Exam 2 Study Guide Flashcards
What are the symptoms for SSRI discontinuation syndrome
(FINISH)
F= Flu like symptoms (aches, pains, chills)
I= Insomnia
N= Nausea
I= Imbalance
S= Sensory disturbance (tremors, sensation of electrical shock)
H= Hyperarousal
What is the first line agent for anxiety disorders? e.g. Social anxiety disorder (SAD)
***First line treatment for chronic anxiety, GAD, panic disorder = SSRI
Treat comorbid depression
Lack abuse risk
Low side effect rate
A patient presents with depressive symptoms alongside pain complaints = what medications
will you consider?
SNRI’s and TCA’s
Highest anticholinergic effect between TCA/BZO/SSRI?
TCA
Venlafaxine (Effexor) notable SEs
can be very activating (patients can be restless)
dose-dependent elevated BP
(NOT anticholinergic)
Tx akathisia
β-adrenergic receptor antagonists (beta-blockers) are generally most effective in thetreatment of Akathisia
(can use BZO but not first line)
Which Serotonergic agent can cause priapism?
Trazodone or escitalopram
Signs serotonin syndrome
muscle spasms, fever, racing heart, headache, and confusion
o S=Shivering
o H=Hyperreflexia/Myoclonic jerks
o I = Increased Temp (Fever)
o V= Vitals Instability (↑↓BP; ↑RR; ↑HR)
o E= Encephalopathy (Confusion)
o R= Restlessness
o S= Sweating (Diaphoresis)
Only tricyclic antidepressant (TCA) thought to be effective in the treatment of obsessive
compulsive disorder (OCD)
clomipramine
Treatment for acute panic attacks =
can use benzo short term in addition to long-term SSRI
performance anxiety tx
propranolol
o CBT
o 1 st line = SSRI or SNRIs
Best meds for GAD (1st/2nd line)
**SSRI (escitalopram, paroxetine) SNRI (duloxetine, venlafaxine)
2nd line= Buspar, SNRI
Can consider short term course of Benzos or augmentation with buspirone (Buspar)
Best meds for SAD
SSRI
Best med for Panic attacks
initially use benzo (short term)
Panic disorder tx (first line, second line, adjunct);what bzo specifically?
Panic disorder
o 1 st line = SSRI, SNRIs
o 2 nd line= TCAs= though limited use
o Adjunct = Benzos USE WITH CAUTION, short-term until other meds reach therapeutic efficacy
alprazolam is FDA approved for panic d/o
OCD tx (first line class & common meds, second line)
Meds + CBT
o 1 st line= SSRI (often need high doses of sertraline, fluoxetine); Luvox
o 2 nd line = SNRI (e.g. venlafaxine) (Clomipramine=Anafranil)
Effects of benzodiazepine use and SE
Enhance activity of GABA at GABA-A receptor
- Potential for abuse and addiction
- Patient become physical dependent and build tolerance
- Can be used to treat Akathisia
- Choice of BDZ depends on time of onset, duration of action and method of metabolism
OTL= Outside The Liver (oxazepam, temazepam, lorazepam) = not metabolized by
the liver - S/E: Anticholinergic, unusual behaviors, hallucinations, daytime drowsiness,
amnesia
MOA of benzodiazepines & what effect does it have on body
MOA: Potentiate effects of GABA (Remember GABA is inhibitory) → drowsiness, cognitive
impairment, dampening of fear and anxiety, impaired balance, moto control, muscle tone
and coordination, anterograde amnesia.
Risk BZO use in elderly
Elderly patients: Increased fall risk, hip fracture risk
What BZO are not metabolized by the liver
OTL= Outside The Liver (oxazepam, temazepam, lorazepam) = not metabolized by
the liver
Benzodiazepine withdrawal symptoms:
Benzo withdrawal is like ETOH withdrawal
* Insomnia
* Anxiety
* Hand tremors
* Irritability
* Anorexia
* Nausea/vomiting
* Autonomic hyperactivity (diaphoresis, tachycardia, HTN)
* Tonic –clonic seizures = life threatening
Note: Abrupt abstinence after chronic use can be life threatening.
A known limitation of Benzo tx for insomnia
rebound insomnia
Short acting BZO half-life, which BZOs, and indication for use
Short Acting = < 6hrs half life
seizure disorders, Panic attacks
midazolam (Versed) and alprazolam (Xanax)
Intermediate acting BZOs half life, which BZOs, and indication for use
6-20 hours half life
insomnia, anxiety
lorazepam, oxazepam, temazepam
Long acting BZO half life, which BZOs, and indication for use
(> 20 hours half life)
Moderate-Severe anxiety
Good for ETOH withdrawal
diazepam, clonazepam, chlordiazepoxide, flurazepam
How to treat BZO overdose
Give Flumazenil (benzodiazepine antagonist) to reverse effects
MOA of Buspirone (Buspar) = Does it cause dependence?
Partial agonist at 5HT-1A = increases post-synaptic serotonergic activity
Low potential for abuse/addiction
General rule before switching med reported to be ineffective
General Rule:If a patient reports medication is not working, look at the dose, optimize it before switching it.
Benefits of benzodiazepines as compared to antidepressants:
rapid onset of action, effective,
well-tolerated
What anxiolytics to consider for patients with substance use
Patients with comorbid substance use – consider nonaddictive anxiolytic alternatives (e.g. gabapentin and antihistamines with anxiolytic properties (e.g. diphenhydramine or
hydroxyzine)
Medical conditions that may precipitate anxiety:
Heart disease
Hyperthyroidism
COPD/asthma
Drug abuse
ETOH/benzo withdrawal
Chronic pain
IBS
Adrenal tumor
Seizure
Diabetes mellitus
First line for PTSD
SSRI (sertraline or citalopram) or SNRI (venlafaxine)
FDA approved meds: sertraline (Zoloft) and paroxetine (Paxil)
Treatment for PTSD related flashbacks and nightmares?
Alpha-1 receptor antagonist (Prazosin)= targets flashbacks; nightmares and
hypervigilance
BZO use in PTSD patients
Benzodiazepines may interfere with the psychological processes needed to benefit from CBT
Many times PTSD patients also have substance use disorders which benzos should be avoided with
Addictive meds are associated with…
Avoid addictive medications (e.g., Benzodiazepines) = high rate of comorbid substance use disorders and lack of efficacy.
dissociative identity disorder (DID) overview (risk factors, associated symptoms, common comorbidity) and first line tx
- Predominantly develops in victims of significant and chronic childhood trauma
- Patients with DID often cope with PTSD
- More than one distinct personality state resulting from a fragmented sense of self.
- More than 70% attempt suicide often with frequent attempts and self-mutilation.
- 1 st line treatment - Psychotherapy
Are there any drugs specifically indicated for DID?
SSRIs to target comorbid depressive and or PTSD symptoms
Prazosin- for nightmares
Naltrexone- reduce self-injurious behaviors
ECT in DID
NOTE:ECT is NOT contraindicated in people with Dissociative Identify Disorder (DID) –note
that these patients have depressive symptoms and hence ECT can be considered as a viable
option especially in combination with psychotherapy.
Depersonalization disorder (what is it, comorbidities, predisposing factors)
unreality or detachment from one’s body, thoughts, feeling and actions
- Increased incidence of comorbid anxiety disorders and major depression
- Predisposing factors: severe stress and trauma
Derealization disorder (what is it, predisposing factors, comorbidities)
unreality or detachment from one’s surroundings
- Increased incidence of comorbid anxiety disorders and major depression
- Predisposing factors: severe stress and trauma
What foods should be avoided with MAOIs?
Tyramine rich foods: red wine, aged cheese, chicken liver, fava beans, cured meats
Initial/sleep-onset Insomnia=
Difficulty initiating sleep
Middle/sleep maintenance insomnia=
frequent nocturnal awakenings
Late/sleep offset insomnia=
Early morning awakenings
Nonrestorative sleep=
waking up feeling fatigues and unrefreshed.
Why should flurazepam be avoided in the elderly?
ANCC question – long half-life, increased risk for confusion and falls
Treatment for insomnia:
Antidepressants = Trazodone (mostly prescribed sedating antidepressant), Remeron (low doses)
Ambien in elderly patients
o Trazodone is an even safer option for the elderly
Ambien special pt instructions
Ambien – take on an empty stomach
Recommended Ambien dose men/women
Men: 10mg Women: 5mg
ramelteon (Rozerem) MOA
- DOES NOT Act on benzodiazepine receptors
MOA – Melatonin agonist – binds to melatonin receptors in brain inhibiting neuronal firing
triazolam (Halcon)
short acting benzodiazepine for sleep disorders
Antidepressants Used for sedating properties
- TCA: amitriptyline (Elavil)
- TCA: doxepin(Sinequan)
- mirtazapine (Remeron)
- trazodone
Med for OSA
Consider armodafinil (Nuvigil) = indicated for daytime sleepiness associated with OSA
eszopiclone (Lunesta) indication
indication helps with staying asleep; maintenance sleep onset. Can be used long-term
What’s Narcolepsy
Excessive daytime sleepiness and falling asleep in inappropriate places
What’s cataplexy
brief episodes of sudden bilateral loss of muscle tone
Narcolepsy with cataplexy tx& what to avoid with it
Treatment: sodium oxybate
not to be used with alcohol or other
CNS depressants
due to increased sedation, CNS depression, loss of
consciousness, coma, death
sodium oxybate pt education
not to be used with alcohol or other CNS depressants
True/false:OTC sedative/hypnotics = tolerance to sedating effects can develop rapidly?
True
Non-pharmacologic sleep Apnea Treatments
weight loss; avoidance of ETOH; CPAP; Uvulopalatopharyngoplasty
REM suppression drugs & what disease would that be beneficial in
SSRI, SNRI (Prozac, Cymbalta, atomoxetine, venlafaxine)
helpful in narcolepsy
Restless leg syndrome characteristics and risk factors
The urge to move legs accompanied by unpleasant sensation in the legs,
characterized by relief with movement, aggravation with inactivity.
Occurs or worsens in the evening.
1.5 -2 times more likely in males
Risk factors: age, iron deficiency, antidepressants, antipsychotics, dopamine
blocking antiemetic, antihistamines; strong familial component
Tx for restless leg syndrome
Remove offending agent; iron replacement
1 st line: Dopamine agonists (pramipexole=Mirapex and ropinirole-Requip) and Benzos
Gabapentin (Neurontin); pregabalin (Lyrica)
Low potency opioids for treatment refractory patients
Periodic Limb Movements of sleep (PLMS)
RLS associated with involuntary, jerking movements of limbs during sleep
Somatic Symptom Disorder
Patient believes they are ill and do not intentionally produce symptoms
Factitious Disorder
No external rewards
Falsifying physical (e.g. seizures/ infection, abdominal pain) and/or
psychological (hallucinations, depression, fever, infection) signs and symptoms
to assume a sick role
Absence of obvious external reward
Repeated & long hospitalizations are common
Txt
Collaboration with PCP
Confrontation in non-threatening manner = AMA possible
Malingering
External rewards present. Think “mal” = bad
Intentional reporting of physical or psychological symptoms
Goal: To achieve personal gain/secondary gain/ external reward (i.e.
avoiding police/incarceration, room & board, narcotics, monetary
compensation)
Not considered a mental illness
Conversion Disorder
psychiatric disorder with symptoms affecting sensory or motor function
Present with at least 1 neurological symptom – sensory/motor which cannot be fully explained by a neurological condition
La bell indifference: Patients surprisingly calm and unconcerned when describing symptoms
*Tx= CBT (w/ or w/o PT) & education
What are ED patients at risk for? Med to avoid?
Anorexia and bulimia are risk factors for developing cardiac arrhythmias due to electrolyte disturbances (e.g. ↓K+)
NOTE: Avoid Bupropion (Wellbutrin) in all eating disorder patients = lowers seizure threshold
Anorexia nervosa
Preoccupation with their weight, body image and being thin
Types (Restricting type & Binge-eating/purging type)
Intense fear of gaining weight or becoming fat
Restriction of calorie intake
Low body weight
NOTE: Pharmacotherapy may not
be a useful treatment modality for
most patients with Anorexia
Bulimia Nervosa & tx
Binge eating with behaviors intended to counteract weight gain (e.g. vomiting, laxative use, enemas/diuretics, fasting, excessive exercise)
Embarrassed by their binge eating and are overly concerned with body weight
Usually maintain normal body weight (may be overweight)
Tx:
o Antidepressant + therapy (CBT, IPT, group therapy)
o First line= SSRIs
o fluoxetine (Prozac) 60-80mg /day is the only FDA approved med
Binge eating disorder and tx (class and specific med)
Not fixated on their body shape and weight
Recurrent episodes of binge eating
No compensatory behaviors (i.e. vomiting and laxative use)
Usually, obese
Txt.
- First line= SSRIs (Lexapro)
- Psychotherapy (CBT, IPT)
Others:
- Vyvanse (FDA approved)- stimulant that suppresses appetite
- Topamax= associated with weight loss
- Orlistat (Xenical) – inhibits pancreatic lipase = decrease amount of fat absorbed from the GI
Pamela, a 26-year-old college student presents today with symptoms of anxiety attacks
lasting 10-20 min w/ symptoms of diaphoresis, palpitations, tremor, dizziness and inability to
concentrate at school. The PMHNP has diagnosed her w/ panic disorder without agoraphobia. What medication will the PMHNP consider for Pamela?
A.Clonazepam
B.Bupropion
C.Lithium
D. Fluoxetine
D. fluoxetine
George, a patient with PTSD presents to the outpatient clinic today w/ reports of middle
insomnia secondary to increased nightmares. The PMHNP knows that this class of
medication is used specifically to treat these symptoms.
A. Benzodiazepines
B. Beta blockers
C. SSRIs
D. Alpha blockers
D. Alpha blockers
What class of drugs are commonly used in OTC sleep aids?
A. Antihistamine
B. Beta blockers
C. Benzodiazepines
D. NMDA antagonists
A. Antihistamine
FDA approved indications for sertraline use
sertraline – MDD, OCD, panic disorder, PTSD, PMDD, SAD
FDA approved indications for buspirone use
GAD, not for MDD
Why give SSRI rather than rapid acting?
Longer-acting, longer half-life
How to taper off SSRI
Average half-life: 2 weeks is wash out period, fluoxetine longer 4-5 weeks
Bridge with short-acting – hydroxyzine pam, low dose clonidine,
propranolol; 25mg Seroquel (addiction);
do no harm and avoid dependence
First step for 30 yo male with OCD, MDD started on fluoxetine low dose and does not feel meds are working.
Optomize dose
Best med: Demenia pt. – increase bx at night, wandering, poor sleep, sleeps during day
trazodone
33 yo male with GAD, started on Prozac 1 week ago complaining of worsening symptoms. No
sign. hx and denies SI
continue fluoxetine and start alprazolam because of initial activating impact of
fluoxetine and no hx of SI
Social phobia tx
CBT
1st line = SSRI or SNRIs
* Benzos can be used as scheduled or PRN
* Beta blockers such as atenolol (50-100mg) and propranolol (20-40mg) 1 hour before
performance or public speaking
List of anxiety disorders
Specific phobia
Social anxiety disorder
Panic disorder
Agoraphobia
Generalized anxiety disorder
Separation anxiety disorder
Brain circuit associated with fear (panic & phobia)?
amygdala-centered
Brain circuit associated with worry (anxious misery, apprehension, expectation, obsessions)?
cortico-striatal-thalamic-cortical
SSRIs are first line in what anxiety disorders
chronic anxiety, GAD, panic disorder
Benefits of SSRIs over other meds
tx comorbid depression
lack of abuse risk
low SE risk
what patient populations to be cautious in with benzos d/t abuse/misuse risk
substance abuse, personality disorder, chronic pain
How to avoid BZO withdrawal adverse effects
taper 10% total dose/week
physical AND behavioral taper
common to convert from SA to LA to facilitate more comfortable taper
BZO with highest abuse potential
alprazolam (Xanax) d/t short half life/rapid onset
midazolam/Versed use
medical/surgical settings
half life < 6 hrs
lorazepam/Ativan use
panic attacks, ETOH/sedative-hypnotic detox
with haldol for acute agitation
intermediate acting, half life 6-20 hrs
oxazepam/Serax use
ETOH/sedative-hypnotic detox
intermediate acting, half life 6-20 hrs
temazepam/Restoril- what is of particular concern? (High risk of… )
high potential for dependence
diazepam/Valium use
Is it typically prescribed for anxiety?
GAD, severe ETOH withdrawal and seizures
Rapid onset
Less commonly prescribed for anxiety d/t Euphoria
long acting, half life > 20 hrs
clonazepam/Klonopin- when to avoid
Avoid in renal dysfunction
Longer half life- 1-2x daily dosing
half life > 30 hrs
which BZOs have longest half life
chlodiazepoxide (intermediate onset, half life 20-110 hrs)
and
diazepam (rapid onset, half life 30-100 hrs)
Which has the Highest anticholinergic effects: Benzo vs. TCA vs. SSRIs
TCAs
propranolol/Inderel for anxiety (class, which anxiet disorders/situations, SE, contraindications)
Beta blocker
Used off-label
Useful for panic attacks and performance anxiety related effects (i.e. palpitations, sweating and tachycardia
Also used for Akathisia
S/E: Bradycardia, hypotension
*Beta blockers can be fatal in a cocaine overdose
*Contraindicated in asthma or COPD d/t bronchospasm risk
hydroxyzine for anxiety (dosing, effects, SE, effect in relation to benzos)
- Fairly wide dosage range
- Individuals respond quite differently to different doses
- For some, 12.5mg is not tolerated, for others 50mg is minimally effective
- Generally start at 25mg once or twice daily, sometimes splitting tablet in half for lower dose
- Sedating (can help with sleep)
- Sometimes weight gain, sometimes paradoxical response
** Again, better if “benzo naïve”
Which anticonvulsants can help anxiety
- Gabapentin (“PRN” or scheduled) (works on voltage-sensitive Ca2+ channels, not GABA)
- Pregabalin
- Tiagabine
- Sometimes lamotrigine, oxcarbazepine (as scheduled)
*Gabapentin most frequently used in this class, but does now have “street value”
What to use INITIALLY for panic attacks
benzos
Flumazenil use/important consideration
Flumazenil is a short-acting intravenously administered antagonist to benzodiazepines that can reverse overdoses or anesthesia from benzodiazepines but can also induce seizures or withdrawal in patients dependent upon benzodiazepines.
Benzo of choice for panic disorder
alprazolam
Benzo of choice for social anxiety disorder
clonazepam
TCA or SSRI for OCD & what meds specifically
SSRI first (: fluoxetine, fluvoxamine (Luvox), sertraline, paroxetine)
TCA clomipramine more effective but SSRI better tolerated
FDA approved: Sertraline, Fluoxetine, Fluvoxamine
Difference between dissociation and depersonalization
Dissociation:
defense mechanism that protects from anxiety by emotionally separating; disruption in integrated sense of self
Depersonalization:
unreality or detachment from one’s body, thoughts, feeling and actions
What should you augment PTSD tx with in severe or resistant cases
Augment with Atypical antipsychotic in severe or treatment resistant cases.
General prescribing sequence in primary insomnia
- short-intermediate acting benzo receptor agonist (zolpidem, eszopiclone, temazepam) or remelteon
- alternate from above if first choice ineffective
- sedating antidepressant (trazodone, mirtazapine, amitriptyline, doxepin)
- combine BzRA or ramelteon and sedating antidepressant
- other sedating agents: gabapentin, tiagabine, atypical antipsychotic
Are zaleplon, triazolam, and ramelteon for sleep onset or sleep maintenance?
sleep onset
Are eszopiclone, zolpidem, temazepam for sleep onset or sleep maintenance?
BOTH
Are suvorexant and doxepin for sleep onset or sleep maintenance?
sleep maintenance
OTC sedative/hypnotics= tolerance to sedating effects can develop rapidly, True/False?
true
Why should Flurazepam be avoided in the elderly?
Low doses of flurazepam appear to be safe for elderly individuals, but they are susceptible to unwanted central nervous system depression at high doses. Sedation.
First line and considerations for sleep disorders in elderly
Always consider sleep hygiene as first-line
Sedative hypnotics are more likely to cause side effects when used (i.e. memory impairment, ataxia, paradoxical excitement and rebound insomnia) = Trazodone is a safer options
First line tx narcolepsy & then narcolepsy with cataplexy
narcolepsy= modafinil
w/ cataplexy= sodium oxybate
REM suppressive drugs
SSRI, SNRI (Prozac, Cymbalta, atomoxetine, venlafaxine)
Activating serotonergic agent that may cause sx that look like restless leg syndrome
venlafaxine/Effexor may trigger symptoms consistent with Restless Leg Syndrome (RLS)
La bell indifference
Patients surprisingly calm and unconcerned when describing symptoms, often seen with conversion disorder
What class of medications can help reduce obsessions and severe fearful preoccupations associated with psychosomatic disorders
SSRI
What’s the biggest risk concern with anorexia and bulimia?
Anorexia and bulimia are risk factors for developing cardiac arrhythmias due to electrolyte disturbances (e.g. _K+)
only FDA approved med for bulimia
fluoxetine 60-80 mg/day
The mechanism of action of this medication for Binge Eating Disorder is
the inhibition or pancreatic lipase which decreases the amount of fat
absorbed from the GI tract = _____________________________
Orlistat
This stimulant medication is FDA approved for Binge Eating Disorder =
Lisdexamfetamine dimesylate
First line treatment for Binge Eating Disorder = __
SSRI
Part of the brain that is implicated in PTSD- responsible for memory and learning
*hippocampus
also: amygdala, and medial prefrontal cortex
Chronotherapy
bright light therapy to help w/ insomnia
should elderly patients be given benadryl for insomnia
no avoid; moderately anticholinergic
Illness anxiety disorder
- Preoccupation with having/acquiring a serious illness
- Somatic symptoms not present or mild in intensity
- Increased anxiety about health
- Performs excessive health related behaviors/maladaptive behaviors
Persists for at least 6 months
Txt
- Regularly scheduled visits with one primary care physician
- CBT
- SSRI for comorbid anxiety & depressive symptoms; other appropriate psychotropic medications.
What class of medications can help reduce obsessions and severe fearful preoccupations associated with psychosomatic disorders
SSRIs
Tx anorexia nervosa
- CBT, family therapy
- SSRI for comorbid anxiety and depression
- May use olanzapine/Zyprexa to treat preoccupation with weight and food
- Premeal anxiolytic (e.g. Alprazolam) to encourage eating by decreasing anticipatory anxiety
Patient with OCD and Bulimia – what treatment of choice will your select?
fluoxetine; tx OCD & only SSRI approved for bulimia
