AKA: First-Generation, Conventional, or Traditional Antipsychotics, Classical Neuroleptics,or Major Tranquilizers.

This class of medications is most often utilized in the treatment of psychotic (positive) symptoms during the course of Schizophrenia.

Here is a list of First-Generation Antipsychotics organized by potency:

Low Potency:

 

• Chlorpromazine (Thorazine)
• Chlorprothixene (Taractan)
• Levomepromazine (Levoprome)
• Mesoridazine (Serentil)
• Thioridazine (Mellaril)

 

Medium Potency: 

 

• Loxapine (Loxitane)
• Molindone (Moban)
• Perphenazine (Trilafon)
• Thiothixene (Navane)

 

High Potency:

 

• Droperidol (Inapsine)
• Flupentixol (Fluanxol)
• Fluphenazine (Permitil, or Prolixin)
• Haloperidol (Haldol)
• Pimozide (Orap)
• Prochlorperazine (Compro)
• Trifluoperazine (Stelazine)

 

Common Side Effects:

 

• Extrapyramidal Symptoms (EPS) like:
• Acute dystonic reactions: muscular spasms of neck (torticollis,) eyes (oculogyric crisis,) tongue, or jaw
• Akathisia: A feeling of motor restlessness
• Pseudoparkinsonism: drug-induced parkinsonism (cogwheel rigidity, bradykinesia/akinesia, resting tremor, and postural instability.
• Tardive dyskinesia: involuntary asymmetrical movements of the muscles, this is a long term chronic condition associated with long term use of antipsychotics and is sometimes irreversible even with cessation of medication.

 

Anticholinergic medications are used to treat EPS:

Anti-Muscarinic agents

 

• Atropine
• Benztropine (Cogentin)
• Biperiden
• Chlorpheniramine (Chlor-Trimeton)
• Dicyclomine (Dicycloverine)
• Dimenhydrinate (Dramamine)
• Diphenhydramine (Benadryl, Sominex, Advil PM, etc.)
• Doxylamine (Unisom)
• Glycopyrrolate (Robinul)
• Ipratropium (Atrovent)
• Orphenadrine
• Oxitropium (Oxivent)
• Oxybutynin (Ditropan, Driptane, Lyrinel XL)
• Tolterodine (Detrol, Detrusitol)
• Tiotropium (Spiriva)
• Trihexyphenidyl
• Scopolamine
• Solifenacin

 

Anti-Nicotinic agents

 

• Bupropion (Zyban, Wellbutrin) – Ganglion blocker
• Dextromethorphan - Cough suppressant and ganglion blocker
• Doxacurium - Nondeplorizing skeletal muscular relaxant
• Hexamethonium - Ganglion blocker
• Mecamylamine - Ganglion blocker and occassional smoking cessation aid[2]
• Tubocurarine - Nondeplorizing skeletal muscular relaxant

 

Buuuuuuuut, there is such thing as “too much of a good thing” since Anticholinergic medications can cause:

Acute Anticholinergic Syndrome:

 

• Ataxia-loss of coordination
• Decreased mucus production in the nose and throat; consequent dry, sore throat
• Xerostomia, or dry-mouth with possible acceleration of dental caries
• Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
• Increased body temperature
• Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia)
• Loss of accommodation (loss of focusing ability, blurred vision – cycloplegia)
• Double-vision (diplopia)
• Increased heart rate (tachycardia)
• Tendency to be easily startled
• Urinary retention
• Diminished bowel movement, sometimes ileus (decreases motility via the vagus nerve)
• Increased intraocular pressure; dangerous for people with narrow-angle glaucoma
• Shaking

 

Possible effects in the central nervous system resemble those associated with delirium, and may include:

 

• Confusion
• Disorientation
• Agitation
• Euphoria or dysphoria
• Respiratory depression
• Memory problems
• Inability to concentrate
• Wandering thoughts; inability to sustain a train of thought
• Incoherent speech
• Irritability
• Mental confusion (brain fog)
• Wakeful myoclonic jerking
• Unusual sensitivity to sudden sounds
• Illogical thinking
• Photophobia
• Visual disturbances
• Periodic flashes of light
• Periodic changes in visual field
• Visual snow
• Restricted or “tunnel vision”
• Visual, auditory, or other sensory hallucinations
• Warping or waving of surfaces and edges
• Textured surfaces
• “Dancing” lines; “spiders”, insects; form constants
• Lifelike objects indistinguishable from reality
• Phantom smoking
• Hallucinated presence of people not actually there
• Rarely: seizures, coma, and death
• Orthostatic hypotension (sudden dropping of systolic blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population.

 

**!!GOLDEN NUGGET!!**

A mnemonic for Anticholinergic Syndrome: 

 

• Hot as a hare (hyperthermia)

• Blind as a bat (dilated pupils)

• Dry as a bone (dry skin)

• Red as a beet (vasodilation)

• Mad as a hatter (hallucinations/agitation)

• The bowel and bladder lose their tone and the heart goes on alone (ileus, urinary retention, tachycardia)

 

The good news is that Acute Anticholinergic Syndrome is completely reversible and subsides once all of the causative agent has been excreted.

 

• Physostigmine is a Reversible Cholinergic Agent that can be used in life-threatening cases.
• Piracetam (and other racetams), α-GPC and choline are known to activate the cholinergic system and alleviate cognitive symptoms caused by extended use of anticholinergic drugs

 

With all of that going on it is no wonder that most doctors have switched to the Second-Generation, or Atypical Antipsychotics. That’s not to say that the Typicals are not used, at all. It’s just that Atypicals better treated both the positive AND negative symptoms of Schizophrenia Spectrum Disorders.

Tags: Conventional Antipsychotics, Typical Antipsychotics, Traditional Antipsychotics, Classical Neuroleptics, Major Tranquilizers, schizophrenia, psychosis, atypical, antipsychotic, Low Potency, Chlorpromazine, Thorazine, Chlorprothixene, Taractan, Levomepromazine, Levoprome, Mesoridazine, Serentil, Thioridazine, Mellaril, Medium Potency, Loxapine, Loxitane, Molindone, Moban, Perphenazine, Trilafon, Thiothixene, Navane, High Potency, Droperidol, Inapsine, Flupentixol, Fluanxol, Fluphenazine, Permitil, Prolixin, Haloperidol, Haldol, Pimozide, Orap, Prochlorperazine, Compro, Trifluoperazine, Stelazine

AKA: SSRIs

• Citalopram (Celexa)
• Initial dose: 20mg/day.
• Maintenance dose: 20 to 40mg/day.

• Escitalopram (Lexapro)
• Initial dose: 10mg/day.
• Maintenance dose: 10-20mg/day.

• Fluoxetine (Prozac)
• Initial dose: 20mg/day.
• Maintenance dose: 20-60mg/day.

• Paroxetine (Paxil, Pexeva)
• Initial dose: 20mg/day, titrated slowly by 10mg a week.
• Maintenance dose: 20-50mg/day, as tolerated/needed.

• Sertraline (Zoloft)

Common Side Effects:

• Nausea
• Nervousness, agitation or restlessness
• Dizziness
• Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction)
• Drowsiness
• Insomnia
• Weight gain or loss
• Headache
• Dry mouth
• Vomiting
• Diarrhea

IMPORTANT: Pharmaceutical companies HAVE to list every side effect reported during clinical trails. So, just because a medication lists a certain side effect DOES NOT MEAN YOU will have it. In fact, most people experience very few side effects and with continued use (2 weeks and beyond), most of the initial side effects dissipate, or resolve completely. Additionally, the dosages listed above are FDA approved for treating Depression in an otherwise healthy Adult. For more specific information in treating your symptoms, consult your doctor.

Tags: Selective Serotonin Reuptake Inhibitors, SSRIs, Citalopram, Celexa, Escitalopram, Lexapro, Fluoxetine, Prozac, Paroxetine, Paxil, Pexeva, Sertraline, Zoloft, Sarafem

AKA: Second-Generation, Atypical Antipsychotics, or simply SGAs.

These medications tend to be superior to that of Typical Antipsychotics because they treat BOTH positive and negative symptoms of Schizophrenia Spectrum Disorders.

Q: What the heck are positive vs. negative symptoms of Schizophrenia?

A: Simply put, positive symptoms are psychotic behaviors like:

• Delusions and paranoia
• Disordered thoughts and speech
• Tactile, auditory, visual, olfactory and/or gustatory hallucinations
• While negative symptoms are disruptions to normal behaviors and emotions and can sometimes be confused with clinical depression, with symptoms like:
• Flat, or dull affect (showing no emotion, monotone voice)
• Lack of pleasure in everyday life
• Lack of ability to begin and sustain planned activities
• Speaking little, even when forced to interact
  
  

Since both negative and positive symptoms exist within Schizophrenia, these newer, Atypical Antipsychotics are the treatment of choice, here is a list:

• Aripiprazole (Abilify)
• Asenapine Maleate (Saphris)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa)
• Olanzapine/Fluoxetine (Symbyax)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

 Common Side Effects:

• Dry mouth
• Blurred vision
• Constipation
• Dizziness or lightheadedness
• Weight gain

Sometimes atypical antipsychotics can cause:

• Problems sleeping
• Extreme tiredness and weakness.

With long-term use, atypical antipsychotics can also carry a risk of:

• Tardive dyskinesia

Though atypical antipsychotics are usually given for Schizophrenia Spectrum Disorders, they have become increasingly popular as an adjunct (or in addition) to an SSRI, or antidepressant. In fact the FDA recently approved Abilify for people who do not respond to antidepressants alone. You’ve all seen the commercials where the Antidepressant and Abilify become friends…?

Tags: Abilify, adjunct, antipsychotic, Aripiprazole, Asenapine, Atypical Antipsychotics, Clozapine, Clozaril, delusions, Fanapt, Geodon, hallucinations, Iloperidone, Invega, Latuda, Lurasidone, Maleate, negative symptoms, newer antipsychotics, non-conventional antipsychotics, Olanzapine, Olanzapine/Fluoxetine, Paliperidone, positive symptoms, Quetiapine, Risperdal, Risperidone, Saphris, schizo, schizophrenia, Second-Generation Antipsychotics, Seroquel, SGAs, Symbyax, Ziprasidone, Zyprexa

Most of the time, I hate stats. It’s one of my least favorite subjects. Frankly, I think most socially appropriate human beings would agree. But, it’s a necessary evil in this field. So, I put together a few points of logistical relevance so you don’t have to go ballistic on this stuff!

5 takeaway points for evaluating statistics and drug studies:

1-Even in a double-blind study, reported side effects can tip off the clinician as to whether the subject has received the placebo, or the actual treatment.

2-The placebo effect-is shown when a sugar pill is given to the control group and can lead to positive (and less likely negative) symptoms just simply by receiving something from a clinician. This speaks to the power of the mind.

3-Our mind can work against us, too, with the nocebo effect-setting someone up for possible negative side effects by telling them that “you may get all these side effects, or symptoms: lupus, scleroderma, blurred vision, dry mouth, and left foot paralysis.” It never fails that someone will report left foot paralysis!! As you may know there is not a single drug That’s the power of suggestion!

4-Here’s a great tip when deciding whether to read a study, or not. If your confidence interval is <1.0 it IS statistically significant!! If it includes 1.0, don’t read the study because it is NOT statistically relevant.

5-Risk ratio-is the point estimate used for cohort studies.

Haha, there has to be a joke in there somewhere!!

But, for real, this is a common question I’m asked when I tell people about the psychopharmacology program.

A: The simple answer is:

“not very much” and “a whole lot” …read on.

A: The complicated answer is:

A psychologist has a minimum of the following:

BA in clinical psychology, sociology, or related field

MA in psychology (can be obtained interim)

Supervised by licensed clinician for 1500 pre-doc hours

Doctorate in psychology (Either PsyD, or PhD, EdD, etc.)

Sup. by licensed psychologist for 1500 post-doc hours

Successful passing of the National Exam

In the United States that is the Examination for Professional Practice in Psychology, or EPPP

Successful passing of the State Ethical Exam

In California it is the California Psychology Supplemental Examination, or CPSE

Accepted application and initial fee to State of licensure

California Board of Psychology, or CA BOP

source:

Please also refer to my other post discussing the requirements that a licensed psychologist must meet prior to licensure.

A psychiatrist has a minimum of the following:

BA in psychology, or a related field

MD from medical school completion

Residency completion

The United States Medical Licensing Examination USMLE is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME)

Passing of the State medical board

Accepted application and initial fee to State of licensure

sources:

-Cloud, J. (2010). Psychology vs. Psychiatry: What’s the Difference, and Which Is Better? Time.

-http://www.usmle.org/

Okay, here is where it gets a bit confusing…

A Medical Psychologist can be a:

1-highly trained and licensed psychologist

WHO CAN PRESCRIBE PSYCHOTROPIC MEDICATIONS:

With a Postdoctoral Master of Science in Psychopharmacology

Licensed psychologist by the Louisiana State Board of Examiners of Psychologists

Licensed Medical Psychologist from the Louisiana State Board of Medical Examiners

Who prescribes psychotropic medications with consultation for the 1st 3 years, in Louisiana

OR

2-highly trained and licensed psychologist

WHO CANNOT PRESCRIBE ANY MEDICATIONS

With a Doctorate in Psychology

Board Certified Speciality from the American Board of Psychological Specialties,

A Division of the American College of Forensic Examiners

sources:

upon request.

CONCLUSION:

The lines between psychiatry and medical psychology are becoming blurred. Though, they are admittedly VERY different fields with different qualifications and degrees. It is this author’s belief that the blur happens from a variety of sources: depictions on television and other media outlets, misinformation, miseducation, interpretation and perception. But, the most important blur is occurring due to the nation-wide scarcity of prescribers, in general! You may have noticed the increasing amount of Nurse Practitioners, Physician’s Assistants and dun-dun-dun-dun-duuuuun… Medical Psychologists!

Some people prefer to call a psychologists who can prescribe a “prescribing psychologist” in Louisiana, New Mexico, Guam, Native American territories, and some state and Federal departments (currently the only places said professional can prescribe.) Makes sense, but in Louisiana, many entities, (including the ones who license folks) call a psychologist who can prescribe psychotropic medications a “medical psychologist” even using the suffix “MP.” ex-Jon Chandler, PsyD, MP

Other similar names have popped up over the years, including: psychopharmacologist, pharmacopsychologist, pharmacology psychologist, psychology pharmacologist, prescribing psychologist, RxP, and as discussed medical psychologist. In my opinion, the varying names for this practice may highlight the general disorganization of the field of psychology. Historically, we have not been our own best advocates…

Hope this clears up some misinformation, or confusion. Thanks for reading.

Sharing is caring,

Dr. Jon Chandler

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I want to hold myself and other colleagues accountable for learning and implementing the material we are learning in our Post-doc Master of Science in Clinical Psychopharmacology so that we will pass the Psychopharmacology Examination for Psychologists (AKA PEP) the first go-round.

Here is a brief introduction to what the heck all that means!

A Post-doc Master of Science in Clinical Psychopharmacology is a post-doctoral degree that can only be obtained when the following prerequisites have been met:

Licensed clinical psychologist

BA in clinical psychology, sociology, or related field

MA in psychology (can be obtained interim)

Supervised by licensed clinician for 1500 pre-doc hours

Doctorate in psychology (Either PsyD, or PhD)

Sup. by licensed psychologist for 1500 post-doc hours

Successful passing of the National Exam

In the United States that is the Examination for Professional Practice in Psychology, or EPPP

Successful passing of the State Ethical Exam

In California it is the California Psychology Supplemental Examination, or CPSE

Accepted application and initial fee to State of licensure

California Board of Psychology, or CA BOP

Preferred to be actively practicing as a psychologist

Time, dedication and money for the course work ahead

Passing of the Psychopharmacology Examination for Psychologists, the PEP

In Louisiana, it is required to become licensed as a psychologist and medical psychologist, and

Consult with a medical doctor, psychiatrist, or medical psychologist for 3 years

I hope this gives you a helpful introduction to the field of medical psychology, prescribing psychology, psychopharmacology, or otherwise known as pharmacopsychology — more on this next time!

Thanks for reading!

Sharing is caring,

Dr. Jon Chandler

As some of you may know, I am glutton for punishment. Or, I must be. Even after the hundreds of thousands of dollar$ in student loans, the countless hours spent studying and emotional strain gaining any degree takes on one’s life… I went back.

It wasn’t for the money, though, that should be a nice bump in pay, it wasn’t for the prestige that comes with prescribing rights, it wasn’t just so we could relocate to one of the best cities in the world, though that is a perk, IT IS for the accessibility I will gain to patients in need of psychological services.

Eventually, this website will document the tail end of my MS in psychopharmacology and the beginning of a career in the pioneering field of medical psychology. Stay tuned.

As always, thanks for reading.

Sharing is caring,

Dr. Jon Chandler

This will be the future space for psychological blog entries.  Please contact me with any topics you might like me to discuss.

Thanks,
Dr. Chandler