Nursing Field Notes / Mental Health · Psychiatric Care Course

Antipsychotics 💊

Typical vs. Atypical Drug Reference — Part 4 of a 4-page Schizophrenia series

NG-235 Mental Health / Pharmacology Series 4 of 4 · the drug reference

📍 SCOPE OF THIS PAGE: the broad antipsychotic drug reference — first-generation (typical) vs. second-generation (atypical), mechanism, and every major side effect including EPS, NMS, and agranulocytosis. For schizophrenia-specific adherence issues and LAIs, see NG-165.

Antipsychotics are used far beyond schizophrenia — bipolar mania, Tourette's, agitation, and more. This page is the class-wide reference: what every antipsychotic does, the two generations, and the side effects — from bothersome to life-threatening — you must recognize.

📄 Simple Nursing original — opens in Drive →

🔷 Typical = 1st genStrong D2 blockade → more EPS. Haloperidol is the prototype.

🔶 Atypical = 2nd genD2 + serotonin blockade → less EPS, more metabolic effects. Clozapine, risperidone.

🚨 NMS = fever + rigidityLife-threatening on ANY antipsychotic. Hold drug, notify HCP.

🧪 Clozapine = agranulocytosisWeekly ANC/CBC. Report sore throat/fever immediately.

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WHAT THEY DO

STEP 1 · MECHANISM & THE TWO GENERATIONS

Every antipsychotic blocks dopamine — the generations differ in how selectively, which sets up their whole side-effect profile.

🧠 Core mechanism — D2 receptor blockade

🧠 Every antipsychotic in this class blocks D2 dopamine receptors somewhere in the brain — the difference between drugs is how selective that blockade is, which is the whole story behind typical vs. atypical.

🔷 First-generation (typical) — strong, non-selective D2 blockade

Blocks D2 receptors broadly across dopamine pathways, including the ones that control movement (nigrostriatal pathway) — this is exactly why EPS is common and prominent with this class.

Prototype: Haloperidol (Haldol)

Indications: schizophrenia; Tourette's syndrome (to control motor tics/movements); severe agitation.

🧠 "Typical = Tics." Strong D2 blockade in the movement pathway is a package deal with typicals — expect EPS.

🔶 Second-generation (atypical) — D2 + serotonin blockade

Also blocks serotonin (5-HT2A) receptors in addition to D2 — this extra serotonin blockade is thought to indirectly restore some dopamine release in the movement pathway, lowering EPS risk compared to typicals.

Prototypes: Clozapine, Risperidone

Indications: schizophrenia and schizoaffective disorder, especially clients not responding to other antipsychotics (clozapine specifically reserved for treatment-resistant cases).

🧠 "Atypical = Ate-ypical calories." Trade less EPS for more metabolic side effects — weight gain, dyslipidemia, hyperglycemia.

⚠️

EXTRAPYRAMIDAL SYMPTOMS

STEP 2 · MOVEMENT SIDE EFFECTS

EPS = movement disorders from D2 blockade in the nigrostriatal pathway. Four distinct presentations — know them by name and by timeline.

⚠️ The 4 EPS presentations — timeline matters

EPS type	What it looks like	Nursing priority
Acute dystonia	Sudden spasm of neck/face/tongue muscles; can involve the airway	Report immediately — often treated with an anticholinergic/antihistamine per order
Akathisia	Subjective inner restlessness, can't sit still, pacing	Often mistaken for anxiety or worsening psychosis — ask directly, don't assume
Pseudoparkinsonism	Tremor, rigidity, shuffling gait, masked face	Fall-risk precautions; mimics Parkinson's disease but is drug-induced and often reversible
Tardive dyskinesia	Involuntary tongue thrusting, lip smacking, facial grimacing	May be irreversible even after stopping the drug — screen regularly (e.g., AIMS assessment)

🧠 NCLEX trap: a client who is pacing and "anxious" on a new antipsychotic is often exhibiting akathisia, not anxiety — assess the medication timeline before assuming it's psychiatric.

🚨

LIFE-THREATENING REACTIONS

STEP 3 · WHAT YOU CANNOT MISS

Two reactions turn a routine antipsychotic order into an emergency — recognize them fast.

🚨 Neuroleptic malignant syndrome (NMS) — can occur with ANY antipsychotic

Life-threatening reaction characterized by:

🌡️ High fever & diaphoresis (hyperpyrexia)
🧠 Change in mental status
💪 Muscle rigidity
🫨 Tremors

Priority actions:

HOLD the antipsychotic

Assess the patient (vitals, mental status, labs)

Notify the HCP immediately

🧠 NCLEX trap: "I should not be concerned about fever and muscle stiffness" is a statement that needs further teaching — fever + rigidity on an antipsychotic is never a "wait and see."

🧪 Clozapine — agranulocytosis risk

Priority to monitor: CBC and absolute neutrophil count (ANC) — required regularly (e.g., weekly during initial treatment per protocol) for as long as clozapine is prescribed.

Report to provider immediately:

Sore throat
Fever
Flu-like symptoms

These are early infection signs from a dangerously low neutrophil count — high risk for serious, potentially fatal infection.

🧠 "CloZAPine ZAPs WBCs." No lab work, no clozapine refill — this is one of the strictest monitoring requirements in psychiatric pharmacology.

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DRUG REFERENCE

STEP 4 · NAME, SIDE EFFECTS, TEACHING

Four commonly tested antipsychotics, side by side.

📋 Four high-yield antipsychotics

Drug	Generation	Normal side effects	Killer / must-report side effects	Notes
Haloperidol (Haldol)	1st gen (typical)	Sedation, anticholinergic effects, EPS (all 4 types)	NMS	Schizophrenia; Tourette's for motor tics
Clozapine	2nd gen (atypical)	Weight gain, drooling, sedation — no need to report these	Agranulocytosis (report sore throat/fever/flu-like sx); NMS	Reserved for treatment-resistant schizophrenia; requires ANC/CBC monitoring
Risperidone	2nd gen (atypical)	Weight gain, sedation, orthostatic hypotension	NMS; use caution in dementia-related psychosis — increased mortality risk in older adults with dementia is a known warning, and a new risperidone order for a client with dementia should prompt the nurse to clarify with the prescriber	Schizophrenia; also used off-label for irritability in select populations
Ziprasidone (Geodon)	2nd gen (atypical)	Hypotension	QT prolongation — monitor ECG/QT interval; avoid combining with other QT-prolonging drugs	Bipolar mania, acute psychosis & agitation

🧠 "ZiprasiDONE — Q-T Done." Ziprasidone prolongs the QT interval and drops blood pressure — monitor ECG and vitals.

💓 Ziprasidone — QT interval visual

🧠 Get a baseline ECG before starting, and avoid stacking with other QT-prolonging drugs.

🗺️ Where the rest of this topic lives — the 4-page series

NG-049 — Signs & SymptomsDopamine hypothesis, positive/negative/cognitive symptoms. NG-128 — CommunicationWhat to say/never say during psychosis, the milieu. NG-165 — Pharmacology (schizophrenia-specific)Adherence barriers, anosognosia, long-acting injectables. NG-235 — You are hereThe drug reference: typical vs. atypical, EPS, NMS, agranulocytosis, QT.

🧠 This page is the reference card — come back here anytime a question names a specific drug or side effect.

⚡

QUICK RECALL

SAY IT OUT LOUD

🔷 Typical vs 🔶 AtypicalTypical = more EPS. Atypical = more metabolic side effects.

⚠️ 4 EPS typesDystonia (fast), akathisia, pseudoparkinsonism, tardive dyskinesia (slow, may be permanent)

🚨 NMSFever + rigidity + altered mental status + tremor → HOLD, assess, notify HCP

🧪 ClozapineAgranulocytosis — ANC/CBC monitoring, report sore throat/fever

🎯 Cover & check — 4 rapid-fire questions

Q1: What's the core mechanistic difference between typical and atypical antipsychotics?

Typicals block D2 receptors broadly and strongly (more EPS); atypicals add serotonin (5-HT2A) blockade, which lowers EPS risk but raises metabolic side effect risk.

Q2: A client on a new antipsychotic is pacing constantly and reports feeling like they "can't sit still." What is this, and what should the nurse NOT assume it is?

Akathisia (an EPS) — the nurse should not simply assume it's anxiety or worsening psychosis.

Q3: Which EPS may be irreversible even after the drug is stopped?

Tardive dyskinesia — involuntary tongue/lip/face movements that develop after months to years of therapy.

Q4: A client on clozapine calls with a sore throat and fever. What should the nurse do?

Treat as a priority — report immediately; these are early signs of agranulocytosis, and CBC/ANC needs to be checked right away.