, Thioridazine
eg. Trifluperazine, Perphenazine
eg .Haloperidol, Fluphenazine,
3) Atypical / 2nd generation antipsychotics
4. How will you treat his present agitated state?
Treatment during the acute phase focuses on
alleviating the most severe psychotic symptoms. This
phase usually lasts from 4 to 8 weeks. Antipsychotics
and benzodiazepines can result in relatively rapid
calming of patients.
Lorazepam (Ativan) has the advantage of reliable
absorption when it is administered either orally or
The use of benzodiazepines may also reduce the
amount of antipsychotic that is needed to control
5) Name a drug that can be used immediately to control
his symptoms. Mention its route and onset of action?
Parenteral short acting drugs
Haloperidol- 5-10 mg intramuscular
Onset of action- 30-60 mts
repeated at 4-8 hrs for the first 24-72 hrs.
Other drugs- fluphenazine
Other option- BZD
6) Will you use injectable long acting depot
preparation to control his symptoms in acute
take months to reach a steady-state concentration and are
eliminated very slowly
difficult to correlate clinical effect with dosage, and it is
extremely difficult to make dosage adjustments to manage
7) Name the drugs which are available as
long acting preparations. Mention its
Haloperidol long-acting decanoate injections
8) Once his agitation & other symptoms are
controlled, which drug can we use to stabilize
Any atypical agent to control symptoms
9) How long should you continue the treatment
10) How does this drug act?
Mesolimbic-mesocortical- behaviour, cognition
Nigrostriatal- vol movement coordination
Tuberoinfundibular – suppresses prolactin secretion
Medullary periventricular – eating
Incertohypothalamic – copulatory behaviour
D2, 5HT2A,D4,D1 - Antagonism
11) What are its adverse effects?
3. Neurological – EPS
6. Skin eruptions
8. GI & hepatic S/E
12) What is meant by SDA?
Serotonin Dopamine Antagonist- second generation
13) Comment on the efficacy and potency of
Positive symptoms- new drugs equal to old drugs
Negative symptoms- newer ones are superior
high (e.g., haloperidol)
low (e.g., chlorpromazine),
intermediate (e.g., loxapine)
affinity for D2 receptor
14) What are the extrapyramidal side effects
likely to occur?
REACTION FEATURES TIME OF MAXIMAL
Acute dystonia Spasm of muscles of tongue,
face, neck, back; may mimic
seizures; not hysteria
1 to 5 days Antiparkinsonian agents are
diagnostic and curative
Akathisia Motor restlessness; not
anxiety or "agitation"
5 to 60 days Reduce dose or change
agents,a benzodiazepines or
propranolol b may help
Parkinsonism Bradykinesia, rigidity,
variable tremor, mask facies,
5 to 30 days; can
recur even after a
Catatonia, stupor, fever,
unstable blood pressure,
myoglobinemia; can be fatal
Weeks; can persist
for days after
immediately; dantrolene or
bromocriptine c may help;
antiparkinsonian agents not
Perioral tremor (may be a
late variant of parkinsonism)
After months or
years of treatment
After months or
years of treatment
15) What are the antipsychotics C/I in patients with
Prolonged QT interval-
3. High doses of haloperidol
Myocarditis & cardiomyopathy-
16) What are the metabolic adverse effects likely
to occur with antipsychotics?
1. Weight gain- max- clozapine & olanzapine
Risperidone produces intermediate weight gain
Quetiapine and ziprasidone produce the least weight
2. Hyperglycemia ,hyperlipidemia, exacerbation of
existing type 1 and 2 DM, new-onset type 2 DM, and
17) Name the antipsychotic causing retinopathy.
18) What are its other significant adverse effects?
Comment on the extrapyramidal A/E produced by
Low incidence of adverse EPS increased central
Depressant effects on cardiac conduction and repolarization.
Impaired ejaculation- alpha blockade, anticholinergic
19) Name the antipsychotic producing
hypersalivation. Why does it cause that? how
will you treat it?
Muscarnic agonism at M4 receptors.
Clonidine , anticholinergics, amitriptyline,scopolamine
patch, ipratropium sublingual spray ,atropine 1% solution,
20) Name the longest acting antipsychotic. What
are its other advantages?
Aripiprazole and its active metabolite – t½ 75 and 94 hrs
Long t ½
partial DA agonist, enhance action at these receptors
when there is a low concentration of dopamine and would
block the actions of high concentrations of dopamine
Min weight gain
Produces no elevation of prolactin
21) Mention the indications & contraindications
Treatment of refractory schizophrenia.
Clozapine is the first drug to be FDA approved for an
antisuicide indication in schizophrenia pts.
Contraindications to clozapine
H/o myeloproliferative disorder
Clozapine-induced agranulocytosis or
patients who cannot tolerate anticholinergic
at risk for drug-induced orthostasis.
significant renal or hepatic disease.
22)How will you monitor a patient on clozapine?
Monitoring of WBC count
Weekly monitoring- 6 months
Every 3 weeks – next 6 months
Monthly there after.
Monitoring of body weight, lipid profile, blood
glucose level also important.
23) Name the antipsychotic with antianxiety &
antidepressant action. What are its advantages and
Ziprasidone – antianxiety & antidepressant
Min metabolic A/E, EPS, sedation
Short t ½
Cardiac depressant action
24)Name the atypical agent preferred in autism?
What are its advantage and disadvantage ?
ADV- similar to other atypical drugs, though EPS more than the
other atypical drugs
25) Name the only antipsychotic given sublingually.
26) Name a 1st generation antipsychotic with
metabolic side effects. ( Wt gain,
27) Other uses of antipsychotic agents
The older neuroleptics (most commonly prochlorperazine)
Intractable hiccups - Chlorpromazine.
Tourette's disorder - Pimozide, Risperidone and haloperidol.
Anxiety disorders (OCD,PTSD) – Quetiapine,Risperidone
Autism – Risperidone, Aripiprazole
Neuroleptic anesthesia – Droperidol + Fentanyl
Menon’s Lytic cocktail regime – CPZ + Pethidine