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Antipsychotic Medications

* I generally write using the pronouns he/him when referring to narcissists, but females are just as likely to be narcissists or exhibit narcissistic traits. So please don't think just because article uses the word him or he that it could not be a woman in that same role.

There are two general categories of antipsychotic medication. These are first-generation (formally known as ‘typical’) antipsychotics and second-generation (‘atypical’) antipsychotics.

Both types affect the neurotransmitter dopamine, inhibiting its transmission. Second-generation antipsychotics also interact with serotonin and other receptor types. In general, second-generation antipsychotics are better tolerated (Chokhawala & Stevens, 2021).

First-generation antipsychotics include (Chokhawala & Stevens, 2021):

  •           Haloperidol (Haldol®, Haldol Decanoate®)
  •           Fluphenazine (Prolixin®)
  •           Perphenazine (Trilafon®)
  •           Chlorpromazine (Thorazine®)

Common second-generation antipsychotics include (Fookes, 2018; Kapitanyan & Su, 2021):

  •           Asenapine (Saphris®)
  •           Iloperidone (Fanapt®)
  •           Risperidone (Risperdal®)
  •           Olanzapine (Zyprexa®)
  •           Quetiapine (Seroquel®)
  •           Ziprasidone (Geodon®)
  •           Aripiprazole (Abilify®)
  •           Paliperidone (Invega®)
  •           Clozapine (Clozaril®)

Long-Acting Injectable Antipsychotics

  • Risperdal Consta®
  • Haloperidol decanoate

Antipsychotic medications are used to treat severe forms of mental illness, such as schizophrenia. Clients prescribed these medications may prefer not to take a pill once or several times a day, which is often required for these medications to be effective.

Clients may forget to take doses or believe they no longer need the medication (e.g., due to remission of symptoms).

Thus, long-lasting forms of antipsychotics are available. For example, Risperdal Consta® is an injectable form of risperidone. Some forms of long-acting injectable antipsychotics (i.e., Haloperidol decanoate) can now be dosed every 3 to 4 weeks. They can improve a client’s treatment adherence and likely outcomes (Kishimoto et al., 2021; MacMillan, 2020).

Conditions Treated by Antipsychotics

Both first and second-generation antipsychotics are used to manage acute conditions associated with psychosis (e.g., delirium) as well as chronic psychotic disorders (principally schizophrenia). In addition, antipsychotics may be used for the treatment of agitation related to other mental health and physical conditions.

Conditions for which an antipsychotic might be prescribed
(American Psychiatric Association, 2022; Chokhawala & Stevens, 2021; Jibson et al., 2022; Sabe et al., 2021):
Schizophrenia and Schizoaffective DisordersIndicated for acute and chronic episodes of psychosis (as well as mania, in schizoaffective disorder) 
Major Depressive DisorderIndicated for psychotic features associated with a severe major depressive episode, and can be used in combination with an antidepressant
Delusional DisorderAppropriate to use for the treatment of delusional disorder and paranoia expressed in personality disorders
Severe AgitationBoth first and second-generation antipsychotics may be used for the treatment of severe agitation
AutismAppropriate to use with children with autism that engage in self-harm or other-harm behavior
Tourette’s DisorderAppropriate to treat motor tics associated with Tourette’s disorder (e.g., Orap®)
Borderline Personality DisorderUtilized to address impulsivity and psychosis related to borderline personality disorder
Substance-Induced Psychotic DisorderIndicated for acute psychosis or agitation related to substance use
Agitation Associated with Delirium and DementiaSometimes used to treat behavioral disturbance in older adults with dementia, the FDA lists a “black box warning” advising caution around use in older adults diagnosed with dementia
Treatment-Resistant SchizophreniaClozapine, a second-generation antipsychotic, is the treatment of choice for treatment-resistant schizophrenia. Clozapine is also associated with a reduced risk of suicide and mortality in those with this condition (Cho et al., 2018).
Antipsychotic Medications

Antipsychotic Medication Side Effects

Antipsychotics have an array of possible side effects, the extent of which is beyond the scope of this course. For additional information please review the resources section of this course.

Side effects associated with most antipsychotics (first and second-generation) include:

  •           Dry mouth, urinary difficulties, and constipation
  •           Sedation
  •           Increased risk of seizures
  •           Abnormal heart rhythm
  •           Low blood pressure
  •           Impaired sexual function

In addition to these common side effects, some potentially serious side effects of which you should be aware include the following:

Extra-Pyramidal Side Effects

In first-generation antipsychotics, one of the most common side effects is called extrapyramidal side effects. These include muscle stiffness, tremors, restlessness, and abnormal movements such as tardive dyskinesia (D’Souza & Hooten, 2021).

Individuals may tolerate second-generation antipsychotics better concerning extrapyramidal side effects; however, this is not the case for all people taking these medications.

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome is a rare but significant adverse event associated with antipsychotics. It should be noted that this condition can result from the use of second-generation antipsychotics, though it is less common. This life-threatening condition includes fever, muscle stiffness, unstable blood pressure, and altered mental status (Berman, 2011).

Metabolic Syndrome

Metabolic side effects such as weight gain are a major issue with the long-term use of some second-generation antipsychotics. Metabolic syndrome is a cluster of issues that include weight gain, elevated blood pressure and blood glucose, and increased cholesterol. It is more commonly associated with second-generation antipsychotics. Metabolic syndrome can lead to the development of cardiovascular illness and type II diabetes (Mayo Clinic, 2021).

Agranulocytosis

Clozapine use can result in the development of a serious blood disorder called agranulocytosis. This involves the loss of the white blood cells that fight infection and can be fatal. Clozapine can also cause inflammation of the heart.

Smoking cigarettes can affect the levels of clozapine in the blood and even lead to high toxic levels if there is a marked cessation. Clients should be informed about these precautions when taking this medication. Individuals on clozapine require careful monitoring and frequent blood tests to ensure safety (RxList, 2021).

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