Class 3 Flashcards
CBT for SAD
exposure (rehearsals: start with simple things then work your way up/ flooding) + restructuring and challenging maladaptive thoughts: when people have negative emotions = negative thoughts, vicious cycle. Thoughts: I’m not good enough, people don’t lie me, I’m weak and people can see that. Pretend survey. Talk to a friend/ coworker.
How to chose Rx
Family members? Taken? Side effects? Half life (manic switch)?
1st line SAD
SSRI: escitalopram(Cipralex), fluvoxamine + CR, paroxetine + CR, sertraline
SNRI: Venlafaxine XR
Pregabalin
Side effects SSRI
: no, diarrhea, headache, insomnia, irritability, increased anxiety, somnolence (2 weeks), long term: weight gain, sexual dysfunction. GI, heart problems, manic symptoms, bipolar in the family
Which SSRIs are associated with less weight gain
• fluoxetine, citalopram and sertraline associated with less weight gain than paroxetine.
Which SSRI is associated with more sexual side effects and more withdrawal symptoms
paroxetine
Which SSRI is associated with more diarrhea
sertraline
Which SSRI is associated with less withdrawal symptoms
fluoxetine
Which SSRI to use if patient also has pain
paroxetine and duloxetine
Which class of antidepressants increases chances of GI bleeding
SSRI
Which classes of antidepressants are associated with QTc prolongation
Tricyclic and tetracyclic antidepressants and selective serotonin reuptake inhibitors.
SNRIs have a better side effect profile
Risk factors for QT prolongation
Heart disease or cardiac abnormalities Over 65 Female Electrolyte abnormalities (hypoCa/Mg) Bradycardia Genetic factors/ congenital QT syndrome
Antidepressants with higher risk of QTc prolongation
citalopram, escitalopram, venlafaxine, mirtazapine, amitriptyline, imipramine, nortriptyline, clomipramine, trimipramine, desipramine, maprotiline, mirtazapine
2n line SAD
Benzo: clonazepam, alprzolam, bramazepam:
Antidep: citalopram (celexa), phenlazine
Anticonvuls: gabapentin
Why use benzos SAD
single presentation, try medication before, 2 weeks away, help with exposure.
Side effects benzos
sedation, dizziness, weakness, ataxia, decreased motor performance, DEPENDANCE, WITHDRAWAL.
Side effects MAOIs
Dry mouth, Nausea, diarrhea or constipation, Headache, Drowsiness, Insomnia, Dizziness or lightheadedness. MAOIscan cause dangerous interactions with certain foods and beverages. You’ll need to avoid foods containing high levels of tyramine ― an amino acid that regulates blood pressure
Side effects gabapentin
GI, weight gain, somnolence, tremor, rash, toxic epidermal necrolysis
SAD performance only Rx
Propanolol, Tenormin; block beta adrenergic receptor activity
SSRIs: onset, full response, titrage dose
2-8 weeks onset of symptom relief. Full response: 12 weeks. Titrage dose: every 1-2 weeks.
Aggravating factors SAD
general stress, big life events, depression
signs of relapse SAD
morbid state, start avoiding more, difficulty sleeping, low mood, isolation, low energy, trouble concentrating
Goal of therapy
you can learn to tolerate and cope with the things you’re afraid of, better than you think you can, not be so frightened of your fear, more confidence in your ability to get through it
Tolerability of therapy
it’s going to be hard, work on your part, what you do outside of therapy.
Prevent relapse
“booster shots”
Treatment plan
Treatment plan: If a treatment relationship is to be established (structure, frequency, goal, expectations of engagement), recommended treatment + options (medication risks + benefits), referrals, psychosocial interventions, consent for collaboration with specialist/ primary care physician, safety planning + contact information.
Algorithm of steps.
Sudden onset of panic attacks
investigate cardio more
Therapy for panic disorder
CBT: exposure + restructuring and challenging maladaptive thoughts. exposure to physical symptoms that they’re afraid of. Create panic symptoms: make them run up and down flight of stairs, breathe into a paper bag, spin on a chair, wear a bunch of layers of clothes, breathe through a straw. Can also do situational exposures. Cognitive therapy: identify anxious thoughts.
Noninvasive brain stimulation using a radioelectric asymmetric conveyor, aerobic exercise, capnometry respiratory training
Main difference in CBT across dx
type of exposure.
2 parts in exposure
: Do the thing you’re afraid+ don’t do the thing you usually do to cope
1st line medication for panic disorder
SSRI: citalopram + CR, fluoxetine, fluvoxamine, paroxetine + CR, sertraline. SNRI: venlafaxine XR
2nd line medication for panic disorder
TCAs: clomipramine, imipramine
other antidep: reboxetine, mirtazapine
benzos: alprazolam, clonazepam, lorazepam, diazepam.
side effects TCAs
Drowsiness, Blurred vision, Constipation
Dry mouth, Drop in blood pressure when moving from sitting to standing, which can cause lightheadedness, Urine retention. Disorientation or confusion, particularly in older people when the dosage is too high, Increased or irregular heart rate, More-frequent seizures in people who have seizures
What to verify before initiating medication
SUD, heart condition
How to initiate antidepressants
Start low (symptoms of anxiety), go slow, increase every 1-2 weeks
What to do if the person has depression and panic disorder
1st line for panic and 1st line for depression: sertraline, Venlafaxine XR, Paxil, Luvox, celexa
Acceptance and commitment therapy
changing the way you think about your thinking/ feelings, people must commitment to behaviors that are consistent with their values.
CBT for GAD
expose to worst case scenario: write out a script/ tell stories, future predictions: anxious because they’re thinking through every option, really afraid of not knowing: expose to uncertainty, help to learn how to tolerate uncertainty ex: write an email and not double checking for punctuation/ go to a restaurant, order whatever without looking, Like worrying because makes them feel prepared: challenge that belief, come up with ways to test that: don’t prepare for something (behavioral experiments) other have negative beliefs about worry: worry about worrying: certain amount of worry is healthy= know that that thing matters to you. Dysfunctional vs functional worry. Problem solving strategies
other non pharmacological for GAD
acupuncture, aerobic exercise, relaxation techniques: muscle relaxtion(muscles tension, restlessness).
1st line GAD
Agomelatine, duloxetine, excitalopram, paroxetine + CR, pregabalin, sertraline, venlafaxine XR
2nd line GAD
Benzo: alprazolam, bromazepam, diazepam, lorazepam
TCAs and other antidepressants: imipramine, bupropion XL, vortioxetine, Seroquel XR, burspirone, hydroxyzine
Buspirone mecanism
partial agonist of 5-HT1a receptor
how long GAD take Rx
1-2 years, may be all their lives.
Why not prescribe bentos
Dependence, withdrawal. SUD, over 65. crutch
CBT for OCD
ERP: exposure and response prevention: count less numbers. Pill counter: what are you thinking, count them once and out that in the bottle, how did that feel. Wait 2 minutes, 5 minutes, 10 minutes. Do it again. Show me how you wash your hands. Practice washing and then not wasking their hands. Touch something contaminated. Contaminate another person.
other therapy for OCD
aceptance and commitment therapy (not taking thoughts so seriously), modular cognitive therapy (OCD beliefs, doubts), organizational training, mindfulness, bibliotherapy, RTMS, surgery
What’s special about prescribing for OCD
higher doses of antidepressants
1st line OCD
SSRI: escitalopram, fluoxetine, fluvoxamine, sertraline
2nd line OCD
clomipramine, citalopram, mirtazapine, venlafaxine XR
Adj in OCD
- Abilify, Risperdal
- memantine, Seroquel, topiramate
- Zyprexa, ziprasidone, Haldol, mirtazapine, amisulpride, lamotrigine, pregabalin, celecoxib, granisetron, ketamine IV, ondansetron, N-acetylcysteine, riluzole
When to use antipsychotics in OCD
when they’re using magical thinking, don’t sleep well very anxious
What patient factors in OCD affect the response rates to treatment?
insight, family that accomadates behaviors, pt’s motivation, how the person understands their own problems
Aggravating factors OCD
more symptomatic when under more stress, triggers
Signs of relapse OCD
re-emergence of obsessions, compulsions, that’s an OCD thought
What is the general risk of suicide in patients with anxiety related disorders?
1.7-2.5 times more at risk for a suicide attempt. Social anxiety and panic disorder, the risk id 20 times higher than the general population.
how does the presence of a co-morbid mood disorder affect the suicide risk?
Increases the risk. More agitated = more desperate, looking for a way out = suicide
Therapy adjustment disorder
CBT: coping mechanisms. Relaxation, meditation, mindfulness, deep breathing, sleep, eating, exercise, pleasant activities, validating. Depathologize.
NP for someone with adjustment disorder
mental health assessment, leave of absence, health promotion/ prevention initiate treatment plan, follow up, safety plan.
Selective mutism looking defiant
protective mechanism: don’t hurt me
Selective mutism therapy
CBT
External reinforcement: rewards: encouragements, small rewards, stars on a chart, time limited. Tell teacher. Explore what her concerns are. General coping statements: it’s going to be okay. Storybooks, fear thermometer.
Opportunities to talk to strangers in non threatening environments: going to the movies, go buy the ticket.
scales to monitor improvement
clinical global impression
hamilton anxiety scale
specific phobias treatment
CBT, pharmaco not really recommended
