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PSYC 342: Psychopharmacology

PSYC 342: Psychopharmacology. ANTIPSYCHOTIC MEDICATIONS. Primary Indication for Use: Schizophrenia. Negative symptoms * Anhedonia Affective flattening Avolition Social withdrawal Alogia. Positive symptoms * Delusions Hallucinations.

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PSYC 342: Psychopharmacology

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  1. PSYC 342: Psychopharmacology ANTIPSYCHOTIC MEDICATIONS

  2. Primary Indication for Use: Schizophrenia Negative symptoms *Anhedonia Affective flatteningAvolitionSocial withdrawal Alogia Positive symptoms *DelusionsHallucinations Functional ImpairmentsWork/schoolInterpersonal relationshipsSelf-care Cognitive deficits *AttentionMemory Verbal fluencyExecutive function (eg, abstraction) Mood symptomsDepression/AnxietyAggression/Hostility Suicidality Disorganization Speech Behavior

  3. DSM IV-TR Diagnostic Criteria 2 or more of the following for most of 1 month: • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • Negative symptoms • Social/occupational dysfunction • Duration of at least 6 months • Not schizoaffective disorder or a mood disorder with psychotic features • Not due to substance abuse or a general medical disorder

  4. What, then, is PSYCHOSIS? • Generally equated with positive symptoms and disorganized or bizarre speech/behavior • Impaired “reality testing” • A syndrome present in many illnesses • remove known cause or treat underlying illness • treat symptomatically with antipsychotic medications

  5. Other Uses for Antipsychotics • Schizoaffective disorder, bipolar disorder, delusional disorder • Off-label use for Tourette’s, autism spectrum disorders, to augment treatment in depression and OCD, dementia, aggression in children • Medical treatment of nausea, hiccups

  6. A bit more terminology…..….before we blast off. Many names….Not all the same thing….. Antipsychotics - neuroleptic - typical and atypical - first gen, second gen, third gen - phenothiazine, thioxanthene, butyrophenone - low, med, and hi potency (1st gens) - chemical and trade names - chlorpromazine/thorazine; olanzapine/zyprexa

  7. An Historical Timeline • The state of affairs prior to the 1950s- available treatments very ineffective • Early 1950s experimental use of chlorpromazine (thorazine) • Once broadly introduced, institutionsemptied out (* but a couple of caveats) • First generation (typical) antipsychoticsdeveloped. • Second generation begins with clozapine (1989)

  8. A “Typical” (1st Gen) Timeline FDA approvalGeneric NameBrand Name 1953 chlorpromazine (Thorazine) 1958 trifluoperazine (Stelazine) 1958 perphenazine (Trilafon) 1959 fluphenazine (Prolixin) 1959 thioridazine (Mellaril) 1967 haloperidol (Haldol) 1967 thiothixene (Navane) 1970 mesoridazine (Serentil) 1975 loxapine (Loxitane) 1977 molidone (Moban) 1984 pimozide (Orap)

  9. Efficacy of Typical Antipsychotics

  10. Mechanism of Action: Dopamine D2 receptor antagonist

  11. Regions affected by D2 blockade • Mesolimbic (midbrain – limbic) and mesocortical (midbrain – forebrain) pathways • Emotional, cognitive regulation and integration • Nigrostriatal Pathway • Basal ganglia – movement • Hypothalamus-pituitary • Hormones, motivation, regulatory processes • Brain stem • Chemoreceptor trigger zone (compazine) • Descending RAS (reticular activating system)

  12. Dopamine related side effects profile • Extrapyramidal side effects (EPS) • Extrapyramidal movement system/basal ganglia • Drug induced Parkinson’s (aka “Thorazine shuffle”) • Acute dystonias • Akathesia • Tardive dyskinesia (sensitization, upregulation?) • Hypothalamic pituitary • Neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction). Aggressive medical care needed. • Heat regulation and susceptibility to heat stroke • Increased prolactin • Sexual side effects

  13. Other Mechanism of Action Table 4: Clinical Potency and Receptor Affinity for Typical Antipsychotic Agents Receptor type              r with Potency Dopamine  D1                 .41
      DopamineD2.94Norephinephrine.24 (hypotension, sedation)
Acetylcholine- .74 (anticholinergic effects)
Serotonin.32
      Histamine-.44  (sedation) From Baldesarrini, 1985

  14. Anticholinergic effects • Memory deficits, clouded cognition • Urinary retention, constipation • Dry mouth • Blurred vision • Tachycardia

  15. Limitations of D2 Blockers • “The Law of Thirds” • Treatment resistant cases • Lack of improvement of negative symptoms • EPS side effects

  16. Next Gen #1 - Clozapine • Introduction and withdrawal in 1970s Europe • Agranulocytosis • Reintroduction in US • Works in some (30-60%) of treatment resistant patients • Does not produce EPS • Improve affect, reduce suicidality • Agranulocyctosis reversible if detected and drug discontinued (testing protocol – weekly, monthly)

  17. What’s Atypical about Clozapine? • NOT a strong D2 blocker (relatively speaking) • Antagonizes other dopamine receptors • Antagonizes 5-HT receptors • Antagonizes histimine, muscarinic Ach, adrenergic NE

  18. The Atypical Boom FDA approvalGeneric NameBrand Name1990 clozapine (Clozaril)1994 risperidone (Risperdal)1996 olanzapine (Zyprexa)1997 quetiapine (Seroquel)2001 ziprasidone (Geodon)2002 aripiprazole (Abilify) 2009 iloperidone (Fanapt)2009 asenapine (Saphris)

  19. A small sample of Next Gens • Search to produce clozapine-like drug without agranulocytosis • Prototype: Risperidone (Risperdal) • Dual action – block D2 and 5-HT2 receptors • Other 5-HT/D2 combos • Olanzapine (Zyprexa) • Sertindole (Serlect) • Quetiapine (Seroquel) • Ziprasidone (Geodon)

  20. Strengths and Weaknesses of 2nd Gens • Able to dissociate clinical effects from EPS side effects • But for some, this is dose dependent • Able to dissociate clinical effects from agranylocytosis • No need for WBC monitoring • Have become wildly popular. Off label use, especially in young and old, has expanded. • Raises serious concerns

  21. Strengths and Weaknesses of 2nd Gens • Expansion to vulnerable populations REAL concern. • Initial promise not entirely fulfilled • Note CATIE and Cutlass studies reported in text • Claims for superior efficacy over 1st gens (for increased tolerability, superior performance with negative symptoms and in treatment refractory) not entirely supported. • Tolerability - similarly lousy compliance rates • Trade-off in side effects profiles

  22. 2nd Gen Side Effects • Metabolic syndrome • Weight gain • Blood sugar dysregulation • Increase risk of developing type 2 diabetes • Rapid and independent of weight gain • Increased risk of cardiac problems • Stroke risk in dementia patients • Electrical activity of the heart (sudden cardiac death)

  23. 3rd Gens • Aripiprazole (Abilify) • 5-HT2 antagonist • Partial agonist at D2 and 5-HT1a • D2 effects at low and high intrinsic dopamine levels • Antidepressant effects, especially when combined with true antidepressants • Amisulpride (Solian) • D2 and D3 blocker, but selectively in limbic regions (not basal ganglia) • Blocks dopamine autoreceptors (increase DA release)

  24. Next: Theories of Schizophrenia • Neurochemical Models • Dopamine Hypothesis • Glutamate Hypothesis • Etiology • Structural anomalies • Heredity • Development • Experimental Research Models

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