OBAT PSIKOSA

Psychosis

Psychosis is a severe mental disorder characterized by hallucinations and loss of sense of reality (a sense ofreality). a serious mental disorder, caused by emotional or organic causes (functional) and showed disruptionto think, react emotionally, remember, communicate, interpret reality and act on the fact that, so the ability tomeet the demands of daily life severely impaired.

Characteristic of psychosis:

1. Supposition

2. Hallucinations

3. Reality testing (-)

Disturbances in the sharpness and awareness, inability to deal with external stimuli or concentrate, physical discomfort, such as patients often memeperlihatkan motor movements repeated without meaning, such as swearing in sheets or clothes, or play a role or want to respond to disturbances of perception, disorientation.

Anti-psychotic drug

Synonym: neuroleptics, major tranquilizers, ataractics, antipsychotics, antipsychotics drugs.

Drug reference: chlorpromazine (CPZ)

indications of use

Symptoms of the target (target syndrome): Syndrome psychosis

Grain-Grain diagostik psychosis syndrome:

     *Hendaya weight in assessing the power of reality (reality testing abilities), manifests in symptoms: kesdaran self (awareness) is interrupted, the power of social norms (judgment) is interrupted, and the power of self-insight (insight) disrupted.
     *Hendaya weight in mental functions, manifest with symptoms: disturbance of mind association (incoherence), unusual thought content (delusions), perception disturbance (hallucinations), impaired sense (not in accordance with the situation), and the strange behavior or uncontrolled (disorganized).
     *Hendaya beratdalam sejari-day functions of life, manifest in symptoms: not able to work, social relationships, and taking care of themselves sendir.

      Psychosis syndrome can occur in:
     *Organic psychosis syndrome: syndrome of delirium, dementia, alcohol intoxication, drug withdrawal symptoms, etc..
     *Syndrome of functional psychoses: schizophrenia, paranoid psychosis, affective psychosis, brief reactive psychosis, etc..

Mechanism of action

Hypothesis: the syndrome of psychosis due to the increased activity of the neurotransmitter dopamine.

Mechanism of action of anti-psychotic drugs are dopamine receptor memblikade post-synaptic brain, especially disistem limbic and extrapyramidal systems (dopamine receptor antagonists)

On the use of anti-psychotic drugs long term, periodic laboratory examinations should be performed: routine blood and complete urine, liver function, kidney function, for early detection of changes due to drug side effects.

Side effect profile
Side effects of anti-psychotic drugs can be:
    • Sedation and psychomotor disturbances
    • autonomic disorders (hypotension, anticholinergic / parasimpatolik: dry mouth, difficulty miksi and defecation, nasal congestion, blurred mta, intra-ocular takanan menigkat, heart rhythm disturbances)
    • extrapyramidal disorders (acute distonasi, akathisia, Parkinson's syndrome, tremor, bradikisenia, rigidity)
    • endocrine disorders (amenorrhoe, rynaecomastia), metabolic (jaundice), hematologic (agranulocytosis), usually for long-term use.
Side affects is there a fast can be tolerated by the patients, there is a slow and there is to need medication to relieve penderuta symptomatic patients.

            So in the use of anti-psychotic drugs to be achieved is the "optimal response with minimal side effects"

            Irreversible side effects: tardive dyskinesia (involuntary repetitive movements on: tongue, face, mouth / jaw, and limbs which disappeared during sleep).

Usually on the long-term use (maintenance therapy) and in elderly patients. These side effects are not associated with a dose of anti-psychotic medication (non-dose related).

If these symptoms occur: anti-psychotic medication gradually discontinued, biased drug administration tried reserpine 2.5 mg / h (dopamine depleting agent), anti-Parkinson's drug & l-dopa can exacerbate the anti-psychotic keadaan.obat replacement is best Clozapine 50-100 mg / h
Anti-psychotic drug almost never cause death due to overdose or to kill diri.namun thus to avoid the consequences which should be beneficial kuarang "gastric lavage" if the drug has recently eaten.

Drug interactions

     Antipsikosik + = potential antipsychotic drug side effects and no evidence of more effective (there is no synergistic effect between the two anti-psychotic medication)

For example: CPZ + reserpine = potentiation hypotensive effect

     Antipsikosik + = tricyclic antidepressant side effects of anti-choline ergik increased (be careful padsa patients with prostatic hypertrophy, glaucoma, ileus, heart disease)

     Antipsikosik + anti-anxiety = sedation increased, useful for cases with symptoms of nervous agitation and a very great noise (acute adjunctive Therapy)

    Antipsikosik + ECT = advisable not to give medication on the morning prior to the ECT (electro convulsive Therapy) olaaaeaha because of the high mortality rate.

     Antipsikosik + anticonvulsants = threshold convulsions decreases  possible attack menigkat -> dose of anticonvulsants should be .. (dose-related). the most minimal decrease seizure threshold is an anti-psychotic drug haloperidol

     Antipsikosik + antacid = effectiveness of anti-psychotic disorder due to decreased absorption

How to use

drug selection

Basically, all anti-psychotic drugs have a primary effect (clinical effects) on the same equivalent dose difference especially at the secondary effects (side effects).

Anti-psikosis	Mg.Eq	Dosis (mg/h)	sedasi	otonomik	Eks.pir
Chloropromazine Thioridazine Perphenazine Trifluoperazine Fluphenazine Haloperidol Pimozide Clozapine levomepromazine	100 100 8 5 5 1,5 2 25 25	50-1600 50-900 8-48 3-60 3-45 1-45 1-6 15-75 50-300	+++ +++ ++ + + + + ++++ ++++	+++ +++ ++ + + + - + ++	++ + +++ +++ +++ ++++ ++ - +

Selection of anti-psychotic drugs to consider the dominant psychotic symptoms and side effects of drug obat.pergantian adjusted for equivalent dose.

      For example in the following examples:

       Chopromazine and thiorodazine a strong side effects sedasif mainly used against dominant syndrome with symptoms of psychosis: noisy restlessness, hyperactivity, insomnia, confusion of thoughts, feelings, behaviors dll.sedangkan trifluoperazine, fluphenazine and haloperidol are used weak sedative side effects of Parkinson's syndrome with symptoms Dominant: apathetic, withdrawn, feeling dull, lose interest and initiative, hipoaktif, there is no impetus to do something etc..

        But the latter drug is most easily lead to the emergence of extrapyramidal symptoms, in patients who are susceptible to these side effects need to be replaced with thioridazine (dose equivalent) where ekstrapiramidalnya very mild side effects. For patients who are to arise "tardive dyskinesia" anti-psychotic drugs without extrapyramidal side effects is Clozapine.

        If the anti-psychotic drugs tetentu not provide clinical response in doses that were optimal interval sufficient period of time, can be replaced with anti-psychotic drugs other (preferably from the group that is not the same), with its equivalent dose, where side-effect profile is not necessarily the same.

       If the history of anti-psychotic drug use earlier, anti-psychotic drug that has proven effective specific and well tolerated side effects it, may be reappointed to use now.

Dosing

In setting the dose necessary mempertimbagkan:

     The onset of primary effects (clinical effects): about 2-4 weeks
     The onset of secondary effects (side effects): about 2-6 hours
     Part time :12-24 hrs -> dose of 1-2 X per day

       Morning and evening doses can be different to reduce the impact of side effects (small morning doses, larger doses of the night) so it does not so interfere with the quality of life of patients.

Starting with "initial dose" in accordance with the "recommended dosage" -> increasedevery 2-3 days -> to achieve "effective dose" (range difference arises psychosis syndrome) -> evaluated every 2 weeks and if need be raised - > "optimal dose" -> maintained about 8-12weeks (stabilization) -> down every 2 weeks -> maintenance dose -> maintained 6 months to 2years (interspersed "drug holiday" 1-2 days / week ) -> tapering off (reduced dose every 2-4weeks) -> stop.

Old provision

                   For patients with psychosis syndrome attacks the "multiepisode" maintenance therapy (maintenance) is given at least 5 years. Granting that this long enough to reduce the degree of recurrence of 2.5 to 5 times.
                   effects of anti-psychotic drugs are relatife last long, until a few days after the last dose still has an indirect effect caused klinis.sehimgga relapse after medication is stopped, usually one month later a new recurrence of symptoms syndrome psychosis.
                  This was due to metabolism and excretion of drugs is very slow, metabolites still have an anti-psychotic activity.
                 In general, anti-psychotic medication should diapertahankan for 3 months to 1 year after all symptoms of psychosis subside sma sekali.untuk "brief reactive psychosis" drug decreased gradually after the disappearance of symptoms within 2 weeks-2 months.
                  Anti-psychotic drug does not cause severe symptoms despite drug release is given in the long term, so the potential for minor drug dependence.
                  In a sudden cessation of the drug can cause symptoms "cholinergic rebound": stomach upset, nausea, vomiting, diarrhea, dizziness, trembling and so this lain.keadan will abate by giving "anticholinergic agent" (sulfas injection atropine 0.25 mg (im ), tablet trihexylphenidyl 3x2 mg / h).
                 Therefore, the joint use of anti-psychotic + antiparkinson, when it was time stopping the drug, antipsychotic drug is stopped first, then following the antiparkinson drug.It seems rooted in his weakest D1 receptors in predicting clinical function, but the affinity of other receptors more difficult mengartikanya. Recent research has focused on the discovery of atypical antipsychotics are more selective for mesolimbik system (to reduce effects on the extrapyramidal system) or the extensive work on central neurotransmitter receptors.

a. Psychological Effects.

      Generally antipsychotic drugs menyebebkan unpleasant subjective effects in healthy people, there are combinations can not sleep, anxiety, and autonomic effects that will cause different symptoms with sedatives or hipnotika usual. Healthy people also experience problems if skills are measured by psychomotor tests and psikotetrik. Conversely, people showed improvements in their skills psychotic psychosis is being reduced.

b. Neurofisiologik Securities.

      Antipsychotic drugs increase the frequency of electroencephalographic pattern, usually slow and increased synchronization. Deceleration (hipersinkron) sometimes focal or unilateral, which can make diagnosis a false interpretation. Changes in frequency and amplitude of drug-induced easily visible and can be quantified with elektronyg reliable technique.
Electroencephalographic changes due to antipsychotic drug first appeared in the subcortical electrodes, and this supports the view that the drug works primarily in the subcortical. Hipersinkron caused drug-induced activation effects of drugs on the EEG of epileptic patients as well as the emergence of seizures in patients who had never previously seizures.

c. Endocrine Effects.

      Antipsychotic drugs cause significant side effects on the reproductive system. Amenoorhea - galactorrhea, false positive pregnancy test and increased libido have been reported in women, whereas in men decreased libido and ginekomasti. Some of these effects are secondary to the inhibition of dopamine inhibition of prolactin secretion can be due to other changes increased peripheral androgen into estrogen.

d. Kordiovaskular Securities.
Orthostatic hypotension and increased pulpus usually due to the use of "high dose" (low potency) phenothiazine. Mean arterial pressure, peripheral resistance and sekuncup volume is reduced, and pulsus speed increases. This effect can be predicted from work on the autonomic nervous drugs. Abnormal egg can occur especially in the use of changes including the extension iterval tiodazin QT and ST segment and T configuration, the last round, flat, easy return due to stopping the drug.

Special attention

· SIDE EFFECTS AND ACTION ARISING FREQUENTLY ABOUT IT:

chlorpromazine (im): orthostatic hypotension ---> change in position (the effect of alpha adrenergic blockade) Th / non-adrenaline injection (effortil, im). non-adrenaline = alpha adrenergic stimulator.

Not because it is given adrenaline by alpha and beta adrenergic beta-stimulators sehimgga adrenetgic effects remain and can occur in shock.

Hipotensiortostatik often can be prevented by not immediately get up after getting shot and left to lie down for about 5-10 minutes.

Haloperidol: Extrapyramidal symptoms / syndromes Parkinson.th / tablet trihexyphenidyl (artane) 3-4 x 2 mg / hari.sulfas atropine 0.50 to 0.75 mg (im)

When the syndrome was under control parkinsom cultivated gradually decreasing doses to determine whether still required the use of antiparkinson medication.

In general, recommended the use of antiparkinson obaat no longer than 3 months (risk arises "atropine toxic syndrome"). Not recommended giving "prophylactic antiparkinson", therefore dpat affect the absorption / absorption of anti-psychotic medication so that the low levels in plasma.

· "Rapid neuroleptization": haloperidol 5-10 mh (im) every 60 min, maximum = 100 mh / h.
Usually within 6 hours was able to overcome the acute symptoms of psychosis syndrome (agitation, psychomotor hyperactivity, impulsive, attacking, noisy, restless, destructive, etc.).

· Contraindications:
-Liver disease (hepato-toxic)
Blood-disease (hameto-toxic)
-Epilepsy (decrease seizure threshold)
-Abnormalities of the heart (cardiac rhythm inhibit)
High-febrile (thermoregulator in SSP)
Alcohol-dependence (CNS depression >>>>>)
Ssp disease (Parkinson's, brain tumors, etc.)
· Special Use

* Thioridazine small doses to patients with a hyperactive child, emotionally unstable and destructive behavior. Also frequently used in elderly patients with emotional disorders (anxiety, depression, agitation) with a dose of 20-200 mg / hari.Hal is due thirodazine labuih tend to blockade of dopamine receptors of the limbic disistem disistem extrapyramidal on ssp (opposite of haloperidol).

* Small doses of haloperidol for "Gilles de la Tourette's syndrome" sangant efektif.gangguan usually arise from between the ages of 2-15 years. There are involuntary movements, repetitive, fast and without purpose that involves many muscle groups (tic). Accompanied by a multiple vocal tic (eg: voice "click", snort, cough, grunt, or kata-kata/kata dirty / koprolalia). Patients able to withstand the tics are volunteering for a few hours.

      neuroleptic malignant syndrome (SNM) is a life-threatening condition caused indiosinkrasi reactions to antipsychotic drugs (especially on "long action" this risk is greater).

All patients with anti-psychotic drug yangdiberikan have a risk for the occurrence of SNM, but with the condition of dehydration, exhaustion or malnutrition, this risk will be higher.

Beads of diagnostic SNM:

Body-temperature over 38 degrees Celsius (hyperpyrexia)

-There is extrapyramidal syndrome (rigidity)

-There are symptoms of autonomic dysfunction (incontinensia urinae)

-Changes in mental status

-Changes in the level of awareness

these symptoms arise and grow rapidly

Treatment:

       immediately stop the anti-psychotic drug

       supportive-care

       dopamine-agonist drugs (bromocriptine 7.5-60 mg / h 3dd, I-dopa 2x100 mg, or amantadin 200 mg / h)

· In elderly patients with the syndrome of psychosis or organic, anti-psychotic drugs given in small doses and minimal side effects autonomic (orthostatic hypotension) & sedasinya (class of "high potency neuroleptics, eg haloperidol, trifuoperazine, flupherazine)

Daftar Pustaka :

maslim.Dr.Rusdi.1994.Tuntunan Praktis Penggunaan Klinis Obat Psikotropik.Jakarta

ww.scribd.com/d http://woc/29018913/Psikosa

Katzung, Betram G.1997. Farmakologi Dasar dan Klinik. Jakarta : EGC.