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M1
conventional
antipsychotic
drug
11-7
1
H1
D2
Stahl S M, Essential
Psychopharmacology (2000)
pure D2
blocker
11-2
Stahl S M, Essential
Psychopharmacology (2000)
Mesocortical pathway
11-3
Increase in
negative
symptoms
Stahl S M, Essential
Psychopharmacology (2000)
Nigrostriatal pathway
EPSs
11-4
Stahl S M, Essential
Psychopharmacology (2000)
Blockade of
receptors in the
nigrostriatal
dopamine pathway
causes them to upregulate
This up-regulation
may lead to tardive
dyskinesia
11-5
Stahl S M, Essential
Psychopharmacology (2000)
Motor and mental features of neurolepticinduced extrapyramidal side effects
Parkinsonism
Tremor (resting), rigidity, bradykinesia, masklike facies
Akathisia
Restlessness, pacing, fidgeting, shifting from jitteriness,
anxiety, irritability, anger, difficulty concentrating
Dystonia
Muscle contractions, tongue protrusion,
torticollis, opisthotonos, fear, distress, paranoia
Tardive Buccolingual-masticatory movements of irregular
dyskinesia
(nonrhythmic) nature; choreiform or athetoid
(writhing) movements of fingers, extremities, trunk
Adapted from Ayd 1995; Casey 1995
D2
antagonist
pituitary lactotroph
D2
receptor
11-32
prolactin
Stahl S M, Essential
Psychopharmacology (2000)
Typical antipsychotic drugs: potencies and
side effect profiles
Drug
Approximate
dose (mg)
Phenothiazines
Chlorpromazine (Thorazine)
Piperidines
Thioridazine (Mellaril)
Piperazines
Fluphenazine (Prolixin)
Perphenazine (Trilafon)
Trifluoperazine (Stelazine)
Thioxanthene
Thiothixene (Navane)
Butyrophenones
Haloperidol (Haldol)
Sedative
effect
Hypotensive
effect
Anticholinergic Extrapyramidal
effect
effect
100
H
H
M
L
95
H
H
H
L
2
M
L
L
H
8
L
L
L
H
5
M
L
L
H
5
L
L
L
H
2
L
L
L
H
5HT2A
SDA
D2
11-16
Stahl S M, Essential
Psychopharmacology (2000)
5HT-DA Interactions
brake
Substantia
nigra
brake
raphe nucleus
11-17
Stahl S M, Essential
Psychopharmacology (2000)
dopamine neuron
dopamine
Substantia
nigra
5HT2A
receptor
serotonin
5HT2A
receptor
serotonin neuron
Raphe
11-18
Stahl S M, Essential
Psychopharmacology (2000)
mesocortical pathway
primary dopamine deficiency
dopamine release
SDA
serotonin
secondary dopamine deficiency
11-27
Stahl S M, Essential
Psychopharmacology (2000)
Nigrostriatal pathway
5HT2A
receptor
11-24
Stahl S M, Essential
Psychopharmacology (2000)
5HT1A
M1
5HT2A
1
H1
2
5HT2C
D1
5HT3
clozapine
5HT6
D4
D3
D2
5HT7
11-37
Stahl S M, Essential
Psychopharmacology (2000)
1
5HT2A
2
risperidone
D2
5HT7
11-39
Stahl S M, Essential
Psychopharmacology (2000)
M1
5HT2A
1
H1
5HT2C
D1
5HT3
olanzapine
5HT6
D4
11-40
D3
D2
Stahl S M, Essential
Psychopharmacology (2000)
1
H1
5HT2A
2
quetiapine
5HT6
D2
5HT7
11-41
Stahl S M, Essential
Psychopharmacology (2000)
5HT1A
1
5HT2A
5HT1D
SRI
NRI
5HT2C
ziprasidone
D3
D2
5HT7
11-43
Stahl S M, Essential
Psychopharmacology (2000)
Side effects of selected atypical agents
polypharmacy
combos
3rd line
treatment
clozapine
D2
2nd line
treatment
D2
noncompliant
(depot)
SDA
1st line
treatment
BZ
D2
in case of
emergency
POSITIVE SYMPTOM PHARMACY
11-52
Stahl S M, Essential
Psychopharmacology (2000)
Hierarchy of Treatment Goals in Medical
Psychotherapy of Schizophrenia
• Acute Phase
– Medical/neuropsychiatric assessment
– Rapid symptom reduction
– Reduce impact of episode on friends, family, housing, activities
• Convalescent Phase
–
–
–
–
Gain trust/alliance with family/caregivers
Assess and mobilize social supports
Ensure human service needs are met (food, clothing, housing)
Ensure safety and predictability of environment
• Adaptive Plateau
– Establish therapeutic alliance/supportive treatment routine
– Achieve effective maintenance medication regime
• Stable plateau
– Psychoeducation: Promote illness self-management strategies, awareness
of relationship between stress and symptoms
– Rehabilitation: Teach adaptive competencies