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Introduction to Antipsychotics

Dr P.Kasi Krishna Raja Department of Psychiatry

Uses/ Indications

Indications for Use

Thought Disorders
Mood Disorders Anxiety Disorders Post Traumatic Stress Disorder ,
Refractory Obsessive Compulsive Disorder

Indications for Use

Psychosis due to a general medical

Delirium, dementia, etc. Substance-induced psychosis

Indications for Use

Tourettes Syndrome and other
movement disorders

Personality Disorders (symptoms) Profound Agitation

Well make the distinction between the
older, original drugs, which well call: Traditional Antipsychotics

VS. The newer, rationally designed drugs

which well call Atypical Antipsychotics

Traditional Antipsychotics
Serendipity dirty drugs All have similar efficacy and work in a
similar fashion Dopamine blockade (D2)

Traditional Antipsychotics
Only treat the positive symptoms of
Schizophrenia (ie, delusions, hallucinations, disorganized thought/speech)

Antipsychotics: Side Effects

Side Effects
Neurological: Secondary Negative Symptoms Extrapyramidal Side Effects Non-Neurological

The fine modulators of movement Outside the primary motor tract ie, Basal Ganglia

Acute Dystonia Parkinsonism Akathisia NMS: Neuroleptic Malignant Syndrome TD: Tardive Dyskinesia

Extrapyramidal Side Effects

Acute Dystonia
Acute onset of muscle

Often involves head (face, eyes)

and/or neck

Laryngeal spasms can impair


Treated with anti-cholinergic


Looks just like Parkinsons, but its

Bradykinesia, Resting Tremor,

Cogwheel Rigidity, etc.

Treatment: anticholinergic

Subjective sense of inner restlessness #1 reason for noncompliance Often confused with agitation,
worsening psychosis

Treated with anticholinergic drugs,

Beta blockers

Neuroleptic Malignant Syndrome

Form of Delirium Medical Emergency Triad of Musculoskeletal Changes
(Rigidity), Autonomic Instability (Blood Pressure, Pulse, Temperature fluctuations), and Mental Status Changes (Confusion, disorientation, mutism, etc.)

NMS Treatment
Discontinuation of offending
medication, supportive therapy

Dantroline and Bromocriptine

Tardive Dyskinesia
A Combination of Choreiform and Athetoid Movements

Tardive Dyskinesia
Involuntary Choreiform + Athetoid
Face most often affected Highest risk is from chronic use of
(Choreoathetoid) movements

Treatments are limited

antipsychotic medications

Tardive Dyskinesia
Often irreversible Best treatment is thus, prevention

Other Side Effects


Anticholinergic Side Effects

Dry Mouth, Dry Eyes Constipation, Urinary Retention Blurred Vision Dulling of Cognition Anti-S L U D G E

Non-neurological Side Effects Cardiotoxicity

Orthostasis Ocular pigmentary changes Photosensitivity ANTI-HISTAMINERGIC Side

Weight gain, sedation

Non-neurological Side Effects

Hyperprolactinemia/ Sexual

Lower seizure threshold


Classification of Antipsychotics
Based on potency, or dosing

High Potency Mid Potency Low Potency

Examples: High Potency

Haloperidol (Haldol) Fluphenazine (Prolixin)

Examples: Low Potency

Clorpromazine (Thorazine) Thioridazine (Mellaril)

Examples: Mid Potency

Thiothixene (Navane) Perphenazine (Trilafon)

Potency Matters
High Potency

More EPS
Less other side effects

Low Potency
More orthostasis, sedation, anticholinergic effects Less EPS


What makes em Atypical?

What makes em atypical?

2.Lower propensity to cause Extra Pyramidal Side Effects and lower incidence of Tardive Dyskinesia

3.Treat negative symptoms of schizophrenia

4.Greater Serotonin (5HT2) blockade than Dopamine (D2) blockade 5.Better efficacy in refractory psychoses

Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify)

What are their Names?

Atypical Antipsychotics
All are FDA approved to treat

Several have FDA approval to treat

Acute Mania (some to prevent mania)

Some have indications to treat agitation

and psychosis in Dementia

Atypical Antipsychotics
Potential for weight gain Potential for Dyslipidemias Risk of developing Type II Diabetes

Take Home Points about Individual Drugs

Atypical Antipsychotics

CLOZAPINE (Clozaril)
Gold standard of atypicals Effectively treats many refractory The closest thing to a treatment for
TD cases

Has Many Side Effects Sedation Orthosasis Anticholinergic Hypersalivation Weight gain

Clozapine (Clozaril)

Clozapine (Clozaril)
Adverse Drug Reactions Seizures Agranulocytosis (must monitor blood
counts weekly)

Dose-related Extra Pyramidal Side

Risk of Stroke

Side Effects Somnolence Increased appetite with increase

in weight


Cataracts in Beagle Dogs

Potential for cardiac conduction

Newest atypical antipsychotic Generally well tolerated

Were Done!
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