​Kembara Xtra - Medicine - Psychosis

​Kembara Xtra - Medicine - Psychosis 
a condition when thoughts and emotions are distorted; observed in dementia, delirium, mood disorders, substance abuse, and schizophrenia
Hallucinations and delusions are positive symptoms. Negative symptoms include anhedonia, poor speech, lack of motivation, social withdrawal, and affective blunting. Poor working memory, poor information processing, inattention, and disorganized speech and/or behavior are cognitive symptoms.

 Incidence
Schizophrenia affects 1.5 out of every 10,000 persons.
Schizophrenia prevalence: peak onset: Males: 18 to 25 years; females: 25 to 35 years; 1% of the population in the United States; a comparable amount globally; seen in 50% of instances of bipolar disorder and 20% of cases of unipolar depression.


Pathophysiology and Etiology 
Numerous factors, including mental, medical, and/or substance usage; Positive symptoms, such as increased mesolimbic dopaminergic activity; Negative symptoms, such as decreased mesocortical dopaminergic activity
Schizophrenia genetics: monozygotic twins have a 50% concordance rate, but there is little environmental influence; many genes are involved.


Risk Elements 
Lower socioeconomic level, drug usage (especially stimulants and THC), and a history of psychosis in the family

Basic Prevention 

Community-based efforts to identify and treat prodromal symptoms early

Substance use, including nicotine dependence, is linked to the metabolic syndrome, autonomic dysfunction, sudden cardiac death, breast cancer, and lung cancer.


Diagnosis 
Distinguish psychosis from delirium: Psychosis shouldn't have fluctuating mentation like delirium does.

History 

 Persecutory, strange, somatic, referential, or grandiose delusions
 Auditory, visual, tactile, gustatory, and olfactory hallucinations
Psychosis is linked to bipolar, unipolar depression, and dementia.
Check for drug usage and previous episodes of epileptiform activity.
Suicide risk is increased by co-occurring depression and mania, prior attempts, drug use, agitation, and poor adherence.

clinical assessment 
Mental status examination findings include uncoordinated speech, behavior, and/or mental processes, thought blocking, response lag, dulled affect, social disengagement, a lack of initiative, poor cognition/speech, and hallucinations.
Focused neurologic symptoms such as parkinsonism, tardive dyskinesia, and akathisia should be watched out for. Catatonia may also manifest as lack of movement or excessive excitation, posturing, mutism, grimacing, or waxy flexibility.


Schizophrenia has both positive and negative symptoms, a prodrome of social isolation, and cognitive impairment. Psychotic/prodromal symptoms in schizophrenia: 6 months or less. Manic-depressive bipolar disorder with persistent psychosis is called schizoaffective disorder. Relationship distance and strange beliefs are symptoms of schizotypal personality disorder. Nonbizarre delusion: Delusional disorder (such as erotomania, grandiosity, jealousy, persecutory, somatic) Mania and despair can both lead to mood disorders with psychotic characteristics. Congruent with mood; insanity subsides as mood rises.
 Substance-induced: alcohol withdrawal and benzodiazepine intoxication, as well as cocaine, bath salts, PCP, THC, amphetamines, hallucinogens, and alcohol intoxication that may last longer than acute intoxication
● Posttraumatic stress disorder (PTSD): psychosis accompanied by traumatic memories, frequently accompanied by visual hallucinations
 Psychosis brought on by a general medical condition, such as autoimmune encephalitis, delirium, a stroke, an infection, collagen vascular disease, a head injury, a tumor, or interictal disease.
 Medications that can cause psychosis include steroids, particularly those that are >40 mg prednisone equivalent, L-dopa, anticholinergics, antidepressants for people with bipolar disorder, interferon, digoxin, and stimulants.


CBC, CMP, LFTs, thyroid-stimulating hormone (TSH), rapid plasma reagin (RPR), HIV, ANA, ESR, vitamin B12, vitamin D, urinalysis, and tox screen are among the tests that were run.
Initial examinations (lab, imaging)
Imaging is not required for a diagnosis. If elderly patients have focal neurologic symptoms, a new onset, or a first break, consider a CT or MRI.
Consider an MRI if symptoms appear suddenly, especially if a fever or headache are present.
If the patient has a history of heart disease and is older than 50, take into account using an ECG to measure the QTc interval.

Tests in the Future & Special Considerations

Think about porphyria, metachromatic leukodystrophy, Wilson disease, and inflammatory diseases.
If it is difficult to discern between delirium and/or rapid-onset psychosis, lumbar puncture should be considered.
EEG should be taken into consideration for seizures and psychosis related to ictal occurrences.
If autoimmune encephalitis is suspected, take anti-NMDA receptor antibodies into consideration.

Ensure everyone is secure both inside and outside, and rule out any medical conditions, including delirium.

Medication – Typical versus atypical antipsychotics constitute the cornerstone of treatment. antagonists of dopamine-2 (D2) with varying affinities for the receptor. Atypicals also inhibit 5-HT2A receptors for serotonin. They address good symptoms before negative ones. Agitation is affected early on; antipsychotic effects can take up to a week.
A mood stabilizer and an antipsychotic may be used to treat mania with psychotic symptoms.
Antidepressant and antipsychotic combination enhances responsiveness more than either one alone for depression with psychotic symptoms. In delirium, the underlying cause must be treated; antipsychotic medication may not be necessary.
Acute dystonia side effects include either diphenhydramine 50 to 100 mg IM/IV or benztropine 1 to 3 mg IM/IV, followed by 0.5 to 2.0 mg BID-TID.
400 mg max. BID-TID each day
- Akathisia (intense restlessness): Lower antipsychotic dose; treat with -blocker or benzodiazepine; may switch to antipsychotic with lower akathisia risk such as quetiapine or clozapine. - Parkinsonism: Lower antipsychotic dose; switch to atypical (particularly, quetiapine or clozapine) and/or add benztropine 0.5 to 2.0 mg PO B
- Tardive dyskinesia: seen in 1/3 of individuals receiving long-term typical treatment and 1/8 of those receiving long-term atypical treatment. Change to quetiapine or clozapine. Otherwise, reduce the dose.
- Neuroleptic malignant syndrome: potentially fatal; rigidity, tremor, fever, autonomic instability, mental status changes; discontinue neuroleptic; ICU; volume resuscitation; cooling blankets; no anticholinergics/antihistamines; consider dantrolene, amantadine, bromocriptine, and electroconvulsive therapy (ECT).
- Anorexigenics and behavioral counseling can reduce metabolic risk. - Metabolic syndrome, sudden cardiac death (risk higher with IM/IV droperidol, IV haloperidol), stroke, heart failure, PNA (elderly), and pulmonary embolism
Initial Line
Clozapine and quetiapine have a decreased incidence of extrapyramidal symptoms and dyskinesias compared to standard antipsychotics. However, they come with a higher risk of weight gain, diabetes, and hyperlipidemia.
Ziprasidone 10 mg IM q2h or 20 mg q4h; NTE 40 mg/day; haloperidol 2 to 5 mg +/ lorazepam 2 mg IM; can be given with 1 mg IM benztropine; NTE 20 mg haloperidol and 8 mg lorazepam per day; and acute psychotic agitation.

Medications

Fluphenazine Haldol Decanoate: 12.5 mg, 12.5-50 mg, q2-3wk; Aripiprazole Abilify Maintena: 400 mg monthly (2-week PO overlap); 300-400 mg monthly; Haloperidol Haldol Decanoate: 50 mg, 50-200 mg, q3-4wk

441-1,064 mg, three-week PO overlap, laroxil. 30 mg PO plus Aristada Initio + lauroxil, or 882 mg IM every six weeks, or 1,064 mg IM every two months, is an alternative to 15 mg/day PO.

Paliperidone  Invega Sustenna: 234 mg, followed by 156 mg in one week, and 39-234 mg each month
Needs 4 months of Sustenna, Invega Trinza: 273-819 mg every three months
Invega Hayfera: 1,092-1,560 mg per six months; requires 4 months of Sustenna or one cycle of Trinza.

Risperidone: 210–405 mg Olanzapine Pamoate 12.5-50.0 mg q2wk (PO overlap), 12.5-50.0 mg q2wk of Risperdal Consta
Perseris: 90 or 120 mg once per month (no PO overlap), 90 mg = 3 mg QD, and 120 mg = 4 mg QD

Risperidone for psychosis in schizophrenia: Start at 1 to 2 mg QD; increase to 2 to 8 mg/day over the course of 1 to 2 weeks; >6 mg rarely more effective and higher risk of parkinsonism; higher risk of prolactinemia/parkinsonism because of D2 blockage
Start taking 20 to 40 mg of ziprasidone PO BID with at least 500 kcal. Target dose is 100 to 160 mg/day divided over two weeks; it prolongs QTc and has a higher risk of akathisia and parkinsonism than other atypicals.
Lurasidone: Start 20 to 40 mg QD with at least 350 calories, increase up to 160 mg QHS over 2 to 4 weeks; less weight gain but high rates of akathisia/parkinsonism; lowers QTc - Aripiprazole: Start 10 to 15 mg QD, may increase to 30 mg/day over 1 to 2 weeks; less weight gain but high rates of akathisia; lowers QTc


Next Line
Start with 5 to 10 mg QHS of olanzapine, and aim for 5 to 20 mg per day within two days. Other than clozapine, other atypical drugs are more likely to cause weight gain, hyperlipidemia, and hyperglycemia; they are also sedative, and smoking increases drug metabolism by 50%.
Starting with 25 mg BID, raise the dosage to 25 to 50 mg q8- 12 hours on days 2 and 3, and by day 4 to 3 to 400 mg. The dose can subsequently be increased by 50 to 100 mg per day, with NTE 800 mg per day divided between BID and TID. This increases weight gain and causes drowsiness and restless legs syndrome. Gradual titration is also better tolerated because it prolongs QTc.
Paliperidone: Start with 3 to 6 mg once day; increase the dose over the course of 1 to 2 weeks. Prolactinemia/Parkinsonism risk is higher than average; little hepatic metabolism is optimum for hepatic impairment.
Asenapine: Start with 5 mg QHS or BID sublingually, and increase to 10 mg BID if necessary over the course of one to two weeks. This medication causes drowsiness and orthostatic hypotension and has a high rate of akathisia and parkinsonism. A transdermal patch is also available.
Iloperidone: Start at 1 mg BID and increase by 2 mg daily if necessary, but a slower rise may be preferable due to the drug's substantial orthostasis (maximum 12 mg BID); this medication has minimal akathisia/parkinsonism, no weight gain, but causes sedation and prolongs QTc.
Brexpiprazole: Start with 1 mg QD for the first 4 days, move up to 2 mg QD for days 5 through 7, and then up to 4 mg/day depending on response. Less weight gain than other drugs, but greater incidence of akathisia than aripiprazole.
In a 6-week study, fasting glucose, cholesterol, triglycerides, and weight were comparable to placebo. Cariprazine: Start at 1.5 mg QD, can be increased to 3 mg QD on day 2, and dosed up to 6 mg QD based on response. Lumateperone: 42 mg daily. No titration is necessary. average mild weight loss, moderate sedation, and mouth dryness

0.5 to 2.0 mg every 8 to 12 hours for first-generation antipsychotics such haloperidol. 10 mg QD or less is the desired amount in divided doses. Low incidence of metabolic syndrome yet high rates of tardive dyskinesia
Starting dose for olanzapine/samidorphan is 5 mg/10 mg QD.
Olanzapine dosage should be increased by 5 mg per week, pending response, up to 20 mg/10 mg QD. Samidorphan, a new opioid-system modulator akin to naltrexone, has been linked to a lower risk of weight gain.
Aspects of Geriatrics
In comparison to a placebo, antipsychotics increase the chance of death in dementia-affected older patients. Parkinson's disease psychosis is accepted as a use for pimavanserin.

Supplemental Therapy 
Antipsychotics work best when combined with psychotherapy, occupational therapy, art therapy, and group therapy.


Alternative Medicine: Treatments for vitamin deficiencies (common with folic acid, B6, B12, and D), omega-3 fatty acid supplements, and glycine
CBD has been suggested as a complementary therapy. Contrast with THC, which can cause psychosis, not at all.

Admission 

Admission in cases of potential damage to oneself or others, severe functional impairment, and newly developing psychosis

Constant Care 
medication management and counseling. Cognitive-behavioral therapies have a great deal of potential.

Take Action 
Close follow-up is recommended after inpatient discharge (high risk of suicide); treatment, exercise, quitting smoking, and AIMS testing are used.
patient observation
Screening for metabolic syndrome (lipid panel, glucose, HgbA1c, CBC, CMP, LFTs, weight, waist circumference, and AIMS tests) should be done at the beginning for patients on antipsychotics. Long-term use should be monitored continuingly.
EPS: Monitor every week until the dose is consistent for two weeks.
Once stabilized, evaluate EPS and TD at least every 6 to 12 months.
Omega-3 is an essential fatty acid that can be found in fish, fruits, vegetables, nuts, and seeds.
 Steer clear of alcoholic and beverages with added sugar.



Schizophrenia prognosis: variable course; 70% of first-episode psychosis patients recover in 3 to 4 months; 20–40% make suicide attempts. 7% of people take their own lives.
The mainstay of treatment is medication, but there are other elements as well, such as psychosocial therapies, cognitive-behavioral therapy, interventions based on self-help, and motivational enhancement strategies.

Complications include: Life expectancy decreased by over ten years compared to the general population (mostly due to heart disease); Metabolic problems brought on by antipsychotic medicines, sedentary behavior, and smoking;