Atypical vs. Typical Antipsychotics

Atypical antipsychotics are also called second-generation antipsychotics (SGAs). They’re a newer class of medications that work differently in your body than previous (first-generation or typical) antipsychotics. Both help to regulate neurotransmitters, chemicals in your body that allow neurons to signal to each other.

Studies have found that the brains of people with schizophrenia are more sensitive to the neurotransmitters dopamine, serotonin, and glutamate. High or low dopamine levels can lead to hallucinations and disordered thinking.

While typical antipsychotics (FGAs) block dopamine in the brain, SGAs block both dopamine and serotonin. This results in some key differences.

The most significant difference is that SGAs are less likely to cause extrapyramidal symptoms. These are movement disorders that are common and serious side effects of FGAs. Some of these side effects can become permanent.

Both types of antipsychotics work to treat positive symptoms of schizophrenia, such as hallucinations and delusions. But SGAs may also help treat negative symptoms, like decreased pleasure or lack of motivation.

Common Atypical Antipsychotics taken:

  • Aripiprazole (Abilify) can be prescribed for adults and adolescents ages 13 and up. You can take it as an injectable solution available through a healthcare professional, or in one of four oral forms:
    • tablet
    • oral solution
    • Abilify Discmelt, an orally disintegrating tablet
    • Abilify MyCite, a tablet with a patch sensor that lets your doctor know you’ve taken the drug
  • Aripiprazole lauroxil (Aristada) is a prodrug, which means it’s inactive until a chemical reaction in your body changes it into aripiprazole. It also requires a medical professional to administer an injection.
  • Asenapine maleate (Saphris) is unique in that it’s available as both a tablet and a patch. Studies show that it’s particularly good at preventing relapse. The FDA has approved its use for children older than 10 to treat bipolar disorder, but not schizophreniaTrusted Source.
  • Brexipiprazole (Rexulti) treats schizophrenia and depression. Doctors usually prescribe it as a once-daily tablet. A generic form is not yet available.
  • Cariprazine (Vraylar) is FDA-approved to treat schizophrenia and bipolar I disorder. It can take a long time to build up in your body and to leave your system. If you stop taking it, you might still feel its effects for up to 4 weeks.
  • Clozapine (Clozaril) is the oldest SGA and remains the “gold standard” for those with treatment-resistant schizophrenia. The FDA has approved its use for reducing suicidal behavior in people with schizophrenia. It’s available as a tablet, an orally disintegrating tablet (Fazaclo), and an oral suspension (Versacloz). Clozapine is not FDA-approved to treat schizophrenia in children or adolescents, but some doctors prescribe it off-label.
  • Iloperidone (Fanapt) is a twice-daily tablet that can treat both positive and negative symptoms of schizophrenia. It can cause serious problems, such as stroke or even death, in older adults with dementia.
  • Lumateperone (Caplyta) is approved to treat schizophrenia and depressive episodes of bipolar disorder. It can increase suicidal thoughts in adults ages 18-24. The FDA has not approved it for pediatric use.
  • Lurasidone (Latuda) is a once-daily tablet that doctors can prescribe for people ages 13 and older. A 2020 study found that lurasidone continued to reduce schizophrenia symptoms in adolescents for the full 2 years of the study.
  • Olanzapine (Zyprexa) is another drug used to treat schizophrenia or bipolar I disorder. It’s available as a tablet, orally disintegrating tablet, or long-acting injectable administered by a healthcare professional. This is one of the atypical antipsychotics that the FDA has approved for adolescents. It can cause serious side effects, such as drug reaction with eosinophilia and systemic symptoms (DRESS).
  • Paliperidone (Invega) is derived from a different drug, risperidone. It comes in different forms, including extended-release tablets and long-acting injectables with different brand names. Paliperidone is approved to treat schizophrenia in children ages 12 and older, but it could have broader potential.
  • Quetiapine (Seroquel) is available in an immediate-release tablet that you take two or three times a day, or an extended-release tablet that you take once daily. It’s the least likelyTrusted Source of the SGAs to cause extrapyramidal symptoms. It’s also FDA-approved for treating schizophrenia in adolescents.
  • Risperidone (Risperdal, Perseris) is one of the earliest SGAs and is the most commonly used SGA among children. Doctors prescribe it for children as young as 5 years to treat irritability associated with autism, but it’s only approved for treating schizophrenia in children 13 years and older. It comes in four forms:
    • regular tablet
    • orally disintegrating tablet
    • oral solution
    • injectable administered by a healthcare professional
  • Ziprasidone (Geodon) is available as a twice-daily capsule, or you can have a healthcare professional give you an immediate-release injection.

Side Effects of Antipsychotics:

All atypicals carry a risk of mild to severe side effects. These side effects differ from person to person and drug to drug.

Some common side effects include:

  • sedation
  • dizziness
  • low blood pressure when standing up (orthostatic hypotension)
  • significant weight gain
  • metabolic syndrome
  • diabetes
  • hypertension
  • abnormal cholesterol
  • heart disease
  • complications in the third trimester of pregnancy
  • suicidal thoughts and behaviors

With some SGAs, extrapyramidal symptoms may still occur, especially at high doses.

It’s important that you take care of your physical health while using antipsychotics. SGAs can cause you to gain weight or worsen overweight or obesity if you already have it, leading to other chronic conditions.

You may also become resistant to your medication, so it’s important to stay in touch with your healthcare team and keep them updated if your medicine stops working.

Finally, be sure to continue your medication, even if you feel better. Suddenly stopping the medication can cause problems and may increase your risk of a relapse of symptoms.

Serious Mental Illness By The Numbers

Serious Mental Illness By The Numbers:

Prevalence and Treatment Rates*:

~ 8.3 million adults with schizophrenia or bipolar disorder mental illness (3.3% of the population)+

~ 5.5 million – approximate number with severe bipolar disorder (2.2% of the population), 51% untreated+

~ 2.8 million – approximate number with schizophrenia (1.1% of the population), 40% untreated+

~3.9 million – approximate number untreated in any given year (1.6% of the population)+

Consequences of Non-treatment*:

~ 169,000 homeless people with serious mental illness**

~ 383,000 inmates with mental illness in jails and prisons

~ 50% – estimated percentage of individuals with schizophrenia or bipolar who attempt suicide during their lifetimes

~ 44,193 suicide deaths in 2015

~ 10% – estimated percentage of homicides involving an offender with serious mental illness (approximately 1,425 per year at 2014 homicide rates)

~ 29% – estimated percentage of family homicides associated with serious mental illness

~ 50% – estimated percentage of mass killings associated with serious mental illness

  • Numbers and percentages of US adults
    +National Institute of Mental Health, 2016
    **2015 Annual Homeless Assessment Report

Paliperidone (Oral Route)

Brand names:

  • Invega
    • Extended-release tablet: 1.5 mg, 3 mg, 6 mg, 9 mg
  • Invega Sustenna
    • Extended-release injectable suspension: 39 mg, 78 mg, 117 mg, 156 mg, 234 mg

Generic name: paliperidone (pal ee PER i done)

Paliperidone is a medication that works in the brain to treat schizophrenia and schizoaffective disorder. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Paliperidone rebalances dopamine and serotonin to improve thinking, mood, and behavior.

What Should I Discuss With My Healthcare Provider Before Taking Paliperidone?
  • Symptoms of your condition that bother you the most
  • If you have thoughts of suicide or harming yourself
  • Medications you have taken in the past for your condition, whether they were effective or caused any adverse effects
  • If you ever had muscle stiffness, shaking, tardive dyskinesia, neuroleptic malignant syndrome, or weight gain caused by a medication
  • If you experience side effects from your medications, discuss them with your provider. Some side effects may pass with time, but others may require changes in the medication.
  • Any psychiatric or medical problems you have, such as heart rhythm problems, long QT syndrome, heart attacks, diabetes, high cholesterol, or seizures
  • If you have a family history of diabetes or heart disease
  • All other medications you are currently taking (including over the counter products, herbal and nutritional supplements) and any medication allergies you have
  • Other non-medication treatment you are receiving, such as talk therapy or substance abuse treatment. Your provider can explain how these different treatments work with the medication.
  • If you are pregnant, plan to become pregnant, or are breast-feeding
  • If you smoke, drink alcohol, or use illegal drugs

Paliperidone tablets are usually taken 1 time per day with or without food.

Typically patients begin at a low dose of medicine and the dose is increased slowly over several weeks.

The dose of the tablets usually ranges from 3 mg to 12 mg. The dose of the Sustenna brand of long-acting paliperidone injection formulation usually ranges from 78 mg to 234 mg every month. The dose of the Trinza brand long-acting paliperidone injection formulation ranges from 273mg to 819mg every 3 months. Only your healthcare provider can determine the correct dose for you.

The tablets should be swallowed whole. They should not be chewed, crushed, or broken.

What Are Possible Side Effects Of Paliperidone?

Common side effects:

Tachycardia, drowsiness, extrapyramidal symptoms, restlessness, headache, increased prolactin, cholesterol abnormalities, increased glucose, vomiting, tremor.

Rare/serious side effects:

Paliperidone may increase the blood levels of a hormone called prolactin. Side effects of increased prolactin levels include females losing their period, production of breast milk and males losing their sex drive or possibly experiencing erectile problems. Long term (months or years) of elevated prolactin can lead to osteoporosis, or increased risk of bone fractures.

Some people may develop muscle related side effects while taking paliperidone. The technical terms for these are “extrapyramidal symptoms” (EPS) and “tardive dyskinesia” (TD). Symptoms of EPS include restlessness, tremor, and stiffness. TD symptoms include slow or jerky movements that one cannot control, often starting in the mouth with tongue rolling or chewing movements.

Temperature regulation: Impaired core body temperature regulation may occur; caution with strenuous exercise, heat exposure, and dehydration.

Second generation antipsychotics (SGAs) increase the risk of weight gain, high blood sugar, and high cholesterol. This is also known as metabolic syndrome. Your healthcare provider may ask you for a blood sample to check your cholesterol, blood sugar, and hemoglobin A1c (a measure of blood sugar over time) while you take this medication.

Schizophrenia and Trauma

Trauma and psychosis can each derail a person’s daily life by causing mental and physical disturbances which significantly disrupt even basic day-to-day functioning and skills. When experienced together, they can wreak emotional and mental havoc if left untreated.

When the onset of a psychotic disorder like schizophrenia happens to occur after a traumatic event, it can be tempting to blame the development of the former on the occurrence of the latter. Causality is comforting, in a way—being able to answer the larger question of why your loved one is living with the symptoms and challenges they currently face is somehow less daunting than having no answer at all.

What causes Schizophrenia?

Scientists identify a variety of causes and risk factors for schizophrenia. Research shows the disorder is brought on by a combination of neurological, genetic and environmental factors, including life experience. Schizophrenics have an imbalance of the neurotransmitters dopamine and serotonin in their brains, which is why they are often prescribed antipsychotic drugs. There may also be a genetic component; the risk factor of one person developing schizophrenia goes up if other close blood relations have been diagnosed with it.

Other factors which play a part in the development of schizophrenia include psychoactive drugs, such as methamphetamines or LSD. These drugs can cause brain damage, psychotic episodes, or trigger a schizophrenic onset.

Childhood factors may also affect onset and development. Fetuses exposed to malnutrition or viral infections in the womb may have a higher chance of getting schizophrenia. And childhood trauma can significantly change how children’s brains and thought processes develop and affect their adult lives.

Can trauma cause Schizophrenia?

While the jury is still out on whether trauma directly causes schizophrenia, according to research conducted by the University of Liverpool, children who experienced trauma before the age of 16 were about three times more likely to become psychotic in adulthood than those who were randomly selected. The more severe the trauma, the greater the likelihood of developing illness in later life. They even found indications that the type of trauma experienced may determine what specific psychotic symptoms will manifest themselves later on.

It is also certainly true that trauma which occurs after the onset of schizophrenia can exacerbate psychotic symptoms—especially if it leads to the development of a co-occurring trauma disorder, such as PTSD. Separately, these conditions can pose serious challenges to a person’s ability to live a “normal” life—together, they can become overwhelming and debilitating without proper care and support.

Source: BrightQuest

Schizophrenia and Breakthrough Symptoms

This seems like a good time to discuss breakthrough symptoms of schizophrenia. This is not easy for me to admit, but important if I want people to understand what it’s like to have a psychotic disorder.

“People can be on the best psychotropic medication targeting a mental health disorder and still experience disruptive and paralysing symptoms. These breakthrough symptoms can be voices, delusions, paranoia, anxiety, or perhaps even depressive features that go unchallenged and uncontrolled by medication. Breakthrough symptoms can be very disturbing, and demoralising, due to the chronic, sporadic, and their seemingly unpredictable nature. This type of symptom activation can be triggered by something external.”

~ psychreg.org

I’ve been feeling numb for a few weeks now and hoping to control it through positive coping strategies such as increased meditation as I did not want to go through a med change of increasing my antipsychotic medication.

It didn’t work and this past week breakthrough symptoms of thought broadcasting and thought insertion which drives my paranoia continued rising to the level of needing a change. After consultation with my psychiatrist I’ve increased my antipsychotics, anti-anxiety medications and one on my antidepressants which is a noradrenergic and specific serotonergic antidepressant (NaSSA) and encourages sleep, i.e. drowsiness is one of it’s side effects.

My breakthrough symptoms can best be summed up as more invasive auditory hallucinations, paranoia and delusions that people can read my mind and insert thoughts into my head against my will. At this time I realize it is just a delusion and not real. If I didn’t make the med change it wouldn’t be long before I believed my delusions despite all evidence to the contrary which would probably require hospitalization. The med change will probably take a couple of weeks until I am completely back at my baseline. It’ll be an interesting couple of weeks, but this is part of the reality of living with a severe mental illness.

#MySchizLife #BreakthroughSymptoms #PsychoticDisorders