ANTIPSYCHOTICS AND ANXIOLYTICS

Antipsychotics

Antipsychotics
o Psychosis

Positive symptoms

Negative symptoms

Dopamine D1 to D5
o Agents

Typical antipsychotics

Atypical antipsychotics

High potency > Less milligrams needed to produce effect

Low potency > vice versa

Typical Antipsychotics

Tx positive symptoms

Targets Dopamine D2
o Adverse Effects

Extrapyramidal Syndrome

Occurs mainly w/ typical antipsychotics; creates imbalance of acetylcholine

to dopamine (decreased dopamine, increased acetylcholine > administer
anticholinergic w/ antipsychotic)

Dystonia
o Early
o Rx: maintain airway, benzotropine (Cogentin) > anticholinergic,
Benzodiazepine
o Facial grimacing
o Involuntary upward eye movement
o Muscle spasms of the tongue, face, neck, and back (back muscle
spasms cause trunk to arch forward)
o Laryngeal spasms

Akathisia
o Early
o Rx: Benzodiazepine (decrease anxiety), Beta-blocker (block sympathetic
effects), anticholinergic
o Restless
o Trouble standing still
o Paces the floor
o Feet in constant motion, rocking back and forth

Pseudoparkinsonism
o Rx: anticholinergics
o Stooped postureRx
o Rigidity
o Bradykinesia
o Tremors at rest
o Pill-rolling motion of hand
o Risk for falls: instruct to walk w/hands behind back to adjust posture

Tardive dyskinesia
o Late, but can be in 5-30 days
o Increased risk in older adults
o Rx: stop drug, helpful medications benzodiazepines, calcium channel
blockers, beta-blockers, clozapine, vitamine E > meds not very effective, so
early prevention preferred
o Protrusion and rolling of the tongue
o Sucking and smacking movements of the lips
o Chewing motion
o Facial dyskinesia
o Involuntary movements of the body and extremities
o Social/self-image impact
o Does not go away

Neuroleptic Malignant Syndrome

Rare but potentially fatal

Symptoms > muscle rigidity, sudden fever, ALOC, fluctuating BP,
dysrhythmias, seizures, coma, death

Rx: stop medication, hydration, cooling measures, antipyretics, benzodiazepines,

muscle relaxants (Dantrium)
Blood Dyscrasias

Agranulocytosis (neutropenic)
o WBC

Less than 3000 discontinue medication

o Symptoms of infection
Common S/E

Most common drowsiness

Antichoinergic effects (repressing rest and relax system)

o Dry mouth
o Increased HR
o Urinary retention
o Constipation
o Visual changes
o Dermatologic effects

Pruritus > itchiness

Photosensitivity > sunlight

Tx: sun block, hats, sunglasses

Typical Medications

Phenothiazines
All typical S/E w/ orthostatic
hypotension
Urine might turn pink or red
All typical S/E
Fluphenazine (Prolixin)
Most risk to developing EPS
Not used often
More risk for decreased BP,
Thioridazine (Mellaril)
arrhythmias, prolonged QT waves
(delayed heartbeat)
OD of penothiazines:
Symptoms: unarouseable, BP fluctuations, tachycardia, dysrhythmias, altered
LOC, organ failure, EPS, NMS
Rx: airway, gastric lavage, activated charcoal, anticholinergics, hydration,
norepinephrine
Caution with patients who have glaucoma
Nonphenothiazines (aka Major Tranquilizers)
Butyrophenone
All typical S/E w/ sedative effect

Haloperidol (Haldol)
Can be given IM
Thioxanthenes
All typical S/E

Thiothixene (Navane)
Not used often
Chloropromazine (Thorazine)

Atypical Antipsychotics

Effective for both positive and negative symptoms

Not likely to cause EPS

Affects Serotonin and Dopaminergic D4, less effect on D2

ATypical Medications *ATYPICAL S/E NOT AS MAJOR AS TYPICAL

No acute EPS
Seizures
Agranulocytosis (discontinue if WBC less
than 3000)
Weight gain, dizziness, sedation,
Clozapine (Clozaril)
increased HR, orthostatic hypotension,
constipation, hyperglycemia,
hyperglycemia, decreased sexual
function, ventricular arrhythmia,
cardiac arrest, mild carditis
Low rates of EPS
Weight gain, dizziness, sedation,
increased HR, orthostatic hypotension,
Risperidone (Risperdal)
constipation, hyperglycemia, rash,
insomnia, possible agranulocytosis,
SI
Agranulocytosis
Weight gain, dizziness, sedation,
increased HR, orthostatic hyptension,
Olanzapine (Zyprexa)
constipation, hyperglycemia
NMS
SZ
Long
Acting
Weight gain, dizziness, sedation,
increased HR, orthostatic hypotension,
Ziprasidone (Geodori)
constipation, hyperglycemia
Prolonged Q-T interval, EKG
Weight gain, dizziness, sedation,
Quetiapine (Seroquel)
increased HR, orthostatic hypotension,
constipation, hyperglycemia
Use in addition to other
antidepressants
Considered both antipsychotic and
Aripiprazole (Abilify)
antidepressant
EPS, agranulocytosis, NMS, CVA, weight
gain, constipation, insomnia, fatigue
Preparations

Haloperidol decanoate (Haldol) > on streets, used often because it is a drug not screened in drug tests
o Peaks 6-7 days

Fluphenazine decanoate (Prolixin) > increased risk for EPS

Seroquel > does not have as many limitations

Injection > given in this form to ensure compliance

o Given every 2-4 weeks
o Viscous liquid, large-gauge needle
o Z-track, do not massage > caustic to underlying tissue
o No more than 15 mins in plastic syringe
o No subQ

Risperdal consta
o Bipolar
o Injection:

Q2weeks to start

Q4weeks for maintenance

No subQ
Cocktail Injection

IM injection
o Haldol 5 mg
o Ativan 2 mg or 1 mg
o Benadryl 50 mg or 25 mg

Aka booty juice

Given during emergencies: DTO, DTS

Requires a MD order

Requires 2 syringes: Haldol not compatible with Benadryl; one syringe with benadryl, the other
with ativan and haldol

Drug Interaction

Alcohol, sedatives, narcotics, benzodiazepine increase sedative effects

Smoking can increase metabolism > same part of liver breaks down nicotine and antipsychotic meds

Kava kava increase risk of dystonia with phenothiazines and fluphenazine > used to help individual relax
Antipsychotics for Older Adults > black box warning (ie Seroquel, Zyprexa)

Increased risk of severe S/E

Dosage should be 25% to 50% less

Dosage needs to be individualized

Dementia-related psychosis associated with increased death

Other

Needs family planning

o Teratogenic effects
o Passes into breast milk
o Creates challenge to psychosis tx
o Haldol typically given to pregnant women cause it is the oldest and well known drug

Only one antipsychotic at a time

Taper off medication

Intervention/Teaching

Medications do not cure mental illness; they alleviate symptoms

Compliance is extremely important (lifetime tx)

Do not abruptly discontinue

Smoking cessation > increased metabolism = antipsychotic meds eliminated faster

Good oral hygiene > for dry mouth; sugarless candies (for DM pts), water

Family planning > pregnancy (encourage birth control)

Routine follow-up > EKG, non-compliance d/t sexual dysfunction S/E

Follow-up labs

EPS

Sunglasses, sun exposure, extreme temp d/t photosensitivity

Orthostatic hypotension > rise slowly, hands behind back

Weight gain diet and exercise

ANXIOLYTICS
Benzodiazepines (BZD)

CNS depressant > ie alcohol

o Minor tranquilizer group

Effects for 10-20 hours?

Rx: anxiety, insomnia, anticonvulsant

Enhance the action of GABA > rest + relax center of brain

Highly protein-bound, metabolized by the liver (caution with liver pts, ie cirrhosis, hepatitis), excreted
in the urine

Use can lead to claims of medication seeking. Be cautious when charting as this will be on their
record permanently

S/E
o Sedation
o Dizziness
o Blurred vision
o Leukopenia > decreased WBC > rare

Drug interactions
o Cross tolerance with other CNS depressants > be cautious especially with respiratory depression

Alcohol, other benzodiazepines

o Do not take with other CNS depressants

Respiratory depression
o Kava Kava and Valerian root (Vallium is made from this) increases sedative effect
o Tobacco, caffeine, sympathomimetics decreases effects
o Benzodiazepines have possible teratogenic effects

Misc

Physical dependency
o Short term tx of acute anxiety and insomnia
o Tolerance weeks to months
o Do not abruptly discontinue

W/D agitation, insomnia, tremors, muscular cramps, sweating, etc.

o Schedule IV controlled substance (ie Vallium, Zanax, Ativan)
o Pts constantly in anxious state, so given frequently in hospitals
o Withdrawal from long-term, high dose benzodiazepine similar to alcohol withdrawal

Life-threatening

Paranoia, delirium hypertension, status epilepticus, increased temperature

Overdose
o Rx: emetic followed with activated charcoal IF CONSCIOUS

Antidote Flumazenil

Maintain airway d/t respiratory depression

IV vasopressors if severe hypotension

ie Sleeping pill (Ativan)

Psych consult

Toxicology

One-to-one sitter if SI
Teaching
o Do not drive motor vehicle or heavy equipment > possible to get DUI
o No alcohol or other CNSdepressants
o Teach non-pharmacological techniques to control anxiety/stress > ie diet, exercise, deep breathing
o Do not stop drug abruptly
o
Anxiolytics
Azapirone (BuSpar)
o Rx: anxiety and depression r/t anxiety
o 1-2 weeks to become effective
o Fewer sedative effects than BZDs
o Long term anti-anxiety issues (ie terminal illness, dementia)
o Interacts with grapefruit

Leads to toxicity

Limit daily to 8oz of juice or fresh grapefruit; keep in mind everyone is individualized
however
Antihistamines
o Diphenhydramine (Benadryl)

Rx: insomnia r/t anxiety

S/S: sedation, dizziness

Avoid alcohol and other CNS depressant as well as OTC drugs

Propanediol (Inderal)
o Beta-blocker > non-selective
o Rx: performance anxiety and social phobia
o Decreased peripheral sympathetic nervous symptom response
o S/S hypotension, bradycardia
o C/I for pts with asthma and COPD > assess HR and BP prior to administration