exam 2 psych

Question 1

Define ICD (intellectual cgnitive disability) aka mental retardation

Epidemiology and statistics

Answer 1

• •“A reduced level of intellectual functioning resulting in diminished ability to adapt to the daily demands of the normal social environment”
• •Global ability, not specific impairments, should be the basis of the diagnosis
• •1-2% of the population
• •1.5 - 2x more common in males
• •Majority classified as mild
• •Mild Intellectual Disability is more common in lower socioeconomic strata, but more severe ID is more evenly distributed among social classes
• •Large majority of individuals live outside of state run institutions. Most live in small group home/supervised living or with family
• •While life expectancy remains lower than the general population, more individuals with intellectual disability are living into old age

Question 2

Diagnostic criteria of ICD (intellectual cognitice disability)

Answer 2

• •Subnormal intellectual functioning
  
  • different IQ scores
• •Adaptive deficits; Failure to develop age-appropriate skills in important areas of functioning
  
  • •Communication
  • •Self-care
  • •Social and interpersonal skills
  • •Health
  • •Work
  • •Safety
• •Onset during the developmental period
  
  • •During the developmental period, meaning before age 18
  • •In practice, onset assumed much earlier
  • •Later onset would be classified as a dementia

Question 3

Define

• •Defined as IQ score more than two standard deviations below the mean (below 70)
• •Corresponds to below the 2nd percentile
• •IQ scores from 70-79 are categorized as borderline

Answer 3

Subnormal Intellect

Question 4

IQ scores categories (9)

Answer 4

• •120 and up-Superior
• •110-120-High Average
• •90-109-Average
• •80-89-Low Average
• •70-79-Borderline
• •50/55-70-Mild Intellectual Disability
• •35/40-50/55-Moderate Intellectual Disability
• •20/25-35/40-Severe Intellectual Disability
• •Less than 20/25-Profound Intellectual Disability

Question 5

General points of ICD

Answer 5

• •Intellectual Disability is a syndrome, not a disease - Final common outcome for many conditions
• •Effects are a function of the timing and duration of insult and extent of CNS exposure
• •More severe cases are more likely to involve an identifiable cause.
• •Cases without an identifiable cause are more likely to be mild

Question 6

Identify 3 genetic disorders (prenatal) that can cause ICD

Answer 6

• •Downs syndrome
  
  • •Trisomy 21
• •Prader-Willi syndrome
• •Fragile X

Question 7

Identify genetic condition that cause ICD

• •Variety of physical stigmata
• •1/700 births
• •Moderate or severe retardation typical
• •Many do not live past 40
• •Often placid and adaptive in childhood
• •Neural plaques and neurofibrillary tangles

Answer 7

Down Syndrome (trisomy 21)

Question 8

Identify genetic conditon that cause ICD

• •Small deletion on chromosome 15
• •Less than 1/10,000
• •Compulsive eating behavior, obesity
• •Hypogonadism, small stature, small hands and feet
• •Children often oppositional-defiant

Answer 8

Prader-Willi

Question 9

Genetic condition that cause ICD

• •1/1000 males, 1/2000 females
• •Females often less impaired
• •Degree of Intellectual Disability can be mild to severe
• •High rates of ADHD, autism
• •Rapid perseverative speech
• •Most common inherited form of Intellectual Disability, 2nd most common genetic form after Down syndrome

Answer 9

Fragile X

Question 10

Describe PKU

Answer 10

• •“paradigmatic inborn error of metabolism”
• •Inability to convert phenylalanine to paratyrosine because of absence or inactivity of phenylalanine hydroxylase
• •Disability tends to be severe
• •Diet control improves behavior and developmental progress- can be normal IQ

Question 11

Prenatal causes of ICD

Perinatal causes of ICD

Postnatal causes

Answer 11

Prenatal causes

Maternal infections (TORCH)

• •Rubella
• •HIV
• •Cytomegalovirus
• •Toxoplasmosis
• •Herpes Symplex
• •Syphilis

•Toxins/Teratogens

• •Maternal substance abuse
  
  • •Alcohol

•Cerebral anoxia

Perinatal causes

• •Infection
  
  • •Meningitis
  • •Encephalitis
• •Trauma
• •Cerebral hypoxia

Postnatal causes

• •Infections
  
  • •Meningitis
  • •Encephalitis
• •Toxins
  
  • •Lead poisoning

Question 12

what is the most common preventice cause of fetal alcohol syndrome

Answer 12

In utero alcohol exposure

Question 13

Differentiate mild vs moderate vs severe/profound intellectual disability

Answer 13

Mild intellectual disability

• •IQ score 55-69, about 85% of cases
• •May be able to hold a job, learn to read and write, complete high school in special education classes
• •May function independently but need assistance and guidance when facing unusual social or economic stress
• •Language development slower than normal, but will be functional
• •Self-care skills also slower to develop
• •Disabilities evident in school, often when diagnosis is made
• •Learn basic skills at around 6th grade level
• •Disabilities may interfere with some social roles or activities (e.g., marriage)

Moderate Intellectual disability

• •IQ score 35-50
• •About 10% of cases
• •Can learn basic self-care, simple language, function with some independence in a supported and sheltered environment.
• •Slowly gain limited language use
• •Some impairment in self-care
• •May have capacities for simple work, basic school skills, and some social activity
• •Generally depend on and function best in structured and supervised setting

Severe/profound intellectual disability

• •IQ scores 20-35 (Severe) and below 20 (Profound) - Total about 5% of cases
• •Will usually require institutional care
• •Limited or no language
• •Motor impairments more clearly showing CNS damage/maldevelopment
• •Restricted mobility
• •Incontinence
• •Likely to have a clear biological cause
• •At the higher end, may benefit from habit training and contribute partially to personal maintenance, with supervision

Question 14

Identify different intellectual disability based on age

***various pysch disorders

Answer 14

Mild: 50-55 to 70 (*85%) Age 9-12

Moderate: 35-40 to 50-55 Age 6-9

Severe: 20-25 to 35-40 Age 3-6

Profound: below 20-25 Age < 3

How old are their friends?

• •“Autistic” behaviors such as self-stimulation and self-injury are more common in moderate to severe
• •Difficulties with social skills, isolation, communication deficits, self esteem issues, and frustration are common sources of distress.
• Range of pysch disorders is extensive
• Incidence several times higher than in the general population
• Includes mood disorders, schizophrenia, conduct disorder, autism, and ADHD.
• Disruptive and conduct disorder behavior more common in mild MR

Question 15

Various treatment principles of ICD

Various treatment options

Answer 15

Treatment principles

• •Normalization principle
• •Right to community living
• •Education and training for all children
• •Employment of adults in the community
• •Use of normal community services and facilities
• •Advocay and appropriate protection

Treatment

• •Careful individual assessment
• •Supportive and optimizing environment
• •Behavior therapy
• •Medications used to treat the symptoms not the ICD itself; depression, behavior dyscontrol, psychosis, and other comorbid pathology

Question 16

Identify condition

•Early thinking about cause blamed cold or otherwise abnormal parents. Often classified before 1980 as a type of childhood schizophrenia - since recognized as distinct entity

***what 3 main xters used to diagnose

Answer 16

Autism Spectrum Disorder

Diagnostic criteria

• •Impairment in reciprocal social interaction
  
  • •Lack of social response
  • •Lack of eye contact
  • •Lack of interest in and response to affection
  • •Lack of response to emotion in others; withdrawn and isolated
• •Impairments in communication and imaginative activity; language abnormalities
  
  • •Delayed development, sometimes mute
  • •Some begin development and then there is an abrupt cessation around age 2
  • •Stereotyped and repetitive expression
  • •Abnormal inflections and intonations
  • •Abnormal use of pronouns
  • •Echolalia (repeated phrases)
• •Markedly restricted range of activities and interests; get stuck on what you like - you obsessed about this particular thing
  
  • ​•Anxiously obsessive insistence on sameness
  • •Narrow range of spontaneous activities
  • •Limited food tolerances
  • •Preference for inanimate objects
  • •Stereotyped and repetitive motor behavior

Question 17

ASD - Autism spectrum disorder

• what sensory impairments
• Epidemiology
• Intellect

Answer 17

Sensory impairment

• •May show evidence of tactile defensiveness
• •“Super” hearing

Epidemiology

• •Estimates of incidence are in the range of 4.9-21 per 10,000, though range higher when less stringent criteria are used. Now see estimates as high as 1 in 86.
• •4:1 more common in males except Rett’s which is almost exclusively female
• •Diagnosed in 2-4% of the siblings of index patients, which is many times higher than the rate in the general population

Intellect

• •IQ scores above 70 are found in only about 30% of patients though new studies indicate this may be as high as 50%
  
  • •About 30% have mild Intellectual Disabilities
  • •About 40% have IQ scores below 50-55.
• •Visuospatial abilities and rote learning skills may be better maintained on IQ tests than are verbal, sequencing, and abstraction skills.
• •These children often exhibit high intertest scatter, meaning there is more variability in their scores than usual.
• •So called “splinter functions” and “savants”

Question 18

Describe levels of ASD

Answer 18

•Level 1: Requiring Support

• •Noticeably awkward social overtures
• •May have difficulty with back and forth conversations
• •Difficulty switching between activities
• •Problems with organization
• •These individuals would have been diagnosed with Asperger’s in the past

•Level 2: Requiring Substantial Support

• •Marked problems with verbal and non-verbal communication
• •Very limited, narrow interests
• •Inflexibility in behavior
• •Distress when need to change focus or action

•Level 3: Requiring Very Substantial Support

• •Severe communication deficits
• •Minimal response to social overtures
• •Inflexibility of behaviors interfere significantly with all daily functions
• •These individuals would have been diagnosed with Autism in the past

Question 19

ASD

• Diagnosis
• Course and Prognosis

Answer 19

•Now also can diagnose with or without:

• •Intellectual impairment
• •Language impairment
• •Can also code for known medical, genetic, environmental cause as well as association with another neurodevelopmental disorder

Course and Prognosis

• •The disorder is lifelong
• •Only 2-3% of patients make a fully normal adjustment (e.g., completing school, obtaining employment, living independently)
• •This is improving with greater understanding and more community supports

Question 20

Identify disorder

• most always females, develop normally (first 5 months) then start to see deceleration of head growth between 5 and 48 months

Answer 20

Rett’s Disorder

• •Apparently normal development for the first 5 months of life
• •Deceleration of head growth between 5 and 48 months
• •Loss of social engagement early on
• •Severely impaired language
• •Severely impaired motor functioning

Question 21

ASD

• Treatment goals
• Treatment coordination

Answer 21

Treatment goals

• •Advancement of normal development, particularly regarding cognition, language and socialization
• •Promotion of learning and problem solving
• •Reduction of behaviors that impede learning
• •Assistance to families
• •Treatment of comorbid psychiatric disorders

Treatment Coordination; works best with a multi-disciplinary team

• •Speech/Language Pathologist
• •Occupational Therapist
• •Behavioral Specialist/Psychologist
• •Primary Care Physician
• •Psychiatrist
• •School Personnel
• •Case Manager
• •Family

Question 22

ADHD classification

Answer 22

• •Attention Deficit Hyperactivity Disorder
  
  • •Predominantly hyperactive/impulsive presentation
  • •Predominantly Inattentive presentation
  • •Combined Presentation
• •Identify as Mild, Moderate, Severe
• •Most common referral issues along with disruptive behavior disorders
• •Problematic across multiple environments
  
  • •Home
  • •School
    
    • •Academic progress
    • •Peer relations

•Two broad categories of difficulty:

• •Difficulty maintaining and focusing attention
• •Hyperactivity and impulsivity

Question 23

ADHD

• Incidence
• Causal influence
• Frontal involvement and behavioral features??
• diagnosed when?

Answer 23

Incidence

• •Reasonable estimate of incidence is 3-5% of school age children
• •Some have argued for estimates in the neighborhood of 10%.
• •3x more common in boys
• •Parents show increased incidence of ADHD, sociopathy, alcoholism, and learning disorders.

Causal influences

• •Causal influences of hypersensitivity to foods or food additives have not been confirmed.
• •Genetic findings suggestive of dopamine receptor pathology
• •Wide range of perinatal and prenatal conditions.
• •Decreased cerebral blood flow and metabolism in the frontal lobes

•Frontal involvement and behavioral features are consistent with neuropsychological findings of impairment in executive functions.

• •Reasoning
• •Planning
• •Organization
• •Impulse control
• Typically diagnosed in early school years , sometimes in preschool
• Becomes evident when formal learning situation requires increasing attention span and impulse control.
• May be evident earlier in organized situations where behavior can be compared with peers

Question 24

Symptoms of Hyperactivity vs Impulsivity vs inattention

Answer 24

Symptoms of Hyperactivity

• •Fidgets with hands or feet or squirms in seat
• •Often leaves seat in school or other situations where remaining seated is expected
• •Often runs about or climbs excessively in situation in which it is inappropriate
• •Often has difficulty playing or engaging in leisure activities quietly
• •Is often “on the go” or acts as if “driven by a motor”
• •Often talks excessively

Symptoms of Impulsivity

• •Often blurts out answers before questions have been completed
• •Often has difficulty awaiting turn
• •Often interrupts or intrudes on others

Symptoms of Inattention

• •Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
• •Often has difficulty sustaining attention in tasks or play activities
• •Often does not seem to listen when spoken to directly
• •Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace
• •Often has difficulty organizing tasks and activities
• •Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort such as schoolwork or homework
• •Often loses things necessary for tasks or activities
• •Is often distracted by extraneous stimuli
• •Is often forgetful in daily activities

Question 25

• ADHD- Predominantly hyperactive-Impulsive Presentation
• ADHD- Predominantly Inattentive Presentation
• ADHD-Combined Presentation

Answer 25

ADHD- Predominantly hyperactive-Impulsive Presentation

• •6 or more symptoms of hyperactivity-impulsivity
• •< 6 symptoms of inattention

ADHD- Predominantly Inattentive Presentation

• •6 or more symptoms of inattention
• •< 6 of hyperactivity/impulsivity
• •More often diagnosed in girls
• •More often diagnosed later

ADHD-Combined Presentation

• •6 or more symptoms of inattention
• •6 or more symptoms of hyperactivity-impulsivity

Question 26

ADHD

• Social and interpersonal effects
• Course
• Management

Answer 26

Social and interpersonal effects

• •Demands on parents
• •Classroom management
• •Relationships with peers

Course

• •There is significant persistence of symptoms into adulthood in 15-20% of cases.
• •In the majority, there is at least partial remission between 12 and 20 years of age.
• •Hyperactivity is often first to diminish.
• •Many adults continue to have learning problems and impulsivity.

Management

• •Consistency of contingencies and expectation
• •Parental education, support, and skill development
• •Behavioral therapy
• •Cognitive Behavioral therapy
• •Development of instructional support plan
  
  • •IEP
  • •Section 504

Question 27

Egleton

ADHD - treatment

Answer 27

ADHD

The pharmacological treatment approach in ADHD is to “retune” these brain areas by increasing DA and NE signaling. In essence “increasing signal to noise ratio”.

• Methyphenidate based
• Amphetamines
• Other

Question 28

Methylphenidate (Ritalin)

• MoA
• Uses
• other
• acute effects
• side effects
• cautions

***Identify products

Answer 28

Concerta:

• ·Extended release tablet
• ·Oral osmotic delivery system
• ·12 hour duration of action
• ·Pharmacokinetics not affected by food

Metadate CD:

• ·Provides efficacy “throughout the day”
• ·Biphasic release (bead technology)
• ·Pharmacokinetics affected by food

Focalin:

• ·d-isomer of methylphenidate
• ·Prescribed at ½ of usual dose

Daytrana (methylphenidate patch):

• ·for children 6-12

Question 29

Amphetamines

• MoA
• uses
• other
• acute effects
• Side effects
• cautions

**Types

Answer 29

Side effects (at normal Pharmacological doses, see drug abuse lecture for abuse side effects)

• GI most common
• ·Abdominal pain, nausea and weight loss, Restlessness, anxiety, insomnia, agitation, aggressiveness, High doses → Convulsions

Cautions;

• Avoid in patients with CV disease
• Avoid in patients with Glaucoma.
• High abuse potential (see drug abuse lecture)
• Avoid MAOI
• Not for previous drug users

Other products

• Adderall - also available as an extended release (mixed amphetamine salts)
• Dextroamphetamine (Dexedrine; single amphetamine salt)
• Lisdexamfetamine (prodrug of dextroamphetamine)

Question 30

Atomoxetine (Strattera)

• MoA
• uses
• Other
• Side effets
• cautions

Answer 30

Question 31

Identify drug and MoA

• •Generally considered second line (for ADHD tx), good for reducing aggression.
• •Care in patients with history of CV disease
• •Salisbury for side effects and mechanisms.

Answer 31

Clonidine or Guanfacine

• Alpha2A adrenergic agonists

Question 32

Identify disorder

• •Common comorbidities with ADHD
• •Possibly due to other cortical problems regulating Limbic function

**Treatment options

Answer 32

Oppositional Defiance Disorder and Conduct disorder

Question 33

Describe treatmnet options of oppositional defiant disorder (3)

Answer 33

ADHD Medications:

• •May need to use higher doses of stimulants compared to ADHD
• •The Alpha2A-adrenergic agonists can be used alone or as an adjunct to methylphenidate.

Mood Stabilizers (see mood disorder lectures):

• •CD is thought to be a precursor for bipolar
• •Lithium is effective at controlling aggression
• •Can be combined with anti-psychotic.
• •Valproate is an anticonvulsant that can be used as a mood stabilizer.

Atypicals (see psychosis lecture):

• •Antagonists at 5HT-2A and dopamine D2 receptors (and many others)
• •Huge side effect profile

Question 34

ASD

• various types per various therapies
  
  • inattention and hyperactivity
  • disruptive behavior

Answer 34

Question 35

ASD

various types per various therapies

• Repetitice behavior rigidity
• Sleep problems

Answer 35

Question 36

Describe tourette’s

**treatment

Answer 36

• •TS is likely due to disinhibition in cortico-striatal-thalamic- cortical loops, with an overly active caudate nucleus (similar to ADHD and OCD, both common comorbidities of TS).
• •Dysfunction within these circuits results in an inability to suppress unwanted movements, behaviors, or impulses. Though many neurotransmitters may be involved TS patients have increased density of the presynaptic dopamine transporter and an increased density of postsynaptic D2 dopamine receptors, suggesting increased uptake and release of dopamine.
• •Thus we typically target dopamine signaling for the tics

Question 37

Enuresis medication (Synthetic vasopressin analog)

• MoA
• Uses
• other
• side ffects
• cautions

Answer 37

Question 38

Enuresis medication - TCA

• MoA
• Uses
• Other
• Side effects
• cautions

Answer 38

Question 39

6 major approaches to pain management

Answer 39

• •Pharmacologic
• •Physical medicine – Physical therapy, spinal modulation
• •Behavioral medicine - CBT
• •Neuromodulation – TENS, Spinal cord stimulation, deep brain stimulation
• •Interventional – Direct injection into pain area of substances such as glucocorticoids or locals
• •Surgical

**Typically a therapeutic regimen will combine multiple approaches

Question 40

Different pharmacological pain treatment

Answer 40

Question 41

Pain med

• Mild to moderate pain
• used in injuries; sprain etc

MoA

Uses

Other

Side effects; oen cause hepatoixcity, some cause gastric ulcers

Cautions

Answer 41

Non-opiod analgesics

Question 42

Opiod receptors (3)

• transduction mechanism
• localization
• physiological effects
• key selective endogenous agonist
• Key selective drug agonist
• key selective antagonist

*****Different interation at opiod receptors

Answer 42

Drugs can be;

• ·Agonist
• ·Antagonist
• ·Mixed agonist
• ·Partial agonist – have limited agonist like effects

Question 43

Opiod classification - higher yield drugs

• strong agonists (5)
• Moderate to low agonists (1)
• Mixed agonist/antagonist partial agonist (1)
• Antagonists (2); 1 main one

Answer 43

Question 44

Gold standard of opiods

• MoA
• CNS effects
• Pupil
• respiration
• CV

*kappa response drives intoxication?

Answer 44

Question 45

Gold standard of opiods cont’d

• GI
• Endocrine
• tolerance and depenence
• withdrawal
• drug interaction
• opiod poisoning
• contraindication

Answer 45

Question 46

Morphine

• Use
• Source
• Structure
• other effects
• pharmacokinetics
  *

Answer 46

Use

• ·Gold standard for comparison among opioids
• ·Relief of moderate-to-severe acute and chronic pain; pulmonary edema; preanesthetic medication

Source:

• ·From poppy plant, Papaver somniferum
• ·Milky substance from seed capsule which is dried and powdered to make opium
• ·Opium contains several alkaloids:
• ·morphine, codeine, papaverine

Structure:

• ·Many semisynthetic compounds made by modification of morphine molecule

Other effects:

• ·Antitussive effects: prevent cough by action in medulla
• ·Codeine/hydrocodone used for cough suppression
  
  • o↓ sensitivity of CNS cough centers to peripheral stimuli
  • o↓ mucosal secretion
  • oaction occurs at doses less than that for analgesia
  • oantagonized by naloxone

Pharmacokinetics:

• ·Route of administration: s.c./i.m./ oral / suppository /pump
• ·Low bioavailability of oral formulation (17-30%) due to 1st pass effect
• ·Readily absorbed from GI tract, nasal mucosa, lung
• ·Metabolism: glucuronide conjugation with urinary excretion
• ·Active metabolites

Question 47

identify opiod

• ·Hydrogenated ketone of morphine
• ·7x more potent than oral morphine, used for severe pain
• ·Less active metabolites than morphine
• ·Oral, IV, IM and extended release formulations

Answer 47

Hydromorphone (Dilaudid)

Question 48

• •Effective analgesic; as potent as morphine
• •No Kappa activity
• •Constipation; biliary spasms are predominant side effects
• •Long t1/2 ~ 1-1.5 days
• •Used in treatment of opiate withdrawal/heroin users; chronic pain
• •“Methadone Maintenance”
• •Tolerance develops slower with methadone than to morphine
• •Previously a major overdose issue in Appalachia, potentially via altered metabolism by CYP SNPs?

***Explaine a major concept of this drug

Answer 48

Methadone (Dolophine)

“Methadone maintenance”

• •Used in Rx for opiate withdrawal
• •1x/day at higher dose than for analgesia
• •Tolerance develops
• •Opioid craving is met without need for IV drug use
• •If opiate such as heroin is taken while on methadone, effects are greatly reduced due to “cross tolerance”

Question 49

• •Only used for recreational purposes in US (can be prescribed to terminal pts in UK)
• •Diacetylmorphine metabolized to 6-monoacetylmorphine then morphine
• •Both Diacetylmorphine and 6-monoacetylmorphine have higher BBB penetration than morphine
• •Effect due to both 6-monoacetylmorphine and morphine
• •6-monoacetylmorphine specific heroin metabolite detectable in urine tests

Answer 49

Heroin

Question 50

• •Orally equipotent to morphine
• •Moderate to severe pain, cough
• •New mono formulation of extended release hydrocodone (Zohydro) is now available.
• –Major concerns for abuse and OD

Answer 50

Hydrocodone + acetaminophen (Lortab, Vicodin):

Question 51

·Management of moderate-to-severe pain, normally used in combination with non-opioid analgesics

·Orally active semi synthetic analog of morphine

Answer 51

Oxycodone

·Oxycontin Delayed release formulation has large potential for abuse, can crush tablet and ingest all at once (drug abuse lecture)

Combined formulations:

• ·Oxycodone/ibuprofen:
• ·Oxycodone/aspirin:
• ·Oxycodone/acetaminophen:

Question 52

Identify synthetic derivatives

• Phenylpiperidine Analgesics (5)

Answer 52

• •Meperidine
• •Fentanyl
• •Sufentanyl
• •Alfentanil
• •Remifantanil

Question 53

• •µ- opioid agonist
• •Less potent than morphine
• •Excitement caused at toxic doses due to metabolite, normeperidine (CNS stimulant); not blocked by naloxone
• •Respiration depressed
• •Cardiovascular effects: postural hypotension
• •Doesn’t suppress cough
• •Causes variable effects on pupil size
• •Side effects similar to morphine with less constipation and urinary retention
• •MAO inhibitors + Meperidine Possibly severe reaction: excitation, delirium, hyperpyrexia, convulsions, respiratory depression
• •Better bioavailability than morphine
• •Tolerance develops slower than with morphine
• •Dependence also develops

Answer 53

Meperidine (Demerol)

• •µ- opioid agonist
• •Excitement caused at toxic doses due to metabolite, normeperidine (CNS stimulant); not blocked by naloxone
• •MAO inhibitors + Meperidine Possibly severe reaction: excitation, delirium, hyperpyrexia, convulsions, respiratory depression

Question 54

m opioid agonist:

• •Meperidine analog
• •80 x as potent as morphine – now major abuse substance
• •Available as patch for chronic pain, or as lozenge (sucker) for breakthrough pain in opioid tolerant patients, including cancer patients.
• •I.V. administration for pre and post-surgery analgesia, rapid onset short duration
• •Produces less nausea in comparison to morphine

Identify derivatives

Answer 54

Fentanyl (Duragesic)

*Fentanyl derivatives

• Sufentanil (Sufenta) – m opioid agonist:
  
  • ·6000 x as potent as morphine
  • ·I.V. administration; anesthesia adjunct; post-op anesthesia
  • ·Less hemodynamic instability, respiratory depression, chest wall rigidity
  • ·Costly
• Alfentanil-μ-opioid agonist:
• Remifentanil- μ opioid agonist:
  
  • ·short acting
  • ·20x more potent than alfentanil
• Carfentanyl - μ opioid agonist:
  
  • •Only human use is abuse

Question 55

Moderate to low opiod - Codiene

• MoA
• Uses
• pharmacogenomics
• precursor for?

Answer 55

Question 56

• ·Weak potency µ-agonist
• ·Analgesic-used in combination with acetaminophen or aspirin for treatment of mild to moderate pain
• •Less potential for dependence

Answer 56

Propoxyphene (Darvon)

Question 57

Mixed agonist antagonists (3)

Answer 57

• •Pentazocine
• •Buprenorphine
• •Tramadol

Question 58

Identify Mixed agonist antagonists

• ·Oral administration
• ·Weak µ-antagonist; k agonist
• ·Analgesia, sedation, respiratory depression
• ·May block morphine mediated analgesia
• ·May precipitate withdrawal in patients receiving opioids
• ·Used primarily for acute pain treatment
• ·Naloxone now included in TalwinÒ to prevent drug abuse
• ·agonists produce psychotomimetic effects
• ·mixed agonists/antagonists, in general, have a lower potential for abuse
• ·Tripelennamine, an antihistamine, given i.v. to patients receiving pentazocine experienced higher degrees of euphoria

Answer 58

Pentazocine (Talwin)

Question 59

·Partial agonist at m receptors; antagonist at k receptors

·Less effective analgesic than morphine

·Route of administration: i.m./i.v./ sublingual

·Recently approved by FDA for treatment of opioid dependence; given sublingually for this effect ± naloxone

·Used here for pregnant addicts (see Chaffin lecture)

Answer 59

Buprenorphine (Buprenex)

Question 60

• ·Chemically unrelated to opiates
• ·Binds opiate receptors
• ·Inhibits NE and 5-HT reuptake
• ·Partial inhibition by naloxone
• ·Side effects – constipation, nausea, vomiting, dizziness, drowsiness
• ·Oral administration for moderate pain

Answer 60

Tramadol (Ultram)

Question 61

opiate antagonist

• 3 types
  *

Answer 61

Question 62

Identify Non-analgesic use (antitussive)

Answer 62

• •Dextromethorphan (Delsym, Tussin):
• •synthetic derivative of morphine
• •suppresses response of cough center; elevates threshold
• •no analgesia
• •less constipation than codeine
• •not antagonized by naloxone
• •Robotripping, major agent in cough syrup abuse in teens

Question 63

MoA; NE inhibits pain by activation of pre and post alpha 2 receptors simulation in projection neurons of dorsal horn and primary afferents

Answer 63

Question 64

2 classes of antidepressant

Answer 64

Question 65

2 types of antiepileptics

Answer 65

Question 66

Topical pain meds vs NMDA antagonists

Answer 66

Topical

• •Lidocaine – local anesthetic
• •Capsaicin – chilli pepper alkaloid adjunctive
  
  • •TRPV1 antagonist
  • •Ion channel expressed on afferent nociceptors

NMDA Antagonists:

• •Ketamine – blocks NMDA and thus glutamate signaling
• •See anesthetics lecture

Question 67

Centrally active muscle relaxants

• Clinical uses

Answer 67

•Centrally acting muscle relaxants are used primarily as antispasmodics or in the relief of lower back pain, all of these drugs can interact with other CNS depressants.

Question 68

Baclofen ******

• Clinical uses
• mechanism
• pharmacokinetics
• main side effects
• other

Answer 68

Question 69

benzodiazepam ****

Clinical use ; IV/IM vs oral

Answer 69

Clinical use:

• •Muscle Spasms – IV or IM
• •Muscle relaxant – oral as an adjunct therapy

Question 70

Carisoprodol (Soma) **

• clinical use
• mechanism
• pharmoacokinetics
• main side effects
• other
  *

Answer 70

Question 71

Answer 71

Chlorzoxazone (Paraflex) *

Question 72

Answer 72

Cyclobenzaprine (Flexeril) ***

Question 73

Answer 73

Metaxalone (Skelaxin) ***

Question 74

Answer 74

Methocarbamol (Robaxin) ***

Question 75

Answer 75

Orphenadrine (Norflex) *

Question 76

Answer 76

Tizanadine (Zanaflex) ***

Question 77

Describe how you pick a medications to use

Pain; 1st line vs 2nd line

• what is never a 1st line

Answer 77

Opiods are not first line for pain treatment

Question 78

Define the following

• Nociception
• Pian
• Acute pain
• chronic pain
• Neuropathic pain
• Allodynia
• Hyperalgesia
• Analgesia

**Some pain facts

Answer 78

•  Pain affects more Americans than diabetes, heart disease and cancer combined.
•  Significant end of life issue as many hospitalized patients experience pain in the last days of their lives and despite therapies to alleviate most pain for those dying of cancer, 50-75% of patients die in moderate to severe pain.
•  An estimated 1/5th of American adults report sleep disrupted by pain or physical discomfort.
•  Most common types of pain, low back pain (27%), severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%).
•  Back pain is the leading cause of disability in Americans under 45 years old.

Question 79

Nociceptive pain

• Somatic vs visceral
• four stages
• transmission
• Perception
• Modulation

Answer 79

Somatic:

•  Arising from skin, bone, joint, muscle, connective tissue
•  Typically throbbing and well localized

Visceral:

•  Arising from internal organs
•  Can be referred or a more localized

Four Stages: Stimulation  transmission  perception  modulation

• Stimulation:
  
  •  Nociceptors found in somatic and visceral structures distinguish between noxious and innocuous stimuli.
  •  Activated by mechanical / thermal /chemical impulses.
  •  Mechanisms of stimuli include bradykinins, H+, K+, prostaglandins, histamine, cytokines etc.
  •  Receptor activation promotes action potentials that are transmitted along afferent nerves to the spinal cord.
• Transmission:
  
  •  Occurs in Aδ and C-afferent nerve fibers.
  •  Fibers synapse in various laminae of the spinal cord’s dorsal horn resulting in release of various transmitters including glutamate, substance P and aspartate.
  •  Signal is transmitted through the spinothalamic tract (see figure).
• Perception:
  
  •  Pain becomes a perceived conscious experience once the signal enters the cortical structures
  •  Behavioral and cognitive functions can modify pain perception.
    
    • o Decreased by – relaxation, exercise, distraction, meditation, guided mental imagery
    • o Increased by – change in neurobiochemical makeup such as depression, anxiety
• Modulation:
  
  •  Body modulates pain via a number of endogenous systems
    
    • o Opioids
    • o Descending spinal tract

Question 80

Describe neuropathic pain

pain classificatin; acute vs chronic

Answer 80

Neuropathic pain is pain that has become disengaged from the original stimuli; neuropathic pain is a result of nerve damage / plasticity changes while nociceptive pain is a function of normal nerve activity.

Pain Classification: Acute / Chronic

Acute pain is a normal physiological process warning us of disease states and potentially harmful situations. Acute pain is generally nociceptive in nature, common causes include: Surgery, acute illness, trauma, labor, medical procedures

Chronic Pain While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, chronic pain is different. Chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years. There may have been an initial mishap – sprained back, serious infection, or there may be an ongoing cause of pain – arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common chronic pain complaints include headache, low back pain, cancer pain, arthritis pain, neurogenic pain (e.g. diabetic neuropathy).

Question 81

6 approaches to pain management

e.g explain management of torn meniscus

Answer 81

Six major approaches:

•  Pharmacologic
  
  • o Pharmacologically the choice of agent is based on pain type and patient characteristics, including the pathophysiology of the pain syndrome, other symptoms and comorbidities, other medications being taken, organ reserves, pharmacokinetics/pharmacodynamics, and the likelihood of adverse effects.
•  Physical medicine – Physical therapy, spinal modulation
•  Behavioral medicine - CBT
•  Neuromodulation – TENS, Spinal cord stimulation, deep brain stimulation
•  Interventional – Direct injection into pain area of substances such as glucocorticoids
•  Surgical

Typically a therapeutic regimen will combine multiple approaches. e.g Torn meniscus

•  Ibuprofen as required
•  Physical therapy followed by
•  TENS (Transcutaneous electrical nerve stimulation) and Ice
•  Potentially surgery if no improvement

Question 82

Identify disorder

• •Academic functioning lags behind normal expectations based on education and level of intellectual functioning
• •IQ is at least average
• •Academic performance is generally at least 2 standard deviations behind

Answer 82

Specific Learning Disorder; different areas of deficit may be ;

• with impairment in reading
• with impairment in mathematics
• with impairment in writing
• classified as mild, moderate, severe
• Prevalence is thought to be between 2% and 10% of the population
• 2-4x more common in boys
• Tends to be familial

*****Patient with learning disorder will have average IQ, no sensory or motor deficits

Question 83

what do you exclude when diagnosing a learning disorder?

Answer 83

• •Not the result of a specific sensory, motor, or neurological disorder
• •Intellectual deficit alone does not account for failures in academic development
• •Not attributable to lack of educational opportunity and learning experiences
• •Now also looking at failure to respond to efforts to remediate

Question 84

additional points of learning disorder

• one factor or multiple?
• causes?
• what deficits can contribute

Associated features of learning disorder

Management

Answer 84

• •Disorders involve skills that are multifactorial and integrative
• •Various subtle dysfunctions can be part of the learning problem.
• •Causes can be equally various
• •Deficits in attention and concentration can be contributory

Associated features

• •Poor self-esteem
• •Learned helplessness
• •Social Difficulties
• •School refusal/drop-out rate of up to 40%
• •Co-occurring disorders including 10%-25% of individuals
  
  • •Mood disorders
  • •Behavior disorders
  • •ADHD

Management

• •Identification and evaluation
• •Educational services
  
  • •Specialized instruction
  • •Test modifications/accommodations
• •Additional services as needed (e.g., speech and language professionals
• •Educating patient and family: understanding the problem

Question 85

Motor disorders (2)

Answer 85

Developmental Coordination Disorder

• •Difficulty with acquisition and execution of coordinated movement
• •Not due to intellectual impairment, visual impairment, neurological condition

Stereotypic Movement Disorder

• •Repetitive, purposeless motor behavior
• •Interferes with daily functioning

Question 86

what is this?

•stereotyped motor behaviors or vocal productions

• •Involuntary
• •Sudden
• •Recurrent
• Nonrhythmic.

identify types of disorders (3)

xters

Answer 86

Tic Disorders

• •Tourette’s Disorder
• •Persistent (Chronic) Motor or Vocal Tic Disorder
• •Provisional Tic Disorder

•Estimates of > 1:100 have some type of tic disorder

xters of tics

• •Behaviors may be as simple as coughs, jerks, or snorts, or more complex phenomena such as facial gestures, echolalia, grooming behaviors, or coprolalia.
• •Tics may be voluntarily suppressed for a period of time, but the patient usually is overwhelmed eventually by the need to perform the behavior.
• •Tics often change over time

Question 87

identify co-occuring disorders with tourette’s

***Triad disorder

Answer 87

• •ADHD (50-60%)
• •OCD (30-70%)
  
  • •Common obsessions include: “Just right” Phenomenon, Violent images, sexual thoughts, symmetry
  • •Common compulsions: touching, blinking, repeating, hoarding
• •“Triad” Disorder
  
  • •ADHD
  • •OCD
  • •Tics

Question 88

Identify disorder

• •Have either motor tic or vocal tic, not both
• •Tics occur many times/day, nearly everyday
• •Marked distress/impairment

Answer 88

Persistent (Chronic) Motor/Vocal Tic Disorder

Question 89

Identify disorder

• •Marked by the presence of both motor and vocal tics
• •Estimated prevalence is 1/2000
• •3x more common in males
• •Mean age of onset is 7 years old

Answer 89

Tourette’s disorder

Question 90

Treatment - medications for tics disorders (4)

Management

Answer 90

• •Tenex
• •Clonodine
• •Atypicals
• •Haldol
• Suggestive of dopamine dysregulation
• Motor component implicates nigrostriatal tract

Management

• •Education
• •Define co-ocurring disorders
• •Hierarchy of clinically impairing conditions
• •Treat the impairing conditions
• •Create balance of supportive/challenging environment

Question 91

Identify communication disorders (4)

**presentation

Answer 91

• •Language Disorder
  
  • •Persistent difficulties with acquisition and use across modalities
• •Speech Sound Disorder
  
  • •Difficulty with speech sound production
• •Childhood Onset Dysfluency Disorder (Stuttering)
  
  • •Difficulties with fluency and time patterning of speech
• •Social (Pragmatic) Communication Disorder
  
  • •Difficulties with social use of verbal and nonverbal communication
• May be the initial presentation of Learning Disorders
• Require involvement of Speech/Language Pathologist
• May present with secondary behavioral problems

Question 92

identify feeding disorders

• •Persistent eating of non-food substances for a period of at least one month
• •May come to medical attention due to complications related to GI complaints
• •Common substances consumed include:
  
  • •Sand, soil, hair, string, cigarette butts, animal droppings, clay, chalk, etc.

Answer 92

Pica

Question 93

identifyy

• •Repeated regurgitation of food over a period of at least one month, regurgitated food may be re-chewed, re-swallowed or spit out
• •Can result in weight loss, failure to thrive and even death
• •May be related to early neglect, stressful life situations or problems in the parent-child relationship

Answer 93

Rumination Disorder

Question 94

Identify disruptive behavior disorders (2)

also included?

Answer 94

•Conduct Disorder

•Oppositional Defiant Disorder

•Also includes:

• •Intermittent Explosive Disorder
• •Pyromania
• •Kleptomania
• •Anti-social Personality Disorder

Question 95

what is the primary feature of conduct disorder

characteristic behaviors

Answer 95

•Primary feature of conduct disorder:

• •Persistent and repetitive pattern of behavior which violates the rights of others or age-appropriate social norms/rules

Characteristic behaviors

• •Aggression toward people or animals
  
  • •Can include sexual imposition or assault, or use of a weapon in more severe cases.
• •Destruction of property
• •Deceitfulness or theft
• •Serious rules violations

Question 97

Conduct disorders

• Asoociated personality features
• Incidence
• Family factors

Answer 97

Asoociated personality features

• •Shallowness in relationships and attachments
• •Inability to feel for others (lack of empathy)
• •Impaired capacity for guilt or remorse

Incidence

• •6-16% among boys
• •2-9% of girls

•Two patterns of onset:

• •Childhood onset-prior to age 10
• •Adolescent onset-no behaviors before age 10
• •Specify if: •With limited prosocial emotions
  
  • •Lack of remorse/guilt
  • •Callous-lack of empathy
  • •Unconcerned about performance
  • •Shallow or deficient affect
  • •Mild, Moderate, Severe

Family factors

• •Parental psychopathology (particularly antisocial personality and substance abuse) is thought to be causally important.
• •Chaotic home environments, with inconsistent enforcement of rules and modeling of antisocial behavior by parents, are commonly observed.

Question 98

Conduct disorder

• related problems
• treatment

Answer 98

Related problems

• •Poor school performance
• •Substance abuse
• •Legal problems
• •Learning disorders
• •About 25-40% will meet criteria for antisocial personality disorder as adults.
• •ADHD is a common comorbid disorder.

Treatment

• •Family therapy
• •Psychotherapy - building capacity for relationships, response to social cues
• •Consistent authoritative environment
• •Social skills and assertiveness training

Question 99

Identify disorder

• •A pattern of angry/irritable mood, argumentative/defiant behavior or vindictivness lasting at least 6 months.
• •Lacks the more serious violations of the rights of others seen in conduct disorder.

**Identify xteristic behaviors

**Treatment

Answer 99

Oppositional Defiant Disorder

Characteristic behaviors

• •Argumentative
• •Difficulty managing limits/transitions
• •Short-tempered and easily annoyed.
• •Can be deliberately annoying
• •Blame others for mistakes or misbehavior
• •May be spiteful and vindictive
• <this>
  </this>

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Treatment

• •Counseling or therapy for the child
• •Evaluation of the family for dysfunctions that either contribute to the disorder or prevent the family from dealing with the child effectively
• •Develop parental skills in behavior management.
• •Rule out depression

Question 100

Conduct disorder and oppositional defiant disoders

• Managemnet-medication

Answer 100

•Some benefit for the use of ADHD medications with children with both Conduct Disorder and Oppositional Defiant Disorder

• •Studies have only been conducted when there are both ADHD and symptoms of either CD or ODD
• •Mood stabilizers are also helpful with CD
  
  • •Some thought that CD symptoms may be early signs of Bipolar Disorder

Question 101

Identify elimination disorders

• •Repeated voiding of urine during the day or night into bed or clothes whether involuntary or intentional
• •Not diagnosed before the age of 5
• •Types
  
  • •Nocturnal only
  • •Diurnal only
  • •Nocturnal and Diurnal

Answer 101

Enuresis

Question 102

Treatment of enuresis (2)

Answer 102

•Behavioral Therapy

• •Bell & Pad
• •Ultrasonic Bladder Alarm
  
  • •80% of typical enuretic volume

•Medication

• •DDAVP-desmopressin
  
  • •Synthetic vasopeptide
  • •Temporary suppression rather than cure

Question 103

elimination disorder

• •Intentional or involuntary passage of stool in inappropriate places
• •Diagnosed after 4 years of age
• •By age 10-12, prevalence is 1% with 5:1 ration males to females
• •Types:
  
  • •With constipation and overflow incontinence
  • •Without constipation and overflow incontinence

Answer 103

Encopresis

Question 104

Management of encopresis (4)

Answer 104

• •Behavioral Strategies
  
  • •Reinforcement of appropriate toileting behavior
  • •Use of bathroom after each meal
  • •Time (at least 15 minutes)
• •Use of laxatives/enemas
• •Education
• •Biofeedback

Question 105

Childhood anxiety disorders (2)

Answer 105

• •Separation Anxiety
• •Selective Mutism

Question 106

Separation anxiety

• definition
• causal factors
• characteristics
• management

Answer 106

• Definition
  
  • •Excessive anxiety in response to separation from major attachment figures or familiar surroundings.
  • •Unduly persistent and/or inconsistent with age.
• Causal factors
  
  • •Fear provoking experiences
  • •Phobic anxiety modeled by parents
  • •Genetic factors
• Characteristics
  
  • •Conforming and eager to please
  • •Prone to nightmares
  • •Physical complaints
    
    • •Secondary to anxiety
    • •Learned means for avoidance
  • •Morbid fears
  • •Restricted social lives
• Management
  
  • •Gradually increase tolerance for separation from home and parents.
  • •Anxiety management
    
    • •Relaxation skills
    • •Cognitive strategies
  • •Supportive approach with positive incentives
  • •SSRI’s

Question 107

Selective mutism

• definition
• management

Answer 107

• Definition
  
  • •Persistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations
• Management
  • •Variety of techniques have been tried including:
    
    • •Behavioral therapy
    • •Family therapy
    • •Speech therapy
    • •Pharmacological treatments
  • •Very difficult to treat

Question 108

Identify disorders now part of trauma and stressor related disorder

1. •Pattern of behavior in which a child actively approaches and interacts with adults

• Not limited to impulsivity but include socially disinhibited behavior
• Child has experienced a pattern of extremes of insufficient care

2. •Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers

• Persistent social and emotional disturbance
• Child has experienced a pattern of extremes of insufficient care

**Treatment

Answer 108

1. •Disinhibited Social Engagement Disorder
2. •Reactive Attachment Disorder

Treatment

• •Prognosis is poor
• •Work to coordinate care
• •Provide respite
• •Educate caregivers

Question 109

Define personality disorders

****5 criteria

Answer 109

Personality disorders

• Enduring patterns of inner experience and behavior that deviate markedly from expectations of an individual’s culture.
• Pervasive, maladaptive, and cause significant impairment in social or occupational functioning
• Lack insight, Sx may be ego-syntonic
• Vulnerable to developing Sx of other disorders

5 criteria for all personality disorders

Enduring pattern of behavior/inner experience, manifested in two or more areas

• Cognition
• Affect
• Interpersonal functioning
• Impulse control

Pattern

• Pervasive and inflexible in a broad range of situations
• Stable, onset no later than adolescence or early adulthood
• Significant distress in functioning
• Not accounted for by another mental/medical illness or by use of a substance

International prevalence is about 6%, vary by gender, and many will meet criteria for more than one PD, classify for all they qualify for

Question 110

Identify cluster A personality disorders

Answer 110

Cluster A – schizoid, schizotypal, and paranoid

• Eccentric, peculiar, and withdrawn
• Familial association with psychotic disorders

Question 111

Identify disorder

• vRequires general distrust of others, beginning in early adulthood and present in variety of contexts

vAt least 4 of the following

• vSuspicion that others are exploiting or deceiving him or her
• vPreoccupation with doubts of loyalty or trustworthiness of friends of acquaintances
• vReluctance to confide in others
• vInterpretation of benign remarks as threatening or demeaning
• vPersistence of grudges
• vPerception of attacks on his or her character that is not apparent to others; quick to counterattack
• vSuspicions regarding fidelity of spouse or partner

Answer 111

Cluster A - Paranoid PD

• vEpidemiology
  
  • v2-4% prevalence, M>W, increased incidence in family members of schizophrenics, may be misdiagnosed in minority groups, immigrants, and deaf individuals
• vDifferential Diagnosis
  
  • vSchizophrenia
  • vSocial disenfranchisement and social isolation
• vCourse and Prognosis
  
  • vChronic, causes lifelong marital and job-related problems
• vTreatment
  
  • vPsychotherapy is the treatment of choice, avoid groups due to mistrust and misinterpretation of other’s statements
  • vAntipsychotics if experiencing transient psychosis

Question 113

Identify personality disorder

vPattern of voluntary social withdrawal and restricted range of emotional expression, beginning by early adulthood and present in a variety of contexts

vAt least 4 of the following

• vNeither enjoying nor desiring close relationships
• vGenerally choosing solitary activities
• vLittle interest in sexual activity with another person
• vTaking please in few activities
• vFew close friends or confidants
• vIndifference to praise or criticism
• vEmotional coldness, detachment, flattened affect

Answer 113

Cluster A - Schizoid PD

• vEpidemiology
  
  • v3-5% prevalence, M>W, increased prevalence of schizoid PD in relatives of schizophrenics
• vDifferential diagnosis
  
  • vSchizophrenia
  • vSchizotypal PD
• vCourse
  
  • vChronic
• vTreatment
  
  • vLack insight of individual psychotherapy, may find groups threatening, may benefit from day-programs or drop-in centers
  • vAntidepressants with comorbid depression

Question 114

• vPattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions, and discomfort in close relationships, begins by early adulthood, present in a variety of contexts
• vAt least 5 or more of the following
  
  • vIdeas of reference
  • vOdd beliefs or magical thinking, inconsistent with cultural norms
  • vUnusual perceptual experiences
  • vSuspiciousness
  • vInappropriate or restricted affect
  • vOdd or eccentric appearance or behavior
  • vFew close friends or confidants
  • vOdd thinking or speech
  • vExcessive social anxiety

Answer 114

Cluster A - Schizotypal PD

• vEpidemiology
  
  • v4-5% prevalence
• vDifferential diagnosis
  
  • vSchizophrenia
  • vSchizoid PD
• vCourse
  
  • vChronic, small minority develop schizophrenia
  • vPremorbid personality type for patient with schizophrenia
• vTreatment
  
  • vPsychotherapy is the treatment of choice à to help develop social skills
  • vShort course of antipsychotics at low doses if necessary, may help decrease social anxiety and suspicion in interpersonal relationships

Question 115

Identify cluster B PD (4)

Answer 115

• Antisocial PD
• Borderline PD
• Historic PD
• Narcissitic PD

Question 116

Personality disorder

vPattern of disregard for and violation of the rights of others since age 15

vPatients must be at least 18yo for this diagnosis with a history of behavior as a child/adolescent that must be consistent with conduct disorder

vAt least 3 of the following

• vFailure to conform to social norms by committing unlawful acts
• vDeceitfulness/repeated lying/manipulating others for personal gain
• vImpulsivity/failure to plan ahead
• vIrritability and aggressiveness/repeated fights or assaults
• vRecklessness and disregard for safety of self or others
• vIrresponsibility/failure to sustain work or honor financial obligations
• vLack of remorse for actions

Answer 116

Cluster B - Antisocial PD

vEpidemiology

• vPrevalence 3% in men and 1% in women
• vHigher incidence in poor urban areas and in prisoners, no racial difference
• vGenetic component: increased risk among first-degree relatives

vDifferential diagnosis

• vDrug abuse

vCourse

• vChronic with some improvement with age
• vMany have multiple somatic complaints, coexisting substance abuse and depression are common
• vIncrease morbidity from substance use, trauma, suicide, and homicide

vTreatment

• vPsychotherapy is generally ineffective, meds may be used to treat symptoms of anxiety and depression but use with caution due to addictive potential

Question 117

Identify PD

• vPervasive pattern of impulsivity and unstable relationships, affects, self-image, and behaviors, present by early adulthood and in a variety of contexts

vAt least 5 of the following

• vFrantic efforts to avoid real or imagined abandonment
• vUnstable, intense interpersonal relationships
• vUnstable self-image
• vImpulsivity in at least two potentially harmful ways
• vRecurrent suicidal threats or attempts or self-mutilation
• vUnstable mood/affect
• vChronic feelings of emptiness
• vDifficulty controlling anger
• vTransient, stress-related paranoid ideation or dissociative symptoms

***what is tx

Answer 117

Borderline PD (cluster B)

vEpidemiology

• vPrevalence up to 6%, W>>M, suicide rate 10%

vDifferential Diagnosis

• vSchizophrenia
• vBipolar II disorder

vCourse

• vVariable, may develop stability in middle age
• vHigh incidence of co-existing major depression and substance use disorders
• vIncreased risk of suicide

vTreatment

• vPsychotherapy is the treatment of choiceà DBT (dialectical behavior therapy) as well as CBT, mindfulness skills, and groups
• vMeds to treat psychotic or depressive symptoms may be needed

Question 118

Identify PD

vPattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts

vAt least 5 of the following

• vUncomfortable when not the center of attention
• vInappropriately seductive or provocative behavior
• vRapidly shifting but shallow expression of emotion
• vUses physical appearance to draw attention to self
• vSpeech that is impressionistic and lacking in detail
• vTheatrical and exaggerated expression of emotion
• vEasily influenced by others or situation
• vPerceives relationships as more intimate than they actually are

Answer 118

Histrionic PD (cluster B)

vEpidemiology

• v2% prevalence, W>M

vDifferential diagnosis

• vBorderline PD

vCourse

• vChronic, some improvement in symptoms with age

vTreatment

• vPsychotherapy is the treatment of choice
• vMeds for associated anxiety and depression as necessary

Question 119

identify PD

vPattern of grandiosity, need for admiration, and lack of empathy beginning in early adulthood, present in a variety of contexts

vAt least 5 of the following

• vExaggerated sense of self-importance
• vPreoccupation with fantasies of unlimited money, success, brilliance, etc
• vBelieves that he or she is “special” or unique and can associated only with other high-status individuals
• vRequires excessive admiration
• vHas a sense of entitlement
• vTakes advantage of others for self-gain
• vLacks empathy
• vEnvious of others or believes others are envious of him or her
• vArrogant or haughty

Answer 119

Narcissistic PD (cluster B)

vEpidemiology

• vPrevalence up to 6%

vDifferential diagnosis

• vAntisocial PD

vCourse

• vUsually chronic, higher incidence of depression and midlife crisis since there is such high value on youth and power

vTreatment

• vPsychotherapy is the treatment of choice
• vAntidepressants may be used if a comorbid mood disorder is diagnosed

Question 120

Cluster C PD (3)

Answer 120

• Avoidant PD
• Dependent PD
• Obsessive - compulsive PD

Question 121

Identify PD

vPattern of social inhibition, hypersensitivity, and feelings of inadequacy since early adulthood

vAt least 4 of the following

• vAvoids occupation that involves interpersonal contact due to a fear of criticism and rejection
• vUnwilling to interact unless certain of being liked
• vCautious of interpersonal relationships
• vPreoccupied with being criticized or rejected in social situations
• vInhibited in new social situations because he or she feels inadequate
• vBelieves her or she is socially inept and inferior
• vReluctant to engage in new activities for fear of embarrassment

Answer 121

Avoidant PD

vEpidemiology

• vPrevalence 2.4%, M=F

vDifferential Diagnosis

• vSchizoid PD
• vSocial anxiety disorder
• vDependent PD

vCourse

• vUsually chronic, may remit with age
• vParticularly difficult during adolescence when attractiveness and socialization are important
• vIncreased incidence of associated anxiety and depression
• vIf support system fails, patient is left very susceptible to depression, anxiety, and anger

vTreatment

• vPsychotherapy most helpful à assertiveness and social skills training
• vGroups may be beneficial
• vSSRIs may be helpful for comorbid social anxiety disorder or major depression

Question 122

Identify PD

vPattern of excessive need to be taken care of that leads to submissive and clinging behavior

vAt least 5 of the following

vDifficulty making everyday decisions without reassurance from others

vNeeds others to assume responsibilities for most areas of his or her life

• vDifficulty expressing disagreement because of fear of loss of approval
• vDifficulty initiating projects because of lack of self-confidence
• vGoes to excessive lengths to obtain supports from others
• vFeels helpless when alone
• vUrgently seeks another relationship when one ends
• vPreoccupied with fears of being left to take care of self

Answer 122

Dependent PD (cluster C)

vEpidemiology

• vPrevalence approx. <1%, W>M

vDifferential diagnosis

• vAvoidant PD
• vBorderline and histrionic PD

vCourse

• vChronic, prone to depression, particularly after loos of person on whom they were dependent
• vDifficulties with employment since they cannot act independently or without close supervision

vTreatment

• vPsychotherapy – CBT, assertiveness and social skills training
• vMeds for associated depression and anxiety symptoms

Question 123

Identify PD

vPattern of preoccupation with orderliness, control, and perfectionism at the expense of efficiency and flexibility, present by early adulthood and in a variety of contexts

vAt least 4 of the following

• vPreoccupation with details, rules, lists, and organization such that the major point of the activity is lost
• vPerfectionism that is detrimental to completion of task
• vExcessive devotion to work
• vExcessive conscientiousness and scrupulousness about morals and ethics
• vWill not delegate tasks
• vUnable to discard worthless objects
• vMiserly spending style
• vRigid and stubborn

Answer 123

Obsessive-compulsive pd (cluster C)

vEpidemiology

• vPrevalence 1-2%, M>W

vDifferential diagnosis

• OCD
• vNarcissistic PD

vCourse

• vUnpredictable course
• vSome can have comorbid OCD but most do not

vTreatment

• vPsychotherapy is the treatment of choice, usually CBT
• vMeds used for associated symptoms as necessary

Question 124

• vRefers to a persistent personality change from a previous pattern due to the direct pathophysiological result of a medical condition.
• vSubtypes include labile, disinhibited, aggressive, apathetic, or paranoid

Answer 124

Personality change due to another medical condition

• Examples: head trauma, stroke, epilepsy, CNS infection, neoplasm

Question 125

PD

• vDiagnosis is reserved for a personality disorder that does not meet full criteria for any of the disorders, but where the clinician chooses not to communicate the specific reason that the presentation does not meet the criteria for any specific personality disorder.
• vExample: not enough information to make a more specific diagnosis, like in the emergency room setting

Answer 125

Unspecified personality disorder

Question 126

Management of personality disorders

Issues with treatmnet

Suggested actions

Answer 126

• vEarly referral to mental health providers
• vPsychotherapy - considered first line
• vMedication s - No medications approved by FDA .
• vTreatment of comorbid psychiatric disorders

Issues with treatment – countertransference reactions

• Anger
• Fear of physical and legal threat
• Sympathy
• Self doubt
• Frustration and attraction

Suggested actions

• vBe aware of feelings
• vLimit setting
• vProper documentation
• vPersonal safety
• vRealistic expectations
• vChaperone for exam
• vDo not see patients afterhours or in social settings

Question 127

Case

A 30yo postal worker rarely goes out with her cowrokers and often makes excuses when they ask her to join them because she is afraid they will not like her. She wishes to go out and meet new people but, according to her, she is too “shy.”

1. vWhat is the likely diagnosis?
2. vWhat is the main difference between this diagnosis and schizoid PD?
3. vWhat would a therapist focus on with this patient to help her symptoms?

Answer 127

1.Avoidant PD

2. Schizoid prefer to be alone, avoidant want relationship but are fearful of rejection
3. Assertiveness and social skills training

Question 128

Case 2

30yo unemployed man has been accused of killing 3 senior citizens after robbing them. He is surprisingly charming in the interview. In his adolescence he was arrested several times for stealing cares and assaulting other kids.

1. vWhat is the likely diagnosis?
2. vBehavior as a child or adolescent must be consistent with which diagnosis?
3. vWhich comorbid issue should be considered in these patients?

Answer 128

1. Antisocial PD
2. Conduct disorder
3. Drug abuse

Question 129

A 30yo man says his wife has been cheating on him because he does not have a good enough job to provide for her needs. He also claims that on his previous job, his boss laid him off because he did a better job than his boss. He has initiated several lawsuits. He refuses couples therapy because he believes the therapist will side with his wife. He believes his neighbors are critical of him.

1. vWhat is the likely diagnosis?
2. vIs this PD more common in men or women?
3. vWhich type of therapy should be avoided and why?

Answer 129

1. Paranoid PD
2. Men
3. Groups due to mistrust and misinterpretation of others’ statements

Question 130

A 23yo medical student attempted to cut her wrist because things did not work out with a man she had been dating over the past 3 weeks. She states that guys are jerks and “not worth her time.” She often feels that she is “alone in this world.”

1. vWhat is the likely diagnosis?
2. vIs this diagnosis more common in men or women?
3. vWhat defense mechanism is common in this diagnosis?
4. vWhat is the main therapy used for this diagnosis?

Answer 130

1. Borderline PD
2. Women
3. Splitting
4. DBT

Question 132

A 40yo man who lives with his parents has trouble deciding how to get his car fixed. He calls his father at work several times to ask very tivial things. He has been unemployed over the past 3 years.

1. vWhat is the likely diagnosis?
2. vWho is more likely to have this diagnosis, men or women?
3. vWhat comorbid condition would this patient be particularly prone to?

Answer 132

1. Dependent PD
2. Women
3. Depression

Question 133

A 33yo scantily clad women comes to your office complaining that her fever feels like “she is burning in hell.” She vividly describes how the fever has affected her work as a teacher.

1. vWhat is the likely diagnosis?
2. vIs this diagnosis more common in men or women?
3. vWhich is more functional, borderline or this diagnosis?

Answer 133

1. Histrionic PD
2. Women
3. Borderline patients are more likely to suffer from depression, brief psychosis, and to attempt suicide, HPD is generally more functional

Question 134

A 45yo scientist works in the lab most of the day and has no friends, according to his coworkers. He has not been able to keep his job because of failure to collaborate with others. He expresses no desire to make friends and is content with his single life. He has no evidence of a thought disorder.

1. vWhat is the likely diagnosis?
2. vIs this PD more common in men or women?
3. vWhat type of treatment may be helpful in this patient?

Answer 134

1. Schizoid PD
2. Men
3. Day programs or drop-in centers

Question 135

A 48yo company CEO is rushed to the ED after an automobile accident. He does not let the residents operate on him and requests the chief of trauma surgery because he is “vital to the company.” He makes several business phone calls in the ED to stay on “top of his game.”

1. vWhat is the likely diagnosis?
2. vWhat mental health diagnosis has a higher incidence in this PD?
3. vWhat is the treatment of choice?

Answer 135

1. Narcissistic PD
2. Depression
3. Psychotherapy

Question 136

A 40yo secretary has been recently fired because of her inability to prepare some work projects in time. According to her, they were not in the right format and she had to revise them six times, which led to the delay. This has happened before but she feels that she is not given enough time

1. vWhat is the likely diagnosis?
2. vWhat are two differences between this diagnosis and OCD?
3. vWhich type of psychotherapy will be most helpful?

Answer 136

1. OCPD
2. OCD is ego-dystonic, OCPD is ego-syntonic and OCPD do not have obsessions or compulsions
3. CBT

Question 137

A 35yo man dresses in a wizard costume every weekend with friends as part of a live action role-playing community. He spends a great deal o time on his computers set up in his basement for video games and to “detect the presence of extraterrestrial communications in space.” He has no auditory or visual hallucinations.

1. vWhat is the likely diagnosis?
2. vThis is the premorbid PD for which other mental health disorder?
3. vWhat distinguishes this PD from the other mental health disorder?

Answer 137

1. Schizotypal PD
2. Schizophrenia
3. These patients are not frankly psychotic, but they can become so transiently under stress, and they have no fixed delusions

Question 138

Migraine

• Pathophysiology
• 2 types (difference between the 2)

Answer 138

• •Begins with abnormal instability or activation of certain cells which spread peripherally and stimulate the trigeminal system
  
  • – This can cause nearby stimulation of chemoreceptors (resulting in nausea and vomiting) and the autonomic nervous system (resulting in pallor, flushing, and congestion)
• •Does not originate with constriction and subsequent dilation of cerebral blood vessels

2 types of migraines

• •Common; no aura
• •Classic; has aura (reversible neurologic symptoms that precede the migraine in 20 minutes)

Question 139

Common migraine

• Diagnostic criteria

Answer 139

–At least 5 attacks fulfilling the following

• •Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)- symptoms in children can be less duration
• •Headache has at least two of the following characteristics:
  
  • –unilateral location
  • –pulsating quality
  • –moderate or severe pain intensity
  • –aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
• •During headache at least one of the following:
  
  • –nausea and/or vomiting
  • –photophobia and phonophobia

Question 140

Classic migraine

• diagnostic criteria
• added difference from common migraine

Answer 140

•Same diagnostic criteria as common migraine except:

• –Presence of an aura.
  
  • •Aura is the complex of neurological symptoms that occurs just before or at the onset of migraine headache
  • •Auras develop gradually over 5-20 minutes and last for less than 60 minutes
  • •Common auras are visual change, paresthesia, confusion

Question 141

Migraine criteria caveats in children

Answer 141

• •Pain is typically bilateral. Unilateral pain usually emerges in late adolescence or early adult life.
• •Migraine headache is usually frontotemporal.
  
  • –Occipital headache in children is rare and calls for diagnostic caution.
• •In young children, photophobia and phonophobia may be inferred from their behavior.

Question 142

Identify migraine type

•At least 2 attacks fulfilling the following:

–Aura consisting of at least two of the following fully reversible symptoms, but no motor weakness:

• •dysarthria
• •vertigo
• •tinnitus
• •Hypacusia (diminished hearing)
• •diplopia
• •visual symptoms simultaneously in both temporal and nasal fields of both eyes
• •ataxia
• •decreased level of consciousness
• •simultaneously bilateral paraesthesias

–At least one of the following:

• •at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
• •each aura symptom lasts ≥5 and ≤60 minutes

Answer 142

Migraine with brainstem aura

Question 143

Identify type of migraine

• •Recurrent attacks of unilateral visual disturbance or blindness lasting from minutes to 1 hour
  
  • –Patients describe a gradual visual disturbance in a mosaic pattern of scotomata that gradually enlarge, producing total unilateral visual loss
• •Associated with minimal or no headache.

Answer 143

Retinal Migraine

Question 144

Treatment goals of migraines

**Non-pharmacologic approach to migraine

Answer 144

•Abortive

• –Disrupt the headache cycle once started

•Preventative

• –Decrease the frequency and severity of headache attacks
• –Generally these medications are tried when:
  
  • •>4-6 migrainous headaches days per month
  • •Multiple missed days of work or recurrent ED visits secondary to migrainous symptoms

•Avoid triggers:

• –Red Wine, certain foods (chocolate, some cheeses, MSG, heavy nitrite containing foods-i.e. highly processed meats), hunger from missing meals, sleep deprivation and irregular sleeping patterns, and stress

Question 145

Abortive pharmacology examples (3)

Answer 145

•NSAIDS

• –Ibuprofen, Naprosyn, Ketorolac

•5HT1 agonists (Triptans and Ergots)available in oral, inhaled and subcutaneous forms (examples below)

• –Sumatriptan (short onset and duration)
• –Zolmitriptan (intermediate onset and duration)
• –Frovatriptan (long onset and duration)

•Dopamine antagonists available in oral and subcutaneous forms

• –Metoclopramide (Reglan)
• –Prochlorperazine (Compazine)

Question 146

Prophylactic pharmacology (5)

**What are the first line of treatment

Answer 146

•β-Adrenergic Blockers

• –Propranolol
• –Atenolol

•Calcium Channel Blockers

• –Verapamil

•Tricyclic Antidepressants

• –Amitriptyline
• –Nortriptyline

•Anticonvulsants (AED’s)

• –Gabapentin (Neurontin)
• –Valproic Acid (Depakote)
• –Topiramate (Topamax)
• –Others (zonesimide, keppra, etc…)

•Serotonergic Drugs

• –Cyproheptadine (Periactin)- particularly effective in children

**First line agents; topiramate, amitriptyline, propanolol

Question 147

Headache type

• •believed to be derived in part by the hypothalamus, especially so in those with prominent autonomic symptoms.
• There is then a secondary activation of the trigeminal-autonomic reflex, probably via a trigeminal-hypothalamic pathway

***Clinical features

Answer 147

Cluster Headaches

• one of the most painful headache conditions. They are defined as an episodic headache condition characterized by attacks of severe unilateral stabbing periorbital or temporal pain. They tend to occur in clusters for approximately 3-6 weeks. They are typically associated with at least one of the following associated
• autonomic features

Question 148

What is the ICDH criteria for cluster headaches

Answer 148

• •At least 5 attacks fulfilling criteria
• •Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
• •Headache is accompanied by at least one of the following:
  
  • –ipsilateral conjunctival injection and/or lacrimation
  • –ipsilateral nasal congestion and/or rhinorrhoea
  • –ipsilateral eyelid oedema
  • –ipsilateral forehead and facial sweating
  • –ipsilateral miosis and/or ptosis
  • –a sense of restlessness or agitation
• •Attacks have a frequency from one every other day to 8 per day

Question 149

Abortive pharmacology of cluster headaches *********(3)

Answer 149

•Treating cluster headaches can be difficult given the short duration of the individual attack. The treatment should begin with immediate use of oxygen and if pain is still present at 20 minutes one should use intranasal or subcutaneous sumatriptan (preferred over oral due to improved onset time).

• –Oxygen
  
  • •Administration of high concentration O2 (12L/min) for 15 minutes will decrease the headache duration-this is the most effective abortive agent
• –Triptans- effective in about 75 percent of patients (pain-free at 20 minutes after administration)
  
  • •Should use a short onset, short duration drug (i.e. Sumatriptan)
• –Intranasal administration of lidocaine drops is possibly helpful

Question 150

Prophylactic pharmacology of cluster hadaches

Answer 150

• •High Dose Steroids
  
  • –Use of high dose prednisone during the patient’s cluster of events (typically dosed for 2-4 weeks) will dramatically lessen the frequency of attacks in the cluster. Is often combine with additional prophylactic agents (see below)
• •Calcium Channel Blockers (i.e. Verapamil) –adjuvant agent of choice
• •Others
  
  • –Lithium

Question 151

Identify headache type

• •most prevalent headache syndrome.
• •Whether these are infact mild migraine headaches or rather a unique condition is continually debated.
• •Patients who suffer from tension type headaches described a sensation of squeezing or pressure around the head. They may also complain of being light and sound sensitive. They are never associated with nausea or vomiting- if this is a complaint then you are most likely dealing with migraine. These symptoms can last minutes or even days and are constant.

Answer 151

Tension Headaches

Question 152

ICDH criteria of tension headaches

Answer 152

•At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling the following:

• –Headache lasting from 30 minutes to 7 days
• –Headache has at least two of the following characteristics:
  
  • •bilateral location
  • •pressing/tightening (non-pulsating) quality
  • •mild or moderate intensity
  • •not aggravated by routine physical activity such as walking or climbing stairs
• –Both of the following:
  
  • •no nausea or vomiting (anorexia may occur)
  • •no more than one of photophobia or phonophobia

Question 153

Pharmacology of tension headaches

• Non pharmacology treatment
• Abortive pharm
• Prophylactic pharm

Answer 153

• Non pharmacology treatment
  
  • •Stress reduction
  • •Biofeedback
  • •Cognitive Behavioral Therapy
  • •Improved sleep hygiene
• Abortive pharm
  
  • •Acetaminophen
  • •NSAIDS
  • •Aspirin
• Prophylactic pharm
  
  • –Tricyclic Antidepressants
    
    • •Amitriptyline
    • •Nortriptyline
  • –Antiepileptic
    
    • •Gabapentin

Question 154

Identify headache type

• •Headaches
  
  • –Nonspecific with variable location
  • –Character: Throbbing and/or pressure type
    
    • •Worsen with Valsalva
• •Pulsatile tinnitus
  
  • –Audible “whooshing”
• •Vision impairment
  
  • –Flashes and floaters
  • –Diplopia
    
    • •Due to either trochlear or abducens palsy
  • –Decrease acuity and impaired visual fields
    
    • •Typically, the vision loss starts in the nasal inferior quadrant and is followed by loss of the central visual field
  • –Visual dimming with Valsalva

Answer 154

Idiopathic Intracranial Hypertension

Question 155

Idiopathic Intracranial Hypertension (IIH)

• Epidemiology
• Pathophysiology
• obesity contribution
• what occur secondary to increased ICP

Answer 155

IIH

Epidemiology

• •IIH is a disorder of unknown etiology that predominantly affects obese women of childbearing age
• •United States Incidence
• –More than 90% of patients with IIH are women of childbearing age
  
  • •0.9 cases per 100,000 in general population (both sexes)
  • •19 cases per 100,000 population in women 20% over ideal body weight
  • •An 8:1 female-to-male ratio for a mean weight 38% over the ideal weight for height

Pathophysiology

• •Old School:
• –Cerebral edema from the elevated ICP
• •Early reports describing edema were later considered to represent fixation artifact (ie, from tissue preparation) rather than in vivo edema.
• •New School
• –Current hypotheses include the link between relatively obstructive segments in the distal transverse sinus and IIH and the presence of increased arterial inflow with an accompanying low-grade stenosis of the transverse sinus

Obesity contribution

• •Obesity increases intra-abdominal pressure and thereby raises cardiac filling pressures.
  
  • –These rises in pressure lead to impeded venous return from the brain (due to the valveless venous system that exists from the brain to the heart) with a subsequent elevation in intracranial venous pressure.
• •If this process is not treated appropriately, chronic interruption of the axoplasmic flow of the optic nerves with ensuing papilledema as a consequence of this pressure may lead to irreversible optic neuropathy

Papilledema

• • Typically bilateral disc edema is noted secondary to the increased intracranial pressure
• •Severity of disc edema does not help to distinguish underlying pathology
• •Untreated increased intracranial pressure ultimately leads to optic atrophy and resultant loss of acuity

Question 156

IIH (idiopathic intracranial hypertension)

• Diagnosis (work up)

Answer 156

Neuroimaging work-up

• •Disc edema necessitates neuroimaging with MRI (with and without) and MRV to rule our mass or dural venous sinus thrombosis
• •IIH findings on MRI:
  
  • –normal or small slitlike ventricles
  • –enlarged optic nerve sheaths
  • –occasionally an empty sella

Lumbar puncture

• •Localize the landmarks: between spinous processes at L3-4 level.
  
  • –This level corresponds to the level of the posterior superior iliac crest.
  • –On obese patients, find the sacral promontory; the end of this structure marks the L5-S1 interspace.

CSF data

• •Normal opening pressures are typically 120-170mm H20
• •Diagnosis of IIH requires pressures of >250mm H20
• •CSF can be drained to normal closing pressures

Question 157

IIH medical treatment

Answer 157

•Weight loss!!

• –Diet
  
  • •As little as a 5-10% weight loss has been demonstrated to yield a reduction in ICP with accompanying resolution of papilledema.
• –Bariatric Surgery:
  
  • •Review of case series/reports (62 total patients)
    
    • –52 (92%) experienced resolution of the presenting symptoms.
    • –Of the 35 patients who underwent postoperative funduscopy, 34 had resolution of papilledema.
    • –Of 12 patients who underwent pre- and postoperative visual field examinations, 11 showed resolution of visual field defects

Question 158

Pharmacologic management of IIH (3)

Answer 158

• •Diuretics
  
  • –Acetazolamide (good data- see next slides)
  • –Furosemide (little data)
• •Corticosteroid
  
  • –Can be used transiently in rapidly progressing visual deterioration
• •Anticonvulsants
  
  • –Topiramate
  • •Weak carbonic anhydrase inhibitor
  • •side effect is weight loss (a necessary goal in most IIH cases), which can help put the disease in remission.

Question 159

IIH surgical treatment

Answer 159

•Failed medical management resulting in:

• –Continued elevations in ICP
• –Progressive visual deterioration
• –Worsening disc edema /early signs of optic atrophy

•Fulminant IIH

***Shunts; ventriculoperitoneal and lumboperitoneal

Question 160

Identify condition

• •Headache
  
  • –Typically unilateral, temporal location and constant ache
• •Vision impairment
  
  • –Typically painless transient and intermittent unilateral visual blurring or vision loss
  • –Neck, torso, shoulder, and pelvic girdle pain that is consistent with polymyalgia rheumatic
• •Fatigue and malaise
• •Jaw claudication
• •Mild fever

Answer 160

Giant cell arteritis (temporal arteritis)

Question 161

Giant cell arterities (temporal arteritirs)

• Epidemiology
• Pathophysiology

Answer 161

• •The reported incidence of GCA ranges from approximately 0.5 to 27 cases per 100,000 people aged 50 years or older
• •Giant cell arteritis (GCA) is primarily a disease of cell-mediated immunity
• “The primary inflammatory response involves the internal elastic lamina within the media of the arterial wall. The subsequent release of cytokines within the arterial vessel wall can attract macrophages and multinucleated giant cells. In turn, activated CD4+ T helper cells respond to an antigen presented by macrophages, which gives diseased vessels their characteristic histology. The inflammation tends to occur in a segmental or patchy manner, although long portions of arteries may be involved”

Question 162

Giant cell arteritis (temporal arteritis)

• Diagnosis
• Treatmnet

Answer 162

Diagnosis

• •ESR and CRP are typically elevated
  
  • –ESR often exceeds 50mm/hr
    
    • •Can be normal in 10-20%
• •Temporal artery biopsy

Treatment

• •Treatment is with high doses steroids which typically relieve the headache symptoms within three days. Given the chronic nature of this condition, most patients remain on a constant low dose steroid regimen for a couple of years.
• •Long-term corticosteroid therapy has frequent and potentially serious consequences, including diabetes mellitus, vertebral compression fractures, steroid myopathy, steroid psychosis, and immunosuppression- related infections.

Question 163

Identify condition

• •a manifestation of abnormal hypersynchronous discharges of cortical neurons

Identify condition

• •two unprovoked manifestation of abnormal hypersynchronous discharges of cortical neurons at leadt 24 hours apart

Answer 163

Seizure

• –Not all seizures are clinically evident
• –Clinical signs depend on localization of discharges
• •Epilepsy is NOT a single seizure
• •Epilepsy is defined as two unprovoked seizures at least 24 hours apart

Question 164

Seizure

• Epidemiology
• Etiology

Answer 164

Epidemiology

• •Lifetime risk of single seizure is 9%
• •Lifetime risk of being diagnosed with epilepsy is approximately 2%
  
  • –Prevalence of active epilepsy is only about 0.8%.

Etiology

• •Children
  
  • –Genetic > Infection > Trauma > Congenital > Metabolic
• •Adult
  
  • –Tumors > Trauma > Stroke > Infection
• •Elderly
  
  • –Stroke > Tumor > Trauma > Metabolic > Infection

Question 165

Seizure clasificiation

Answer 165

• It is essential to classify seizure to help diagnose etiology and begin appropriate treatment.
• International League Against Epilepsy Classification
• –Determined by clinical expression combined with EEG findings
• –They defined two subsets of seizure:
  
  • •Partial Onset
    
    • –Simple Partial Seizures
    • –Complex Partial Seizures
  • •Generalized Onset

Question 166

Differentiate the types of partial onset seizures

Answer 166

•Simple Partial Seizure

• –Focal ictal discharge that does not spread
• –Patient remains completely aware of surroundings, no change in level of consciousness is noted
• –May present as an aura only
  
  • •Epigastric rising, déjà vu, sensation of fear, olfactory hallucination
• –May be isolated motor or sensory activity

•Complex Partial

• –Focal ictal discharge which may spread
• –Level of consciousness is impaired
• –Automatisms are often seen
  
  • •Lip smacking, repeat swallowing, perseveration of motor activity
• –Often accompanied by post-ictal confusion

Question 167

Identify seizure type

***Identify the different types

• •These seizures do not have clear localizable onset on EEG
• •Clinically these often appear as abrupt loss of consciousness with generalized convulsions

Answer 167

Generalized seizures

•Multiple different types:

• –Generalized Tonic Clonic (Grand Mal)
• –Myoclonic
• –Atonic
• –Staring (Petit Mal or Absence)

•Almost always associated with postictal confusion or lethargy

–Exception to this rule is Absence Seizures (or Petit Mal)

Question 168

Seizure type

• •Rapid brief muscle jerks the can occur bilaterally with or without synchrony.
• •Can be small movements involving focal areas of face or limbs or could be massive involving bilateral spasms affecting the head, arms and legs

Answer 168

Myoclonic seizure

Question 169

Seizure type

• •Astatic Seizures resulting in sudden loss of muscle tone
• •These can appear as total truncal collapse (generalized atonic) or simply head drops (fragmental atonics)

Answer 169

Atonic (Drop Attacks)

Question 170

Identify select epilepsy syndrome

• •This is the most common sign of neurologic dysfunction in newborns and should always be investigated
• •Overall prevalence is 0.5% of all newborns
  
  • –Greater frequency in preterm infants <36 weeks gestation
• •Four general patterns are observed:
  
  • –subtle, clonic, tonic, and myoclonic.
• •Etiologies are highly variable but are broadly classified:
  
  • –Genetic, Infectious, Hypoxic, Metabolic, Trauma

Answer 170

Neonatal seizures

Question 171

Select epilepsy syndrome

• •Previously a catastrophic epilepsy syndrome
• •Variety of etiologies including: cerebral dysgenesis, tuberous sclerosis, phenylketonuria, intrauterine infections, or hypoxic-ischemic injury and many others
• •Seizures appear as brief symmetric spasm of the head, trunk or arms.
  
  • –Characteristically appear like clasp knife extension of arms towards midline
• •EEG shows hypsarrthymia
• •Very refractory to traditional anti-epileptic drugs
• •Can be treated in some cases with ACTH
  
  • –$20K dollars for the treatment
  • –Lots of risks

Answer 171

Infantile Spasms (West Syndrome)

Question 172

Select epilepsy syndrome

• •Generalized epilepsy syndrome, often outgrown
• •Onset is typically between ages 4-10
• •Seizures last seconds and can occur hundred of times per day
• •Often confused with ADHD due to poor school performance
• •Can have an association with generalized tonic clonic seizures in ~30%
• •Typical EEG pattern is 3Hz Spike and Wave
• •Treatment of choice is with Ethosuximide

Answer 172

Childhood Absence Epilepsy

Question 173

Select epilepsy syndrome

• •A broad group of epileptic conditions characterized by:
  
  • –Mental Retardation
  • –Uncontrolled seizures (variety of types-Atonic Seizures are common)
  • –Characteristic EEG pattern
• •Seizures usually begin by age 4
• •Notoriously refractory to medications
• •Surgical intervention and devices may help

Answer 173

Lennox-Gastaut Syndrome

Question 174

Seizure type

• •Generalized convulsions which occur with fever
• •Onset is usually seen between age 6 months and 6 years
• •Seizures typically occur early in febrile illness and are less likely due to how high the temperature gets, but rather how rapidly it rises.

***General rules?

Answer 174

Febrile Seizure

•General Rules about Febrile Seizures

• –1/3 will have more than one episode
  
  • •Highest rates of recurrence seen in those with onset before age 1
• –Risk of developing epilepsy is approximately 2% for simple febrile seizure-this is not much different than the general population
  
  • •Risk of epilepsy increases to ~10% if it’s a complicated febrile seizure
• –These do not typically require imaging or treatment. Baseline EEG is occasionally obtained if history is compelling.

Question 175

Identify seizure type

• •Onset is between 4 and 13 years in children who are otherwise normal.
• •The prognosis is uniformly good. Seizures disappear by mid to late adolescence in all cases.
• •Carbamazepine is the drug of choice

Answer 175

Benign Focal Epilepsy of Childhood (Benign Rolandic Epilepsy)

•Seizures are variable depending on time of day

• –Daytime seizures are usually focal with twitching of one side of the face, speech arrest, drooling from a corner of the mouth, and paresthesia of the tongue, lips, inner cheeks, and face
  
  • •Consciousness is preserved during these daytime seizures
• –Nighttime seizure typically quickly generalizes to appear as global tonic clonic activity

Question 176

Idnetify condition

• •Characterized by myoclonic jerks, usually in the morning
• •Can rarely have generalized convulsions
• •Onset between ages of 8-20
• •Most often there is a family history of epilepsy
• •Not outgrown
• •Valproic Acid is the treatment of choice
• •Carbamazepine will make these worse

Answer 176

Juvenile Myoclonic Epilepsy (JME)

Question 177

• •Most common epilepsy syndrome in adults
• •Often are associated with auras which precede a complex partial seizure
  
  • –Common auras include epigastric rising, odd smell, feeling of detachment or unreality, déjà vu, amongst others
  • –Have highly variable clinical expression

Answer 177

Temporal Lobe Epilepsy

• •Most often the epileptic zone is coming from the mesial temporal lobe, especially the hippocampus

Question 178

• •Notoriously deceiving due to clinical presentation
• •Has an incredibly diverse array of clinical appearance
  
  • –Dancing, singing, hopping, walking aimlessly are all presentations I have personally seen
  • –If occurring at night can be almost impossible to determine whether they are a parasomnia or epilepsy without EEG monitoring.
• •Status Epilepticus of the frontal lobe can be easily missed due to atypical clinical appearance.

Answer 178

Frontal lobe Epilepsy

Question 179

• •One of the most common conditions neurologists evaluate because of difficulty discerning from true epilepsy
• •Are usually a stress response and frequently are not consciously controlled.
  
  • –Frequent association with previous sexual trauma, PTSD, Bipolar disorder, and other personality disorders
• •Unfortunately, this can also occur as a stress response to having actual epilepsy-this can make management very challenging.

Answer 179

Non-epileptic Spells

Question 180

Epilepsy evaluation

Answer 180

EEG

• •The most helpful test in evaluation and diagnosis of epilepsy or evaluation of new onset seizures or seizure-like spell
• •Helps distinguish between focal or generalized
• •Epilepsy monitoring [Continuous Video EEG] can define and distinguish between epilepsy and non -epileptiform events.

Question 181

Give examples of image findings that are linked to epilepsy

Answer 181

• –Hemorrhage (Subdural, Intraparenchymal, and Subarachnoid)
• –Stroke
• –Infection (abscess and encephalitis)
• –Tumors
• –Vascular malformation
• –Heterotopic tissue
• –Mesial Temporal Sclerosis

Question 182

Henderson lecture

Serotonin and Migraines

• CV effects
• CNS effects
• Synthesis and inactivation
• 5-HT receptors
• Role of serotonin (5-HT) in migraine

Answer 182

•Cardiovascular

• •Induces vasoconstriction and has positive inotropic and chronotropic effects on heart

CNS effects

• 5-HT neurons in raphe nuclei of brain stem and project throughout the brain and spinal cord. Regulate sensory perception and nociception

Synthesis and inactivation of 5-HT

• •Serotonin is preferentially inactivated by monoamine oxidase A (MAO-A) isoform, platelets only express the MAO-B isoform
• •5-Hydroxyindoleacetic acid (5-HIAA) is the urinary metabolite of 5-HT

5-HT Receptors

• •There are seven 5-HT receptor subtypes
• •The role of 5-HT1B/1D receptors in migraine.
  
  • –*5-HT1D induce vasoconstriction of cranial blood vessels.
  • –*5-HT1B is an autoreceptor and its activation inhibits nociceptive trigeminal afferents, which reduces migraine pain.

Role of Serotonin in Migraine

• •Urinary and platelet 5-HT levels decrease during Migraine attacks
• •*Triptans are 5-HT1B/1D agonist used to treat migraine pain. Intravenous infusion of 5-HT aborts spontaneous headache

Question 183

Summary of headache treatments

• Tension headaches
• cluster
• migraine

***Localization, xters, 1st DOC, 2nd DOC, prophylaxis

Answer 183

Question 184

Prevalence of headaches types (migraine and tension, cluster)

Answer 184

• •Migraine & Tension
  
  • –Most likely to encounter in clinical setting
• •Cluster
  
  • –Prevalence much rarer (<1 million/yr.)
  • –Many cases not easily recognized, especially in ER setting

Question 185

Types of migraine headaches

• whats the difference in this 2 types
• what is aura

Answer 185

Migraine headaches

• Common; no aura
• Classic; aura

Aura; Sensory disturbance in brain prior to headache

• –Visual disturbance → scintillating scotoma
• –Sensory disturbance → Focal paresthesia
• –Motor disturbance → Weakness or paralysis
• –Auditory Disturbance → Excessively sensitive to noise or light

Question 186

Migraine

• Stages
• Characteristics of migraine attacks
• pathophysiology
  *

Answer 186

Migraine Stages

• •Prodome (1 – 2 days prior to attack) GI effects Mood changes
• •Aura (20- 60 min prior to attack)
• •Attack 4hrs – 3 days
• •Postdrome

Characteristics of migraine attack

• •POUND (Pulsating Headache lasting 4-72 hOurs that is Unilateral, Nauseating and Debilitating)

Pathophysiology

• •Genetically susceptible patients
• •Triggers: stress, certain foods, odors, change in sleep habits
• •Neurovascular headache: a disorder in which neural events results in further dilation of cranial blood vessels, which in turn, results in pain and further nerve activation
• •Migraine is not caused by a primary vascular event
• •Migraine is likely caused by brain-stem nuclei that normally mediate sensory input and exerts neural effects on cranial vessels

Question 187

Migraine drug therapy

• 2 goals
• Types of drugs
  
  • one will reduce migraine frequency
  • anothe used to treat migraine attacks

Answer 187

Migraine goals

• 1.Abortive: disrupt headache cycle
• 2.Preventative: Reduce the number of Migraine attacks with Migraine prophylactic drugs
  
  • 1.(*if attacks are occurring frequently)
  • 2.4 - 6 migraine days per month

Types of drugs

• •Prophylactic drugs
  
  • •Reduce migraine frequency

• Rescue/abortive drugs (Acute)

• •Drugs used to treat Migraine attacks once they occur.
• •These can be further divided into nonspecific pain-reducing drugs and migraine-specific drugs.

Question 188

how do beta blockers help with migraines

• 2 drugs
• contraindication
• effect of treatement; abortive or prophylactic?

Answer 188

Prophylaction; beta blockers

• •Propranolol and Atenolol taken orally (FDA approved)
• •May take three weeks to be effective
• •Relatively well tolerated and effective
• •Side effects are reduced energy, tiredness
• •Contraindicated in patients with asthma

Question 189

Prophylactic use of migraine

•*Side effects limit use and include significant antimuscarinic properties (dry mouth and constipation), weight gain and tiredness.

Answer 189

•Amitriptyline and Nortriptyline are taken orally

Question 190

Exaples of anticonvulsants used in migraine prophylactics

***which is contraindicated in pregnancy?

Answer 190

Anticonvulsants

• •Valproic acid, Topiramate, Gabapentin & Levetiracetam taken orally
• • Effective in some patients.
• •Mechanisms of anti-migraine activity not clear. Increases in gamma-aminobutyric acid (GABA) signaling could play a role.
• •Valproic Acid is contraindicated in pregnancy because of teratogenicity.
• •Side effects include drowsiness, anorexia, nausea, ataxia, alopecia, tremor as well as liver toxicity.
• • Used especially in migraine patients with epilepsy or anxiety disorders

Question 191

prophylactics of migraines

• also used in cluster headaches
  *

Answer 191

Calcium Channel blockers

• •Verapamil
  
  • –Also used for Cluster Headaches
• •Antihypertensive drug that reduces the incidence of migraine through mechanisms that are not clear
• •Side effects:
  
  • –negative inotropic cardiac effects and hypotension
  • –Constipation

Question 192

Chronic migraine prophylactics

• •blocks neuromuscular conduction by binding to receptor sites on motor nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. When injected intramuscularly in therapeutic doses, causes muscle paralysis

Answer 192

Prophylactic; BOTOX

• •Prophylaxis - Migraine (Chronic)
• •Multiple injections given in head/neck muscle areas

Question 193

Identify

• Group of drugs taken just before a migraine attack or as soon as possible after onset of migraine attack

Answer 193

Migraine Abortive drugs

• •Nonspecific agents that treat pain and are used to abort a migraine attack include: NSAIDS, Ibuprofen, naproxen, acetaminophen, ketorolac
• •Acetaminophen, Aspirin, ibuprofen, naproxen. Combinations of acetaminophen, aspirin and caffeine can also help
• •Ketorolac (IV or oral) use for a max of 5 days
  
  • because it can cause liver toxicity so you have to stop
• ​•Ibuprofen and acetaminophen can be used in pregnancy.
  
  • –*All NSAIDs should be avoided in the last trimester due to increased bleeding and premature closure of the ductus arteriosus.

Question 194

Identify migraine abortive agents

• •Used for moderate to severe migraine attacks and can be combined with an antiemetic to curve nausea
• •*They are rescue agents that are not used for prophylactic therapy

***Mechanism

**route of administration

**side effects

Answer 194

Ergot Alkaloids

•Ergotamine and Dihydroergotamine

• •The anti-migraine activity of ergot alkaloids are likely to be attributed their agonist effects at 5-HT1 receptors
• •Also have partial agonist and antagonist activity at serotonergic, dopaminergic and adrenergic receptors

Routes of administration:

• •Ergotamine sublingual (extensive first pass effect).
• •Dihydroergotamine: nasal spray, or injection (sc, im, or iv)

Side effects

• •Nausea and vomiting
  
  • •Problem given that nausea and vomiting are associated with migraine.
• •Significant generalized vasoconstriction can also be a significant problem
  
  • •(Myocardial infarction, Peripheral ischemia, Vasoconstriction, Coronary, Vasospasm).
• •Ergots cannot be used in pregnancy
  
  • •Pregnancy X drug, they may cause fetal stress and miscarriage.

Question 195

Identify Contraindications for Ergotamine and Dihydroergotamine

Answer 195

• •Pregnancy X (vasoconstriction, fetal stress and miscarriage)
• •Presence of peripheral vascular disease (tingling, peripheral vasoconstriction)
• •Presence of Ischemic Heart Disease Can induce angina, coronary vasospasms
• •Cannot be used in combination with Triptans (must have 24 hr delay)

Question 196

Identify migraine abortive agents

• •are the ‘supporting pillar of migraine therapy’
  
  • –Most effective in treating migraine
• Identify several types
• Side effects
• mechanism

Answer 196

Triptans

• •There are several Triptans including Sumatriptan, Rizatriptan, Zolmitriptan, Naratriptan and Frovatriptan
• •The Triptans are used to abort a migraine attack and they are not used for migraine prophylaxis

•The Triptans cause significantly less nausea and generalized vasoconstriction as compared to the Ergot alkaloids

•Mechanism: The Triptans have a more selective mechanism of action relative to the Ergots. They are selective 5-HT1 (specifically 5-HT1B/D) receptor agonists

Question 197

Migraine abortive agent - triptan type

• •Prototype triptan that has a short onset and duration of action.
• •Administered subcutaneously, orally or via nasal spray and provides relief within approximately 1 hr and has a half-life of 2 hrs.
  
  • –Onset as short as 20 minutes
• •Onset of action for SubQ <nasal>
  </nasal><li>•Limitations include low bioavailability, short plasma half-life</li>

</nasal>

Answer 197

Triptans; Sumatriptan

Question 198

Migrane abortive agent - triptan type

• •Given orally and have onset of action of approximately 1hr
• •Lipophilicity may result in greater distribution to the brain stem.
• •Greater bioavailability (70%) relative to sumatriptan (15%)
• •More effective than sumatriptan with lower instance of recurring headaches.
• •Longer duration of action (half life of 6 hrs) compared to sumatriptan
• •P450 metabolism and 50% of drug excreted in urine unchanged
• •Lower dose in renal dysfunction

Answer 198

Triptans: Naratriptan and Zolmitriptan

Question 199

Migrane abortive agents - triptan type

• •is the longest acting Triptan (half-life of more than 24 hrs).
• •Highest affinity for 5-HT1B receptor.
• •Slower onset of action than other triptans.
  
  • –True only when comparing oral formulation

Answer 199

Triptans; Frovatriptan

Question 200

Migrane abortive agents - triptan type

•Available as quick dissolving tablet (sublingual)

• –Faster onset than sumatriptan
• –Less nausea than sumatriptan
• –Half-life 2 hrs
• –Metabolism MAO

Answer 200

Triptans; Rizatriptan

Question 201

Migraine abortive agents; triptans

• Adverse effects
• contraindications
• drug interactions

Answer 201

•Adverse effects

• –*Headache recurrence
• –Include tingling, paresthesia, dizziness, flushing, neck pain and drowsiness

•Contraindications

• –Use of ergot alkaloid within 24 hrs
• –peripheral vascular disease
• –ischemic heart disease

•Drug interactions

• –Should avoid concurrent use with Serotonin Selective Reuptake Inhibitors as it could induce serotonin syndrome that manifests as restlessness, hallucinations, loss of coordination, diarrhea

Question 202

Non-pharmacologic migraine treatments

Answer 202

•Avoid Triggers

• –See Dr. Ferguson’s Lecture (S17)

•Live a boring life

• –Extremely regimented everyday. Same sleep cycle/time, routine meal times, same amount/time for caffeine, etc.

Question 203

Identify headache disorder

•Episodic severe unilateral stabbing headaches that tend to appear at the same time each (circadian rhythm)

• acute treatments
• prophylactic

Answer 203

Cluster headaches

•Acute Treatments for cluster headache attack include:

• –Oxygen (10 – 15 L/min, Dr. Ferguson listed 12 L/min)
• –Triptans (rapid onset triptans; e.g., sumatriptan)
• –Lidocaine (intranasal)

•Prophylactic

• –High dose prednisone
• –Calcium channel Blockers (Verapamil)
• •Mechanism not clear, see S26

Question 204

Headache disorder

•Headache pain is a squeezing sensation or pressure felt around the head that is not associated with nausea or vomiting.

• Abortive meds
• Prophylactic meds

Answer 204

Tension Headaches

•Abortive medications

• –Acetaminophen and NSAIDS

•Prophylactic medications

• •Tricyclic antidepressants (nortriptyline, amitriptyline)
  
  • –See S23 for potential mechanism
• •Antiepileptic (gabapentin)
  
  • –See S24 for potential mechanism

Question 205

Identify headache disorder

• •Pain due to increases in intracranial pressure and the disorder occurs most frequently in obese young women
• •Treatments include weight loss and removal of drugs that could be responsible for IIH (including: tetracycline containing drugs, oral contraceptives and hypervitaminosis)
• –Weight loss discussed by Dr. Ferguson

***drugs, mechanism, side effects

Answer 205

Idiopathic Intracranial Hypertension (IIH)

•Drug therapy includes the use of carbonic anhydrase inhibitors:

• _–*Acetazolamide and Topiramate_

•Mechanisms:

• –reduce CSF production (see next two slides)

•Side effects:

• –Nausea and fatigue (similar to motion sickness), tingling in the hands and feet and altered taste, distal paresthesia, concentration difficulties and weight loss

***can also use diuretics and corticosteroids

Question 206

Define the following

1. •“A pervasive and sustained emotion, feeling or tone that influences a person’s behavior and colors his or her perceptions of the world.”
2. •Alteration in mood with severity enough to result in significantly decreased functionality of an individual

***Common causes of this disorder??

Answer 206

1. Mood
2. Mood disorder

**Common medical causes; •Cerebrovascular disease, •Endocrinopathies, •Neurologic disorders •Viral illnesses •Carcinoid syndrome •Malignancy •Collagen vascular disease

•Metabolic disorders •Neurological disorders •EtOH •Antihypertensives •Steroids •Levodopa •Sedative-hypnotics •Anticonvulsants •Antipsychotics •Diuretics •Sulfonamides •Withdrawal

Question 207

Identify mood disorder

• •Must have 5 of the symptoms below for at least a 2-week period. Anhedonia or depressed mood must be present.
  
  • •Depressed mood
  • •Change in appetite or body weight (>5% in month)
  • •Feelings of worthlessness or guilt
  • •Insomnia or hypersomnia
  • •Diminished concentration
  • •Psychomotor agitation or retardation
  • •Fatigue or loss of energy
  • •Recurrent thoughts of death or suicide
• •Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
• •The symptoms are not attributed to a substance or physiological process
• •Not better explained by another psychiatric disorder (schizophrenia, delusional disorder, etc.)

Answer 207

Major Depressive Disorder

Question 208

Major Depressive Disorder

• Epidemiology
• Age groups and variation

Answer 208

Epidemiology

• • Lifetime prevalence of 17%
• •Onset at any age, with average age of 40
• •Twice as prevalent in women during reproductive years, equal after menopause
• •More common in rural areas vs. urban
• •Increased mortality for patients with medical comorbidities
• •Upwards of 15% will commit suicide

Age groups and variation

• •Child and adolescent population
  
  • •Somatic complaints, irritability, poor academic, truancy, substance abuse
• •Geriatric population
  
  • •Depression more common in older persons than the general population (25-50%)
  • •Under-diagnosed and under-treated
  • •Correlation with low socioeconomic status, loss of a spouse, physical illness, and social isolation
    
    • •Important to rule out biological causes
  • •Higher risk of suicide!

Question 209

Majr depressive disorder

• Etiology
  
  • physiologic vs genetic vs psychosocial factors vs immune disturbance

Answer 209

•Physiologic

• •CSF shows decreased 5HT and 5-HIAA in patients with clinical depression
• •Thyroid dysfunction, hypercortisolism
• •Sleep dysfunction
• •Alteration in neurophysiology and neuroanatomy

•Genetic

• •First degree relatives of this with MDD have a 2-4 times increased risk as compared to the general population
• •50-70% in monozygotic twins vs. 10-25% in dizygotic
• Psychosocial factors
• Immunologic disturbances

Question 210

Pnemonic to remember major depressive disorder

Answer 210

Major depressive disorder - SIGECAPS

• •S - Sleep
• •I - Decreased Interest
• •G - Guilt
• •E - Decreased Energy
• •C - Decreased Concentration
• •A - Change in Appetite
• •P - Psychomotor retardation
• •S - Suicidal ideation

Question 211

Major depressive disorder

• Course and prognosis

Answer 211

• •50% of patients with a first-time episode will have had significant symptoms prior to diagnosis
• •Episodes last 6-13 months untreated, 3 months treated
• •Recurring episodes become more frequent and severe
• •50-60% will respond to antidepressant medications
  
  • •Response significantly increased with inclusion of psychotherapy
• •5-10% may suffer a manic episode 6-10yrs after diagnosis with MDD – typically occurs around early thirties after 2-4 MDEs
• •Not a benign disorder – chronic disorder with frequent relapse!
• •After first hospitalization
  
  • •50% recover in the first year
  • •25% relapse within the first 6 months
  • •30-50% in the first 2 years
  • •50-75% in 5 years
• •Relapse significantly lower in those who continue pharmacologic prophylaxis

Question 212

Major depressive disorder

• Prognostic factors
  
  • positively affected by?
  • Negatively affected by?

Answer 212

•Prognosis positively affected by:

• •Mild severity of episodes
• •Absence of psychotic symptoms
• •Short hospital stay
• •Stable social support and functioning
• •Absence of personality disorder
• •Advanced age of onset

•Prognosis negatively affected by:

• •Male gender
• •Coexisting dysthymic disorder
• •Substance abuse
• •Comorbid anxiety disorders
• •History of more than one previous MDE

Question 213

Major depressive disorder

• Treatment

Answer 213

•Pharmacotherapy

• •Medications usually take 4-8 weeks to work
• •SSRIs, SNRIs, Alpha antagonists – safe and relatively well tolerated
  
  • •May have GI symptoms, headache, sexual symptoms (anorgasmia), rebound anxiety
• •TCAs – lethal in overdose
  
  • •Sedation, weight gain, orthostatic hypotension, anticholinergic effects, QTc prolongation
• •MAOIs – risk of hypertensive crisis when ingesting large quantities of tyramine
• •Psychotherapy: CBT, DBT, supportive, psychodynamic, family psychotherapy
• •ECT: induction of a seizure lasting ~1 min, use of general anesthesia, used in treatment recalcitrant patients
  
  • •64% to 87% of patients with severe MDD respond
  • •Up to 95% of patients with MDD with psychotic features
• •TMS and rTMS: pulsed input of magnetic energy to stimulate nerve cells of the brain
  
  • •Used in treatment recalcitrant patients
  • •Non-convulsive, can be performed on a outpatient basis
  • •Daily for 4-6 weeks
• •Vagal nerve stimulation
• •Deep brain stimulation

Question 214

Identify mood disorder (epidemiology and treatment)

• •Depressed mood for the majority of the time for 2 years
• •At least 2 of the following:
  
  • •Poor concentration or difficulty making decisions
  • •Hopelessness
  • •Poor appetite or overeating
  • •Insomnia or hypersomnia
  • •Low energy
  • •Low self esteem
• •Person has not been without symptoms for more than 2 months at a time
• •Can have a major depressive episode continuously for 2 years
• •There have never been manic or hypomanic episodes and criteria has never been met for cyclothymia

Answer 214

Dysthymic Disorder Aka Persistent depressive disorder

• •Affects 5-6% of all persons
• •Onset before 25 years of age in 50% of patients
• •30-50% of those in psychiatric clinics
• •2-3x more common in females
• •Frequently accompanies MDD, less likelihood of full remission between episodes.
  
  • •25% develop MDD, 20% develop a bipolar disorder, >25% have life long symptoms.
• •Patients can common experience “double depression”
• •Treatment very similar to MDD – SSRIs, SNRIs, TCAs, MAOIs Psychotherapy

Question 215

Identify mood disorder

• •Initial onset between late teens and early 20s
• •Prevalence 2.5 % in adolescents, overall about 4% of the population
• •Studies suggest an inability to maintain full time employment even with higher education; patients more likely to be divorced and unemployed

Answer 215

Bipolar disorders

• •Prevalence equal in men and women for Bipolar I, but Bipolar II more common in women

Question 216

Bipolar I disorder

• Epidemiology

Answer 216

• •Lifetime prevalence of 1-2%
• •Men and woman affected equally
• •No specific ethnic differences, however seen more frequently in high-income areas vs. low income
• •Onset usually before the age of 30 with the mean age of 18
• •Can be diagnosed in children as young as 8
• •75% of women and ~70% of men who suffer from bipolar I disorder will begin disease course with a major depressive episode
• •Most patients experience both depressive and manic episodes
• •5-20% experience only manic episodes
• •Manic episodes
  
  • •Rapid onset (hours to days to weeks)
  • •Untreated can last for roughly 3-6 months

Question 217

Bipolar I Criteria (DSM-5)

Answer 217

• •A distinct period of abnormally and persistently elevated, expansive, goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day
• •During that period, 3 or more of the following must be present (4 if the mood is only irritable)
  
  • •Inflated self-esteem or grandiosity
  • •Decreased need for sleep (eg. Feels rested after only 3 hours of sleep)
  • •More talkative or pressured speech
  • •Flight of ideas or subjective “racing thoughts”
  • •Distractibility
  • •Increase in Goal Directed activity (work or sexual) or psychomotor agitation (purposeless, non-goal directed activity)
  • •Increase in risk taking behavior (unrestrained spending, gambling, sexual indiscretion…)
• •Mood disturbance severe enough to cause marked impairement in social or occupational functioning or to necessitate hospitalization
• •The episode is not attributable to a substance or general medical condition

Question 218

Bipolar I disorder

• xters of mania

Answer 218

Mania

• •D – Distractibility
• •I – Irritability
• •G – Grandiosity
• •F – Flight of ideas
• •A – Activity (increased)
• •S – Sleep deficit
• •T – Talkativeness

Question 219

Bipolar I disorder

• Etiology

Answer 219

• Multifactorial: biological, environmental, psychosocial
• Genetic factors
• •1st degree relative of patients with bipolar disorder are 5-10x more likely to develop it
• •40-70% Concordance rates in monozygotic twins; 5-25% in dizygotic
• •Highest genetic link of all major psychiatric disorders
• •GWAS have found several genetic variants
  
  • •One locus CACNA1C regulates Ca2+ channels
  • •Lithium down regulates Ca2+ channels

Neurobiology

• •Evidence from fMRI and diffusion tensor imaging studies
• •Some patients may have disruptions in growth and pruning of white matter connections in areas of emotion regulation
• •Decreased connections between prefrontal networks and limbic structures (esp. amygdala)
• •Compared to healthy controls BP patients show reduced gray matter volume in hippocampus, lingual gyrus, amygdala, caudate, putamen, thalamus, insula, and dorsal prefrontal cortex

Question 220

Bipolar I disorder

• Course and prognosis
• prognosis positively affected by
• negatively affected by

Answer 220

Course and Prognosis

• •Untreated episodes can last for several months
• •90% of those who suffer their first attack have a second within 5 years
• •Course is usually chronic with relapses
  
  • •Episode interval stabilized to roughly 6-9 months after first 5 episodes
  • •May not necessarily include depression, pure mania in 5-20%
• •5-15% are “rapid cyclers”
• •60% will have at least one psychotic symptom during a mood episode in lifetime
  • •Psychosis can occur in manic, depressed, or mixed phases
  • •More common in manic episodes
  • •These do not occur in hypomanic episodes
  • •Hallucinations are typically auditory
  • •Delusions are most often grandiose, religious, and/or persecutory
• •Prognosis worse than MDD

Prognosis negatively affected

• •Poor occupational status
• •Alcohol dependence
• •Psychotic features
• •Depressive features
• •Inter-episode depressive features
• •Male gender

Prognsis positively afffected by

• •Short duration of manic episodes
• •Advanced age of onset
• •Few suicidal thoughts
• •Few co-existing psychiatric or medical problems

Question 221

Bipolar I disorder tx

Answer 221

• Monotherapy vs. combine therapy depends on severity on presentation and response to medications
• Mood stabilizers:
• •Lithium – first line agent, ~70% show partial reduction in mania, only medication used that reduces suicide risk
• •Valproic Acid – first line agent, especially useful in rapid cyclers
• •Carbamezapine, Oxcarbazepine
• •Lamotrigine – first approved for bipolar depression

•Atypical Antipsychotics:

• •Risperidone, Olanzapine, Quetiapine, Aripiprazole, Ziprasidone
• •Lurasidone – first approved for bipolar depression
• ECT
• Psychotherapy – focuses on recognition of symptoms in cycling, goal of improved function

Question 222

Bipolar II disorder

• onset compared to bipolar I
• criteria??

Answer 222

• •Earlier age of onset than bipolar I
• •Greater marital disruption than bipolar I
• •Greater risk of attempting and completing suicide than bipolar I or major depressive disorder
• •Up to 90% of life in a depressive episode

DSM -5 criteria

• •For diagnosis of bipolar II disorder – necessary to meet criteria for a hypomanic episode AND criteria for a past or current MDE
• •Hypomanic episode
  
  • •A distinct period of abnormally and persistently elevated, expansive, goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day
  • •Not severe enough to cause social or occupation impairment
• •No history of manic episode or psychotic features!

Question 223

Bipolar II

• Epidemiology
• Prognosis and treatment

Answer 223

Epidemiology

• •Overall prevalence is unclear
• •Some studies have shown bipolar II to be slightly more common in women
• •Onset before 30 years of age like Bipolar I
• •Frequently misdiagnosed as unipolar depression and thereby inadequately treated

Prognosis and treatment

• •Course tends to be chronic like Bipolar I
• •Requires long-term treatment
• •May have an overall better prognosis than bipolar I disorder
• •Treatment - Largely the same as bipolar I, however, May require less periods of hospitalization

Question 224

Bipolar I vs bipolar II differences

• Mania/hypomania
• Timing of episode
• Major depressive episode

Answer 224

•Bipolar I

• •2/3 depressed
• •1/3 manic or mixed

•Bipolar II

• •90% depressed

•NOTE: both types spend ~50% of their lives in mood episode

Question 225

Identify mood disorder based off criteria

• Numerous periods of hypomania (but not meeting criteria for a full hypomanic episode) alternating with periods of depressive symptoms (but not meeting criteria for a full MDE) for at least 2 years
• The patient has never been symptom free for >2 months
• No history of a true MDE, hypomanic or manic episode in lifetime

Answer 225

Cyclothymic disorder

Question 226

Cyclothymic disorder

• Epidemiology
• Course and prognosis
• Treatment

Answer 226

Epidemiology

• •3-5% of all psychiatric outpatients
• •Lifetime prevalence of 1%
• •Frequently co-exists with borderline personality disorder
• •3:2 female to male ratio
• •50-75% have an onset between 15 and 25 years of age
• 30% have a family

Course and prognosis

• •Most have major depression as a primary feature
• •Usually progresses to a chronic course
• •1/3 of all sufferers will eventually develop bipolar I/II disorder
• •Alcohol and other substance abuse common with cyclothymic disorder
  
  • •Present in 5-10%

Treatment

• •Mood stabilizers
• •Lithium, carbamezapine, valproate
  
  • •Dosages similar to treatment of bipolar I
• •Antidepressant therapy should be used with caution – patients susceptible to antidepressant-induced hypomanic or manic episodes
  
  • •Present in 40-50% of all patients with cyclothymic disorder
• •Psychosocial therapy
  
  • •Best directed towards patient awareness of disorder
  • •Prevention of full-blown manic attacks

Question 227

differential diagnosis of the mood disorders ; manic/hypomania symptoms vs depressive symptoms vs psychotic symptoms

• MDD
• dysthymic
• bipolar I
• bipolar II
• cyclothymic
• bipolar other specified
• schizoaffective disorder

Answer 227

Question 228

Depression treatment drug options (5 classes)

Answer 228

• TCA’s
  
  • Inhibition of presynaptic reuptake
• SSRI
  
  • Specific serotonin reuptake inhibitors
• SNRI
  
  • Combo reuptake inhibitors (of both 5-HT and NE)
  • less side effects than TCA?
• MAOI
  
  • Monoamine oxidase inhibitors
  • dont prescribe till nothing else is working
• Others

Question 229

SSRI

• use/importance
• xters
• therapeutic window - wide or narrow?

Answer 229

SSRI

• •First line drugs for depression and most anxiety disorders
• •All SSRIs share some common characteristics.
  
  • –Few autonomic side effects
  • –Increase alertness, usually taken in a.m.
  • –Seldom cause cardiac arrhythmias
  • –Low sedation
• Wide therapeutic window

Question 230

what class of drugs?

MoA?

Answer 230

SSRI

• •Block the presynaptic serotonin reuptake pump
  
  • –Increases the amount of serotonin available in the synapse
  • –Increases postsynaptic serotonin receptor occupancy
• •Inhibition is rapid after SSRI therapy is started, but antidepressant effects of SSRIs may not appear for three to six weeks after initiation of treatment
  
  • –May be due to a gradual “down regulation” or decrease in some postsynaptic serotonin receptor types in response to the increased amount of synaptic serotonin available

Question 231

SSRI

• Pharmacokinetics
• adverse effects

Answer 231

SSRI Pharmacokinetics

• •Well absorbed from gut
• •Hepatic cytochrome P450 metabolism
• •Protein binding ranges from 80-90%

Adverse effects

• •Relatively safe in overdose
• •All side effects associated with excess 5-HT
• •Cardiovascular effects are minimal
• •All side effects less in Citalopram / Escitalopram

Question 232

SSRI

• black box warning
• contraindication? - dont use with what drug? what happens if you do?

Answer 232

SSRI Black box warning

• Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders;Fluoxetine is FDA approved for the treatment of OCD in children ≥7 years of age and MDD in children ≥8 years of age.
• •SSRI’s should not be used concurrently with monoamine oxidase inhibitors
• •Could lead to “Serotonin Syndrome”
  
  • ​–Agitation –Restlessness –Confusion –Insomnia –Seizures –Severe hypertension –GI symptoms –Diaphoresis –Rigidity –Hyperthermia –Tachycardia
  • Serotonin syndrome can be caused by a combination of drugs.e.g. Linezolid (oxazolidinone antibiotic) has some MAO-I activity and can promote serotonin syndrome in patients on antidepressants
• Allow 1-3 months of washout after discontinuing a SSRI before starting an MAOI.​

Question 233

SSRI prototype

• •Currently the most widely prescribed antidepressant
  
  • –free of anticholinergic effects, orthostatic hypotension, weight gain
• •Inhibits cytochrome P450 isozymes
  
  • –Potentially large number of drug interactions
  • –Less so for Citalopram and Escitalopram
• •First drug approved to treat bulimia nervosa; also used in treatment of anorexia nervosa, panic disorders, phobic disorders, OCD, fibromyalgia, autism, premenstrual syndrome

Answer 233

Fluoxetine is prototype

Question 234

SNRI

• MoA
• USe
• Other
• Side efffects
• Cautions

Answer 234

MoA

• NE and 5-HT reuptake inhibited (SNRI)
  
  • ·Similar effect on neurotransmitters as TCAs
  • ·considerably less side effects due to less antagonist effects

Use

• Duloxetine (Cymbalta) Acute and maintenance treatment of major depressive disorder, treatment of generalized anxiety disorder; management of pain associated with diabetic neuropathy, management of fibromyalgia
• Venlafaxine (Effexor); Major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder
• Desvenlafaxine (Pristiq); Major depressive disorder, active metabolite of Venlafaxine (thus similar side effects) rarely used except as controlled release formulation

Question 235

TCAs

• lead to?
• MoA
• Use
• other

Answer 235

Question 236

TCA side effects

Answer 236

Question 237

TCA cautions

Answer 237

Question 238

MAO Inhibitors

• MoA
• Use
• Other

Answer 238

Question 239

MAOI side effects

Answer 239

Question 240

MAOI cautions

Answer 240

Question 241

Identify medication

• ·Treatment of major depressive disorder, including seasonal affective disorder, adjunct in smoking cessation
• ·Weak DA, NE, 5-HT reuptake inhibitor
• ·Few anti-cholinergic effects
• ·Few cardiovascular effects
• ·Few sexual dysfunction side effects
• ·May cause agitation, insomnia, nausea, weight loss, seizures
  
  • oContraindicated in epilepsy/seizures, anorexia nervosa

Answer 241

Bupropion (Wellbutrin, Zyban)

Question 242

Herbal drug people use for depression

• can cause serotonin syndrome when used with SSRI and SNRI

Answer 242

Hypericum (St. John’s Wort)

• •Source: Hypericum perforatum
• •Inhibitor of MAO
• •Inhibitor of 5-HT reuptake
• •Improve mood, sleep;
• •decrease anxiety
• •If taken with SSRI:
  
  • –hypertensive crises
• •Studies in US do not support its use in treatment of major depression

Question 243

• •Unknown mechanism via serotonin
• •Considerable sedation (blocks H1)
• •Orthostatic hypotension mediated via a1 blockade
• •No anticholinergic side effects
• •Minimal effects on cardiac conduction
• •Priapism – can lead to permanent impotence (rare)
• •Persistent clitoral erection in women
• •Higher therapeutic index than TCA’s

Answer 243

Trazodone (Desyrel)

Question 244

• •Tetracyclic antidepressant
• •Stimulates NE and 5HT release by blockade of a-2 and 5HT-1 receptors respectively (autoreceptors)
• •Increased appetite and weight gain early in therapy
• •Sedating
• •Few sexual side effects

Answer 244

Mirtazapine (Remeron)

Question 245

Medication considered based on the special considerations

• High suicide risk
• concurent depressiona n panic attacksOCD
• depression associated with chronic pain
• weigth gain on other anti-depressants
• sensitivity to anticholinergic side effects
• sexual dysfunction
• eating disorder and depression

Answer 245

Question 246

Mania - primary treatment

MoA

Use

Other

Answer 246

•Lithium – “Mood Stabilizer”

• –Reduces both manic and depressive symptoms
• –Greater activity against manic symptoms

Question 247

Mania tx - lithium

• Side effects
• Cautions

Answer 247

Question 248

Identify other drugs used to treat mania (3)

MoA

Answer 248

Anticonvulsants

• •Carbamazepine (Tegretol); block Na+ channels
  
  • Fewer adverse effects as compared to lithium
  • Monitor serum Na+ and CBC’s, hepatic function
• •Valproate (Depakote); Block Na+ channels, increase GABA
  
  • Very effective in “rapidly cycling” patients
  • Contraindicated in hepatic disease
  • Monitor platelets/hepatic function
• •Lamotrigine (Lamictal); block Na+ channels, inhibit glutamate release
  
  • Titrate slowly due to risk of Steven-Johnson’s syndrome

Question 249

General points about anxiety vs anxiety disorders

Fear and anxiety

Answer 249

Anxiety

• •Anxiety is essentially a universal experience
• •Anxiety is not intrinsically abnormal or pathological
• •Anxiety has adaptive value and serves useful functions
• •Anxiety is a complex mixture of physiological and psychological processes
  
  • •Expressed in individually variable ways
  • •Differences expressed in language

Anxiety Disorders

• •Anxiety, like any human function or process, can be disordered
  
  • •Excessive or disproportionate
  • •Produced by otherwise innocuous stimuli
  • •Arising spontaneously and inappropriately
• •Can be a primary disorder, or can arise secondary to many medical conditions
  
  • •As well as other psychiatric conditions

Fear and anxiety

• •Fear is thought of as a response to a known, identifiable, external threat
• •Anxiety is a response to a vague, internal, non-present threat
  
  • •More anticipatory in nature
• •The difference is not as important as it once was, when psychodynamic theories of neurosis dominated conceptions of anxiety

Question 250

• Endogenous vs exogenous anxiety
• Manifestations of anxiety

Answer 250

• •Endogeneous anxiety occurs spontaneously, without identifiable precipitant
  
  • •Assumed to reflect internal, primarily biological states
• •Exogeneous anxiety is associated with environmental stress or threat

Manifestations of anxiety

• •Varies greatly in its manifestations from one person to another.
• •May or may not be obvious to others
• •Can present with various combinations of physical or psychological symptoms
• •Often presented in primary care in terms of physical and somatic complaints

Question 251

Anxiety

• Psychological symptoms
• Somatic complaints
• Physical signs

Answer 251

Psychological symptoms

• •Feelings of fear, worry
• •Apprehensiveness
• •Sense of impending doom
• •Difficulty concentrating
• •Hypervigilance
• •Irritability
• •Avoidance
• •Derealization

Somatic complaints

• •Insomnia and fatigue
• •Headache
• •Dizziness and lightheadedness
• •Shortness of breath
• •Palpitations and chest pain
• •Upset stomach and diarrhea
• •Lump in the throat
• •Motor tension, restlessness
• •Paresthesias
• •Dry mouth
• •Frequent urination

Physical Signs

• •Diaphoresis
• •Cool, clammy skin
• •Tachycardia
• •Flushing and pallor
• •Hyperreflexia
• •Trembling, easy startling

Question 252

Anxiety disorders (identify all)

Answer 252

Anxiety disorders

• •Panic disorder
• •Agoraphobia
• •Obsessive-compulsive disorder
• •Generalized anxiety disorder
• •Post traumatic stress disorder (PTSD)
• •Acute stress disorder
• •Social and simple phobia
• •Anxiety due to a general medical condition
• •Substance induced anxiety disorder

Question 253

Panic disorder

• Essential feature
• symptoms

Answer 253

Panic disorder

•Essential feature is panic attacks

• •Discrete, intense, and unanticipated episodes of marked physical and emotional symptoms
• •Typically last 20-30 minutes

•Common symptoms of panic attacks

• •Trembling
• •Shortness of breath
• •Feeling of impending doom; fear reoccurence of future attack
• •Chest pain
• •Sweating
• •Nausea

Question 254

Panic disorder

• occurence of panic attack
• commonly associated with?
• age of onset

Answer 254

Panic disorder

• •About 3 in 4 patients describe initial attack as entirely spontaneous
• •Not surprisingly, often presents in ER as possible heart attack
• •Often involves fear that one is going to die, something terrible is going to happen, or that one will go crazy or lose control in some fashion.
• •Commonly associated with agoraphobia.
• •Nine of ten patients have at least one comorbid disorder
  
  • •Most frequent: depression (40-80%), substance abuse, other anxiety disorders
• •Age of onset typically between late teens and early 30s; unusual after age 40
• •Onset often occurs within 6 months of a significant stressful life event
• •4-8x higher risk of panic disorder among first degree relatives of panic disorder patients; 2-3x more common in women

Question 255

• •Fear of places or situations where escape might be difficult or help might not be available in the event of a panic attack
• •Discomfort with being alone, in public places, or with traveling.
  
  • •Will either avoid these situations or endure them with marked distress.
  • •May require the presence of a companion to tolerate.
• •Patient may be restricted to home, or even to a single room.

Answer 255

Agoraphobia

Question 256

Obsessive-compulside disorder

• describe both components
• age of onset
• treatment (2)

Answer 256

• •Obsessions are recurrent and intrusive ideas, thoughts, images, or impulses,experienced as senseless or repugnant
• •Compulsions are actions the person feels compelled to take, and usually feels unable to resist
• •Compulsions are repetitive stereotyped actions associated in an unrealistic way with an obsessional idea
  
  • •Example: obsessions about contamination and compulsive hand-washing
  • •The action in some way discharges tension
  • •Patients can resist compulsive acts for a time, usually experiencing escalating tension and anxiety
• •Both obsessions and compulsions are experienced as unwanted and irresistible
• •The obsessions and compulsions interfere with functioning, by virtue of the distress they cause, the time they take, interference with other activities, etc.
  
  • •Two of three patients are depressed
• •Onset is typically in the late teens or early twenties
  
  • •Mean age of onset is 20
  • •Fewer than 15% have onset after age 35
• •Commonly treated with medication (antidepressants) and behavioral therapies

Question 257

Identify anxiety disorder

• •Excessive and continuous anxiety about multiple phenomena (e.g., work or school performance), more days than not, for more than 6 months
• •Typical symptoms involve restlessness, poor concentration, irritability, muscle tension, and sleep disturbance
• •Patients often report being anxious for as long as they can remember
• •Common comorbid disorders include social and specific phobias, panic disorder, and depression

Answer 257

Generalized anxiety Disorder

Question 258

Describe PTSD anxiety disorder

• associated with?
• onset
• symptom flunctuation

Answer 258

•Associated with traumatic events outside the range of normal experience

• •Confrontation with threat of death, serious injury, or other threat to physical integrity
• •Experience of intense fear, helplessness, horror
• Onset may be delayed for long periods after the precipitating event
• Symptoms tend to fluctuate over time
• •Only about 30% recover completely
• •Vulnerability to subsequent stressors

Question 259

PTSD

• Major symptoms
• Typical features

Answer 259

Major symptoms of PTSD

• •Persistent re-experiencing of the stressor through nightmares or flashbacks
• •Avoidance of related stimuli
  
  • •intense response to stimuli that are reminders of the precipitating event
• •Blunted response to the present environment
  
  • •Diminished interest in activities
  • •Feelings of detachment or estrangement
  • •Emotional constriction

Typical features of PTSD

• •Persistent symptoms of increased arousal
  
  • •exaggerated startle response
  • •insomnia
  • •hypervigilance
  • •irritability
  • •poor concentration
• •Survivor guilt

Question 260

Identify anxiety disorder

• •This is the diagnosis we give immediately after traumatic event if patient is experiencing symptoms:
  
  • •3 days-1 month
• •If duration goes beyond this time period we need to consider PTSD dx

Answer 260

Acute Stress disorder

Question 261

Identify anxiety disorder

•Primary feature: persistent and irrational fear and avoidance of benign stimuli

**Diff types

Answer 261

Phobias

Social Phobia

• •Specifically involves fear of being humiliated or embarrassed in public situations.
  
  • •Common situations include speaking or eating in public, meeting strangers or attending parties
  • •Fears of looking foolish or being laughed at or criticized
  • •fearfulness can engender a kind of self-fulfilling prophecy
• •Common comorbid depression, isolation

Simple phobias

• •More focal and circumscribed
• •Types
  
  • •Animals
  • •Natural Environment
  • •Situations
  • •Blood-injection-injury
• •Blood-injection-injury
  
  • •Runs in families
  • •Bradycardia and hypotension follow initial tachycardia

Question 262

Treatment of anxiety disorder - phobias?

Answer 262

Integrated approach to treatment

• •Education
• •Support
• •Correction of maladaptive thinking
• •Skill development
• •Behavioral techniques for modification of arousal
• •Medication

Question 263

Biological basis of anxiety

• Fear vs Worry

Answer 263

Question 264

treatment options of fear/anxiety

Answer 264

Question 265

Identify anxiolytics

• Now 1st line for most anxiety disorders
• commonly used in depression (will cover mechanism in more depth in mood disorder lecture)

***Uses, other, side effects

Answer 265

SSRIs (Fluoxetine / Sertraline)

SSRI– commonly used in depression (will cover mechanism in more depth in mood disorder lecture)

• •Amygdala, prefrontal cortex, striatum and thalamus are regulated by serotonergic projections from raphe nuclei.
• •Increased serotonin is believed to lead to a downstream adaptive change in receptors rather than acute actions. These changes normalize activation of amygdala and CSTC loop

Question 266

Identify anxiolytics

• commonly used in depression (will cover mechanism in more depth in mood disorder lecture)
• •Similar to SSRI
  
  • •Amygdala, prefrontal cortex, striatum and thalamus are regulated by NE
  • •Increased serotonin is believed to lead to a down regulation and desensitization of post synaptic NE receptors. These changes normalize activation of amygdala and CSTC loop

Answer 266

SNRIs (Venflaxine)

Use and side effects similar to SSRI

Question 267

• •Paradoxical increase in anxiety, restlessness, insomnia in first few weeks.
• •Resolves by 2-3 weeks
• •Major concern for compliance
• •Can co-prescribe a short term low dose benzodiazepine to combat this for the first month

Answer 267

Jitters

Question 268

Tricyclic antidepressant (TCA)

• ·MoA Similar actions to SNRI though a lot more side effects
• Use; 2nd line GAD and Panic disorders if SNRI / SSRI are ineffective
• Other; Very slow onset of action (2-4 wks)
• Side effects; Jitters, frequently increased anxiety initially

See mood disorder lecture for others

Answer 268

Imipramine

Question 269

•FDA Labeled Indications

• –Anxiety Disorders
• –Panic Disorders
• –Skeletal Muscle Spasms
• –Preanesthetic
• –Status Epilepticus
• –Alcohol Withdrawal
• –Insomnia

Not all approved for the above indications

Answer 269

Benzodiazepines (BDZs)

Question 271

Benzo

• CNS effects (table)
• Resp effects
• Cardio effects

Answer 271

Respiratory Effects

• Anxiolytic dose; None
• Hypnotic dose; None
• Anesthetic dose; Slight decrease

Cardiovascular Effects

• None, except at really high doses

Question 272

PK considerations

**for benzo

Answer 272

• •Important in choice of BDZ.
  
  • –Rate of onset, duration of action, & accumulation with continued dosing vary considerably among different agents.
• •Highly lipid soluble
  
  • –lipophilicity varies 50 fold among BDZ’s
• •Completely absorbed from GI tract.
  
  • –Antacids prevent BDZ absorption.
• •Cross placenta and are secreted into breast milk.

Question 273

benzo metabolism

**Phase I to III

Answer 273

• Hepatic metabolism
• BDZ’s do not induce or inhibit cytochrome P450 isozymes.
• t1/2 of active metabolite may be >> parent
• Long t1/2’s can cause cumulative effects with multiple dosing
• Phase I: Initial oxidative step, results in N-desalkylated active metabolites. Quickest reaction, inhibited by cimetidine.
• Phase II: Hydroxylation at R3 to yield another active metabolite. Slowest reaction
• Phase III: Glucuronidation followed by urinary excretion

Question 274

Benzo side effects

Answer 274

• •Drowsiness and confusion are the most common
• •Motor incoordination at higher doses
• •Cognitive impairment
• •Anterograde amnesia (forget experiences 1-3 hr after dose) (useful for anesthesia)
• • Visual disturbances (blurred vision)
• •Digestive disturbances (nausea, vomiting, constipation)
• •Dry mouth, Bitter taste
• •Vertigo
• •Rebound …dose tapering required for short half-life drugs (very common)
• •Interaction with alcohol and other depressants can lead to respiratory depression and death

Question 275

Benzo

• Precautions and contraindications

Answer 275

• •Elderly: doses should be 1/3 to ½ of those typically prescribed
  
  • –BDZ’s with shorter t1/2 more appropriate (Lorazepam, Oxazepam)
• •Liver Disease: BDZ effects potentiated because of ¯ in metabolism
  
  • –BDZ’s with no active metabolites are more appropriate
• •COPD: Effects of Midazolam on respiration are exaggerated in patients with asthma, chronic bronchitis and emphysema
• •Obstructive Sleep Apnea: Hypnotic doses of BDZ’s may aggravate sleep related breathing disorders.
  
  • –Probably related to the muscle relaxant effects of BDZs.
• •Alcohol or other Sedative-Hypnotics: Effects of BDZs are additive with these and can cause overdose with severe respiratory depression
• •Pregnancy and Nursing:
  
  • –BDZ’s cross placenta and enter into breast milk
  • –Chlordiazepoxide and diazepam have been reported to increase the chance of birth defects when used during the first 3 months of pregnancy.

Question 276

benzo

• tolerance and dependence
• Withdrawal

Answer 276

Tolerance and Dependence

Tolerance:

• Hypnotic
• Muscle relaxant
• Anticonvulsant

No tolerance to anxiolytic effects

Physical Dependence can occur with extended therapy

Withdrawal

• •Symptoms are similar to those for which BDZ was originally prescribed
• •Severity depends on the drug, dose and t1/2
• •Drugs with shorter t1/2 have more severe symptoms
• •Symptoms (rebound insomnia and anxiety) occur more frequently with short acting BDZ’s

Question 277

Symptoms of BDZ withdrawal

Answer 277

Typical withdrawal regimen

• •Patient was taking 40 mg/day diazepam for muscle relaxant effects following shoulder dislocation
• Gradual withdrawal is indicated for people on BDZs for prolonged periods (reduce little every week) ??

Question 278

• •BDZ antagonist
  
  • –Used as antidote for BDZ overdose
• •I.V. administration
• •May precipitate withdrawal or may cause seizure activity if BDZ is used as an anticonvulsant
• •Side effects: dizziness, nausea, vomiting, agitation

Answer 278

Flumazenil (Romazicon)

Question 279

Identify Non-benzodiazepine

Answer 279

Buspirone (Buspar): Non-BDZ

Question 280

Identify med

Answer 280

Pregabalin (Lyrica)

Question 281

identify med

Answer 281

Meprobamate (Miltown)

Question 282

• •Nonselective beta-adrenergic blocker
• •Useful in reducing somatic symptoms of anxiety (palpitations, sweating, tachycardia)
• •Should be reserved for managing short term situational anxiety “stage / exam fright”

Answer 282

Propanolol (Inderal)

Question 283

1. •Antihistamine (H1 receptor antagonist) (Santanam lecture in spring)

• Causes sedation
• Useful for GAD especially if associated with insomnia

2. •5HT2 receptor antagonist

• single agent or augment SSRI in GAD, especially when associated with insomnia
• weight gain and sedation main side effects

Answer 283

1. Hydroxyzine (Atarax):
2. Mirtazapine (Remeron)

Question 284

Anxiety meds

• GAD; 1st line, 2nd line, other, notes
• Panicl 1st line, 2nd line, other, notes

Answer 284

Question 286

Anxiety pharma

• Social, generalized; 1st line, 2nd line, other notes
• Social non-generalized
• PTSD

Answer 286

Question 287

• •A sudden, recurrent and transient disturbance of mental function or movements of the body that result from excessive discharging of groups of brain cells.
• •An epileptic seizure occurs when there is an imbalance between inhibitory and excitatory neurotransmission.
• •Disease of the cerebral cortex
• •Seizures correlate with abnormal EEG activity
• •Epilepsy affects 0.3 to 0.6% (3-6/1000) of the population

**Classes of epilepsy

Answer 287

Epilepsy

•Idiopathic Epilepsy:

• –No specific anatomic cause for seizure
• –May be inherited

•Symptomatic Epilepsy:

• –Drug use
• –Hypoglycemia
• –Brain Injury
• –Tumors

Question 288

classes of seizures

Answer 288

•Generalized

• –Convulsive
• –Absence
• –Myoclonic
• –Atonic
• –Febrile
• –Status epilepticus

•

•Partial

• –Simple
• –Complex

Question 289

Define status epilepticus

**what leads to brain damage

Answer 289

• •Generalized tonic-clonic seizures so frequent that another seizure occurs before the patient returns to normal consciousness from the postictal state
• •Medical emergency with a high mortality rate
• HYPOXIA lead to BRAIN DAMAGE

Question 290

Identify treatment of status epilepticus

Answer 290

• I.V. BDZ (lorazepam / diazepam /midazolam)
• Followed by I.V. Phenytoin / Fosphenytoin
  
  • •This is given even if seizure has stopped indication is to prevent seizure from reoccurring
• If refractory
  
  • •More phenytoin and more BDZ
• Then if still refractory
  
  • •Phenobarbital / Pentobarbital / Midazolam / Propofol
    
    • –No consensus on best option
• •May need to supply respiratory support

Question 291

History of a seizure

• 3 parts

Answer 291

•AURA:

• –Warning: sensation/mood may help to identify location of seizure
• –Present in:
  
  • •Convulsive / Partial
• –Absent in:
  
  • •Absence, Myoclonic

•ICTUS:

• –The seizure itself

•POSTICTUS:

• –The period after the seizure
  
  • •Absent in absence

Question 292

Therapeutic goals of seizure

Answer 292

• •It is estimated that 85% of patients with uncomplicated tonic-clonic seizures can achieve complete seizure control.

•Therapeutic Goals:

• –Cessation of all seizures
• –No alteration in (important because may be on therapy for the res of their life)
  
  • •Intellect or alertness
  • •Physical abilities
  • •Reproductive ability due to therapy

Question 293

Principles of seizure therapy

Answer 293

• •Treat underlying causes of the seizures:
  
  • –Work at the source to prevent the pathological firing of the neurons of the seizure foci.
  • –Prevent the spread of excitation from the source to surrounding normal tissue.
• •Proper drug selection for the individual patient:
• –Factors influencing anticonvulsant selection: (important issues for compliance)
  
  • •Drug’s potential effectiveness
  • •Drug’s potential for causing problems
  • •Convenience
  • •Cost
• •Avoid unnecessary drug combinations

Question 294

Why are serum levels of drug vital?

Answer 294

•Utilize serum levels of anticonvulsants

• –They can help the physician avoid producing unpleasant and unexpected consequences of drug toxicity.
• –They can help insure adequate dosages in patients with persisting seizures
• –They can help increase patient compliance

Question 295

drug used in epilepsy

Mechanism of Action:

•Inhibition of seizure spread

• –Blockade of Ca2+ influx
• –Enhancement of Cl- mediated inhibitory post synaptic potentials (IPSPs)

•Suppression of epileptic focus

• –Enhanced affinity for inactivated Na+ channels at more depolarized membrane potentials
• –Enhancement of the inhibitory surround via stimulation of Cl- mediated IPSPs

Uses:

• •Used in all types of epilepsy except absence epilepsy and atonic seizures
• •Highly effective in the treatment of generalized tonic-clonic seizures, partial and status epilepticus

Answer 295

Phenytoin (Dilantin)**

Question 296

Phenytoin (Dilantin)

• Pharmacokinetics/chemistry
• Side effects
• Drug interactions

Answer 296

Pharmacokinetics/chemistry

• •Oral administration (I.V. for Status Epilepticus)
• •Highly protein bound in plasma (~90%)
• •Phenytoin metabolism is rate limited and the enzyme system involved is saturable within the therapeutic range of plasma concentrations

Side effects

• Gingivial Hyperplasia; Would not be popular side effects for teen age girls. Would hurt compliance
  
  • Common in children ~20%
  • Note can also occur with:• Cyclosporine • Nifedepine, diltazem, verapamil
• Hirsuitism

Drug interactions

• •Metabolism of phenytoin can be enhanced (Carbamazepine)/decreased via microsomal enzymes.
• •Phenytoin induces CYP3A4
  
  • –May reduce levels of Digoxin, steroids, vitamin K.
  • –Patients should be treated with vitamin K supplements to prevent hypoprothrombinemia and bleeding.

Question 297

• •Prodrug of Phenytoin
• •Highly water soluble
• •Can be administered IM
• •Side effect profile improved compared to parenteral phenytoin

Answer 297

Fosphenytoin (Cerebryx)

Question 298

Seizur emed

***Trigerminal neuralgia

**Unique feature of metabolism

*8Side effects

Answer 298

Carbamazepine (Tegretol)**

•Almost completely metabolized to the 10,11-epoxide, which is pharmacologically active

•Autoinduction of metabolism

• –CYP 1A2 / 2C / 3A
• –Rate of metabolism increases in first 4-6 weeks
  
  • •Naïve patient t 1/2 = 30 hr
  • •After a few weeks t½ = 10-20 hr

•Process stabilizes after about a month

Side effects

• •G.I. upset
• •Vertigo, diplopia, blurred vision, ataxia
• •Hematological disorders – aplastic anemia (rare), thrombocytopenia, hyponatremia, agranulocytosis, leucopenia
• •Hepatotoxicity
  
  • –Routine liver panels

Question 299

Seizure med - NO ANTIDOTE so rarely used

Mechanism of action:

• •Enhances the GABA-mediated Cl- flux that causes membrane hyperpolarization.
• •Increases threshold for firing and inhibits spread of activity from focus

Uses:

• •Generalized tonic-clonic epilepsy
• •Partial seizures
• •Prophylaxis or treatment of febrile convulsions
• •Now typically only used in neonates

Answer 299

Phenobarbital (Luminol)*

Question 300

Seizure med

Mechanism of Action:

• •Interacts with GABAergic neurons-potentiating inhibitory effects
• •Induces blockage of both Na+ and K+ channels.
• •Inhibits T-type calcium channels
• •Hisone deacetylase inhibitor (epigenetics)

Effects on GABA + Blockade of Na+ channels gives a BROAD spectrum of action

****USes

Answer 300

Valproic acid / Divalproex (Depakote)**

Uses:

• •Absence seizures refractory to ethosuximide
  
  • –Often used as first choice
• •Myoclonic seizures
• •Reflex epilepsies (especially photosensitive)
• •Generalized tonic clonic seizures-used as combination therapy
• •Complex partial seizures-used as combination therapy
• •Bipolar disorder

Question 301

Valproic acid

• feature
• side effects
  *

Answer 301

features

• •Low molecular weight fatty acid
• •Well absorbed from gut and is metabolized to active metabolites and inactive conjugates before excretion
• •Multiple formulations including oral, extended release, “sprinkles”

Side effects:

• •Alopecia (5%)
• •Transient GI effects (16%); nausea and vomiting
• •CNS-mild behavioral effects, ataxia, tremor, not a CNS depressant
• •Hepatic failure (rare); elevated liver enzymes (dose dependent)
  
  • –Patients under 2 years of age are at the greatest risk of liver failure.
• •Possible decrease in platelet and clotting function
  
  • –avoid in patients with bleeding disorders

Question 302

Valproic acid

• Drug interactions
• pregnancy

Answer 302

Question 303

Seizure med

only indication for absence seizures

Answer 303

Ethosuximide (Zarontin)*

• •Blocks t-type Ca2+ channels of thalamic interneurons that appears to interrupt the neuronal hypersynchrony of thalmocortical pathways seen in absence seizures

Question 304

identify

***Prototype of benzo

other benzo drugs

• •Inhibits Spread: Myoclonic, Atonic
• •Metabolized to Diazepam; adjunctive treatment
• •IV agent status epilepticus (2)

Answer 304

Lorazepam (Ativan)**

• Prototype of the benzodiazepines
  
  • •Other benzodiazepine drugs commonly used:
• Clonazepam (Klonopin)*
  
  • •Inhibits Spread: Myoclonic, Atonic
• Clorazepate (Tranxene)
  
  • •Metabolized to Diazepam; adjunctive treatment
• Clonazepam and diazepam
  
  • •IV agent status epilepticus

Question 305

Seizure med

• used for diabetic neuropathy

Answer 305

Gabapentin (Neurontin)

Mechanisms of Action

• •Blocks voltage dependent Ca2+ channels that have α2σ1 subunits
• • Chemically related to GABA, but does not work through the GABA receptor
• •Increases release of GABA from central neurons
• •No direct effect on GABA receptors

Uses

• •Partial seizures – adjunctive to other anticonvulsants
• •Adjunctive therapy for partial seizures-Pediatric patients (3-12 y.o.)
• •Postherpetic neuralgia
• •Diabetic Neuropathy
• •Migraine

Side effects

• •CNS: ataxia, dizziness, drowsiness, nystagmus, tremor
• •Weight gain
• •Dyspepsia, constipation

Drug interactions

• •Does not alter serum concentration of other anticonvulsants
• •Bioavailability is reduced with concurrent use of antacids

Question 306

seizure med

Mechanisms of Action

• •Inhibits voltage-sensitive Na+ channels of presynaptic membrane, similar to phenytoin and carbamazepine
• •Inhibits glutamate and aspartate release
• •May inhibit Ca2+ channels

Uses

• •Adjunct in treatment of partial seizures
• •Generalized tonic-clonic
• •Atonic
• •Absence seizures
• •Add-on therapy for Lennox-Gastaut syndrome

Answer 306

Lamotrigine (Lamictal)**

Question 308

seizure med

Answer 308

Topiramate (Topamax)*

Mechanisms of action

• •Inhibits voltage-dependent sodium channels of presynaptic membrane
• •Potentiates the action of GABA by binding to a novel modulatory site on the GABAA receptor
• •Blocks excitatory amino acid receptors (kainate/AMPA)

Uses

• •Adjunctive therapy in partial seizures
• •Adjunctive therapy in primary generalized seizures
• •Lennox-Gastaut syndrome in patients > 2 years of age
• •Good monotherapy in patients with refractory Partial and Tonic / Clonic generalized
• •Migraine

Question 309

seizure med

Mechanism of Action

•Unknown, No appreciable metabolism

•

Uses

• •Adjunct therapy for partial seizures
• •Becoming more popular in other seizures
• •Useful in patients with medical illnesses involving the liver and on hepatically metabolized drugs with potentially serious side effects (e.g., coumarin, cyclophosphamide)
• •Migraine
• •

Side Effects

• •CNS: somnolence, dizziness, headache

Answer 309

Levetiracetam (Keppra)**

Question 310

Seizure med

Mechanism of Action

• •Modulates calcium and glutamate flux
• •Structural similarity to gabapentin

Uses

• •Adjunctive treatment of partial onset seizures
• •Neuropathic pain
• •Diabetic peripheral neuropathy

Answer 310

Pregabalin (Lyrica)

Question 311

Antiepileptic med and seizure type

• broad spectrum vs
• narrow spectrum

Answer 311

Question 312

Anticonvulsants and women

Pregnancy

Answer 312

Oral Contraceptives

• •The effective levels of contraceptives are altered by anticonvulsants
  
  • –Hepatic metabolism
  • –Plasma protein binding
• •Consequences
  
  • –Unplanned pregnancy
  • –Increased birth defects

Pragnancy

Planned pregnancy

• •increase folic acid prior to conception
• •Switch from barbiturates and phenytoin and stabilize on new drug
• •Possible Teratogenic Effect of Phenytoin Administration:
  
  • –“Fetal Hydantoin Syndrome”: Characteristics: cleft lip, cleft palate, congenital heart disease, slowed growth, mental deficiency
• •25-30% of women with epilepsy will have increased seizures during pregnancy DESPITE continued use of medication.
  
  • –Changes in metabolism: increased drug clearance, increased maternal volume

Question 313

cautions with taking anticonvulsants in preganancy

Answer 313

• •More frequent lab values
• •Optimal therapy: Monotherapy at lowest possible dose to control seizures
• •Do not completely remove anticonvulsant
• •Do not switch anticonvulsant if pregnancy was unplanned
• •Lack of Anticonvulsant Therapy During Pregnancy in Epileptic Patients:
  
  • –Frequency of Seizures Increase
  • –Anoxic conditions can increase the incidence of birth defects (7% compared to 2-3% in general population)
• •Malformations increase with combination therapy
• •Lower doses may be beneficial in 1st trimester
• •Therapeutic drug monitoring:
  
  • –To detect alterations in metabolism—especially important during last trimester when increased drug clearance may require dosage adjustment

Question 314

Non pharm epilepsy therapy

Answer 314

• Vagal Nerve Stimulation
  
  • Implant of pulse generator
    
    • •Mechanism unknown
  • Uses
    
    • •Partial onset seizures
    • •Refractory patients for multiple drugs
    • •Depression
  • •Very expensive
• Surgery
  
  • •Removal of epileptic foci
  • •Only as a last resort