Day 1 - Psych Part 1 Mood, Anxiety

Question 1

Neurotransmitter changes: (1) Anxiety disorders (2) Depression (3) Mania (4) Alzheimer’s (5) Huntington’s (6) Schizophrenia (7) Parkinson’s disease

Answer 1

(1) Inc. NE, Dec. Serotonin & GABA (2) Dec. NE, Dopamine, & Serotonin (3) Inc. NE & Serotonin (4) Dec. ACh (not give anticholinergics) (5) Dec. ACh & GABA (think: Choreiform) (6) Inc. Dopamine (7) Dec. Dopamine, Inc. ACh

Question 2

Pathological grief/bereavement criteria

Answer 2

(1) Depression criteria met for at least 2 weeks, after first 2 months following loss (2) Generalized feelings of hopelessness/helplessness/worthlessness/guilt (3) Suicideal ideation (4) Distressing feelings not diminish intensity by 6 mo. (5) Inability to move on, trust others, & re-engage in life by 6 mo.

Question 3

Med conditions assoc. w/ severe depression

Answer 3

(1) Hypothyroidism (2) Hyperparathyroidism (3) Parkinson’s disease (4) Stroke, especially ACA (5) CNS Neoplasms (6) Pancreatic cancer

Question 4

Meds known for causing sx of depression

Answer 4

(1) Sedatives - Alcohol, Benzos, Antihistamines (2) Stimulant withdrawal (3) Methyldopa (antihypertensive, used in pregnancy) (4) 1st gen. antipsychotics (e.g., Haloperidol) (5) Metoclopramide/Perchlorperazine (6) Glucocorticoids (steroids - mania, insomnia, also) (7) Insufficient thyroid replacement, causing hypothyroidism (8) Alpha-Interferon (tx viral hepatitis, depression is contraindication)

Question 5

Suicidal risk factors - scale used

Answer 5

SAD PERSONS: (1) Sex (men) (2) Age (younger than 19, older than 45) (3) Depression (4) Prior attempts (5) Ethanol (6) Rational thought process (psychotic/irrational) (7) Support lacking (8) Organized plan (9) No spouse (10) Sickness; Also schizophrenia & owning hand gun

Question 6

Sx of atypical depression; Meds

Answer 6

Hypersomnia, psychomotor retardation, hyperphagia (& weight gain), hypersensitivity to rejection; MAO Inhibitors work better than TCAs, SSRIs also work

Question 7

Cause & 1st line tx for seasonal affective disorder

Answer 7

Depression in winter months, lack of exposure to light; Tx w/ light phototherapy; SSRIs & bupropion may also be useful

Question 8

Name antidepressants in following categories: (1) SSRIs (2) TCAs (3) MAO Inhibitors (4) NDRI (5) SNRI (6) Tetracyclics

Answer 8

(1) Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Citalopram, Escitalopram (2) Imipramine, Amitriptyline, Desipramine, Nortriptyline, Clomipramine, Doxepin (3) Phenelzine, Selegiline, Tranylcypromine (4) Bupropion (5) Venlafaxine, Duloxetine, Milnacipran, Nefazodone (SARI?) (6) Mirtazipine, Trazodone

Question 9

Drugs not taken w/ SSRIs due to risk of serotonin syndrome

Answer 9

(1) Other SSRIs (2) SNRIs (3) MAOIs (4) St. John’s wort (5) Tryptophan (6) Drugs - cocaine, amphetamine, ecstasy (7) L-Dopa/Dopamine

Question 10

Serotonin syndrome p/w

Answer 10

Mental status changes: anxiety, agitation, delirium, restlessness, disorientation; Autonomic excitation: diaphoresis, tachycardia, hypertension, vomiting, hyperthermia, diarrhea; Neuromuscular hyperactivity - tremor, rigidity, hyperreflexia; Ocular clonus (slow continuous horizontal eye movements), Spontaneous or inducible clonus at ankle, Babinski b/l

Question 11

Serotonin syndrome Tx

Answer 11

D/c serotonin agents; Supportive care, normal vital signs, Sedate w/ benzos; High temp - sedation, intubation, & mechanical cooling; Paralysis relieves hyperthermia (caused by muscle movement); No need for antipyretics; If agitation despite Benzos, use Serotonin antagonist (i.e., Cyproheptadine); After resolution, assess need to resume serotinergic agent

Question 12

Serotonin withdrawal syndrome p/w; Worse offenders; Tx

Answer 12

Dizziness, nausea, fautigue, muscle ache, chills, irritability; Paroxetine & Venlafaxine; Switch to SSRIs w/ long half-life, like Fluoxetine

Question 13

Name SNRIs generic (brands only FYI); For those not used for tx of depression, give use

Answer 13

Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Nefazodone (Serzone), Milnacipran (Savella) - fibromyalgia only, Sibutramine (Meridia) - weight loss only

Question 14

Eval. prior to TCAs in children

Answer 14

Screen PMH for heart disease, palpitations, syncope, and near-syncope (since TCAs can cause arrhythmias); FH for sudden death prior to age 40, long QT syndrome, arrhythmias, hypertrophic cardiomyopathy; EKG prior to initiation & again once optimized

Question 15

Sx of TCA overdose

Answer 15

Cardiotoxicity (tachycardia, hypotension, conduction abnormalities); CNS toxicity (sedation, obtundation, coma, seizures); Anticholinergic (mydriasis, xerostomia, ileus, urinary retention, dementia/confusion)

Question 16

Best TCA for elderly & why

Answer 16

Nortriptyline (over amitriptyline), since less anticholinergic side effects

Question 17

TCA overdose mgt

Answer 17

ABCs; Activated charcoal, Continuous cardiac monitoring for at least 6 hrs, Frequent neuro checks, EKG, Electrolytes, TCA level, Gastric lavage in acute phase, IVF if hypotension; Most important - prolong QRS give sodium bicarb & if seizures give Benzos (maybe Barbs or Propofol - NOT phenytoin for toxin induced seizures)

Question 18

Foods w/ tyramine; Assoc. conditions

Answer 18

Fermented, aged, smoked, pickled, spoiled; Cheese, beers, wine, miso soup, avocados, brown bananas, etc. ; MAOi hypertensive crisis & migraine

Question 19

Bupropion contraind in which pt pops

Answer 19

Lower threshold of seizure, so avoided in pts w/ eating disorders (anorexia/bulimia), history of seizure disorder, & any other seizure risk (MAOi in last 14 days, withdrawing from alcohol or sedatives like benzos)

Question 20

ECT indications

Answer 20

(1) Severe depression refractory to antidepressants (2) Depression w/ sychotic feat. (3) Severe suicidality (4) Depression w/ catatonic stupor (5) Depression w/ food refusal, leading to nutritional deficiency (6) Situations where rapid antidepressant response required (7) Previous good response to ECT (8) Medical conditions prevent use of antidepressants (e.g., elderly on lots of meds) (9) Bipolar disorder or mania (10) Schizophrenia psychosis

Question 21

s/e of Lithium use in tx of bipolar disorder

Answer 21

(1) CNS depression & tremor (2) Thyroid changes (hypo/hyper, or goiter with euthyroid) (3) Nephrogenic DI (reversible w/ discontinuation - polydipsia, polyuria) (4) GI - n/v, diarrhea, metallic taste changes, weight gain

Question 22

Tx for nephrogenic DI 2/2 Li toxicity

Answer 22

Hydrochlorothiazide & Amiloride (added for Li, closing Na channels)

Question 23

Depression mgt in pt with bipolar disorder

Answer 23

Mild: Li or Lamotrigine alone; Moderate: second mood stabilizer (Lamotrigine) or atypical antipsychotic (Olanazipine, Risperidone, or Quetiapine); Lamotrigine has significant drug intx w/ Valproic acid and Lamotrigine; Adding antidepressant to mood stabilizer not shown to be effective; Severe depression - try other mood stabilizers or ETC

Question 24

Dx criteria for adjustment disorder w/ depressed mood

Answer 24

(1) Clinically significant behavioral or emotional reactions causing significant distress or social/occupational impairment (2) Sx develop in response to identifiable psychosocial stressor, other than bereavement (3) Sx begin w/i 3 mo. of stressor (4) Sx disappear w/i 6 months of disapperance of stressor

Question 25

MDD vs. Adjustment disorder w/ depressed mood

Answer 25

Adjustment disorder w/ depressed mood occurs w/i 3 mo. of identifiable stressor & disappears within 6 mo. of disappearance of stressor; Not meet MDD criteria

Question 26

Acute stress disorder v. PTSD

Answer 26

Acute stress disorder: sx last less than 4 weeks; PTSD: sx lasting longer than 6 mo.

Question 27

Tx for PTSD

Answer 27

Psychotherapy & SSRIs first-line; Other antidepressants may be used; Benzos avoided; Mood stabilizers; Alpha blockers improves nightmares; Atypical antipsychotics if refractory to other therapies