First Pass Miss Exam 1 Flashcards
What factors fall under social factors? (Three categories, bio-psycho-social)
- Current family relationships and interactions (not experiences, which would be psychological factors)
- Supports and stressors
- Racial, religious, socioeconomic, and cultural background -> think social determinants of health
What is affect?
The outward expression of mood -> objectively observed
What are the components of affect which are clinically useful?
- Variability - does it fluctuate through the interview? (labile affect)
- Intensity - Dysphoric vs euthymic (normal) vs euphoric
- Appropriateness to mood - is their self-reported mood in congruence with their affect?
List the 10 components of the MSE?
Appearance and behavior Psychomotor abnormalities Speech Mood Affect Thought Process Thought Content Sensorium and Intellectual Function Insight Judgment
What are the components of thought content?
Hallucinations, delusions, illusions, recurring themes, and suicidal / homicidal ideation
What is formication?
A tactile hallucination of bugs crawling under the skin, often associated with substance withdrawal
A speaker has no goal-directed associations and never gets to the desired end point when asked a question. How do you describe their speech?
Tangential
What are the types of dysphoric mood?
Flat -> most severe dysphoria
Blunted -> mood seems a little flatter than expect
Constricted -> almost normal but still clearly less intense in feeling
What are the names for normal sensory hallucinations which happen when falling asleep or waking up?
Falling asleep - Hypnagogic
Waking up - Hypnopompic (hopping out of bed)
What are two types of recurring themes? What are these in general?
- Obsessions - irresistible thought or feeling which cannot be eliminated from consciousness - luke obsessing over gary
- Negative ruminations - i’m gonna die
These are topics so important that the interview seems to keep returning to it
What are the components of sensorium and intellectual functioning?
Consciousness Orientation Attention and concentration Memory Abstraction Fund of knowledge
What are the two types of visual hallucinations and what is this common in?
- Formed images - i.e. people
- Unformed images - i.e. light flashes
Most common hallucination in psychosis due to another mental illness
(for example, Parkinson’s)
What are the four primary infant reflexes? When do they disappear?
BMR-P - 12,3,4,6
- Babinski - 12 months
- Moro - 3 months
- Rooting - 4 months
- Palmar - 6 months
Disappears like the ocular nerve numbers, 3, 4, 6 months
What is attachment and its significance of attachment to infancy? What are the possible effects if it is not there?
Emotional connection that develops between infant and primary caregiver
Effects of deprivation longterm:
- Anaclitic depression
- Social / emotional deficits - poor socialization / language / trust in others
- Physical effects - failure to thrive, even death
When does separation anxiety develop and what is it?
Occurs by 9 months, separation from primary caregiver gives normal anxiety - this is when object permanence starts and when the child can orient to name
Stranger anxiety begins at 6 months
What is the order of postural developments in infancy? From lying down to walking.
Lifts head to prone by 1 month Rolls over by 4-5 months Sits and rolls by 6 months Crawls by 8 months Stands by 10 months Walks by 12-18 months
2-4-6-8-10-12
Head->Roll->Sit->Crawl->Stand->Walk
What are the toy playing milestones in infancy?
6 months - passes toys hand to hand - once they can sit, they can do dis
10 months - Pincer grab (thumb to finger) - think of them having to grab something to stand
When does gender identity set in and when is it fixed? Is it innate?
Begins at 18 months - you feel male or female
Fixed by 24-30 months.
Yes, majority of it is innate
What are the four C’s of toddlership (Child rearing working)?
Cruises - takes first steps by 12-18 months, runs by 24 months
Climbs stairs 18 months
Cubes stacked - 3 x age in years = 6 by two years
Cutlery - feeds self with fork and spoon - 20 months
Kicks ball - not a C, but 24 months
Runs by 2 years (same as rapproachment, parallel play, kicking ball)
What are the three D’s of preschool years (Don’t forget they’re still learning)?
Drive - can ride tricycle with 3 wheels (age 3 for three wheels)
Drawings
Dexterity - Hops on one foot by age 4, Uses buttons / grooms self by age 5, can use buttons or zippers by age 5 (full dressing of self by age 5)
REVIEW PAGE 258
What are the two L’s of preschool years (don’t forget they’re still Learning)?
Language - 3 zeros for age 3 - knows 1000 words. Can also use complete sentences by age 4.
Legends - At age 4, when can use complete sentences, can also tell complete stories.
What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?
3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex
Erikson - Initiative vs Guilt
What are Freud’s and Erikson’s second stage and their timing?
Both 1-3 years (toddlerhood)
Freud - Anal phase - urges centered on controlling bowel functions / body functions (potty training)
Erikson - Autonomy vs Shame and Doubt
What is Piaget’s second stage and how long does it last? How is their thinking?
Preoperational stage 2-7 years
Child uses symbols and language
-> Thinking and reasoning are intuitive, not logical / deductive.
-> cannot understand metaphors
What is Piaget’s third stage and what characteristics underlie it?
Concrete operations, Ages 7-11 (preoperational was 2-7), ends the same year as Freud’s latency stage
Ability to understand other’s viewpoint (no longer egocentric), ability to organize / group according to characteristics of objects
What is Erikson’s fourth stage? Years?
5-13 years: Industry vs Inferiority
Child must understand his family is part of a larger society, and focuses on learning and doing
Industry - develops a sense of mastery over environment / accomplishment
Inferiority - when a child cannot master tasks
What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?
3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex
Erikson - Initiative vs Guilt
What are the leading causes of death in people 0-1 years? 1-14 years? 15-35? 35-44?
0-1: Congenital malformations, premature birth, SIDS
1-14: Accidents, cancer, congenital malformations
15-35: Accidents, Homicide, Suicide
35-44: Accidents, Cancer, Heart Disease
45-64: Cancer, Heart Disease, Accidents
65+: Heart Disease, Cancer, Chronic Respiratory Disease
What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?
3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex
Erikson - Initiative vs Guilt
What are Freud’s and Erikson’s second stage and their timing?
Both 1-3 years (toddlerhood)
Freud - Anal phase - urges centered on controlling bowel functions / body functions (potty training)
Erikson - Autonomy vs Shame and Doubt
What is Piaget’s second stage and how long does it last? How is their thinking?
Preoperational stage 2-7 years
Child uses symbols and language
-> Thinking and reasoning are intuitive, not logical / deductive.
-> cannot understand metaphors
What is Piaget’s third stage and what characteristics underlie it?
Concrete operations, Ages 7-11 (preoperational was 2-7), ends the same year as Freud’s latency stage
Ability to understand other’s viewpoint (no longer egocentric), ability to organize / group according to characteristics of objects
What is Erikson’s fourth stage? Years?
5-13 years: Industry vs Inferiority
Child must understand his family is part of a larger society, and focuses on learning and doing
Industry - develops a sense of mastery over environment / accomplishment
Inferiority - when a child cannot master tasks
What are Freud’s and Erikson’s third stage and their timing? What are the feature’s of Freud’s phase?
3-5 years (preschool years)
Freud - Phallic Phase
-> preoccupation with illness / injury
-> Oedipal complex -> child competes with parent to focus on parent of opposite sex
Erikson - Initiative vs Guilt
What are the leading causes of death in people 0-1 years? 1-14 years? 15-35? 35-44?
0-1: Congenital malformations, premature birth, SIDS
1-14: Accidents, cancer, congenital malformations
15-35: Accidents, Homicide, Suicide
35-44: Accidents, Cancer, Heart Disease
45-64: Cancer, Heart Disease, Accidents
65+: Heart Disease, Cancer, Chronic Respiratory Disease
What are the five stages of grief?
- Denial
- Anger
- Bargaining
- Despair / Depression
- Acceptance
What are the types of denial? Define: magical thinking, excessive fantasy, regression, withdrawal/rejection
- Magical thinking - things will be different by magic
- Excessive fantasy - nothing is wrong, loss is imagined
- Regression - make others assure them nothing is wrong, child-like
- Withdrawal / rejection - avoiding and rejecting those who confront them with the truth
How does the topographic model of the mind explain psychiatric illness? Structural model = id, ego, superego
Symptoms are the result of repressed memories or ideas which can be treated with lifting the repression -> memories can be recalled and symptoms resolved
Structural model - symptoms caused by conflict of the various conscious parts, and usage of defense mechanisms to resolve this
When is repression? How does this differ from denial and suppression?
Involuntary withholding of an unacceptable idea / impulse from consciousness
Denial -> Refutation of external data. Repression is denial of inner data
Suppression -> Intentional and temporary withholding of an unacceptable idea / impulse
What is idealization and when is it used?
Attributing perfect qualities to others while ignoring any flaws (to ignore negative thoughts)
- > avoids anxiety or negative feelings such as contempt, envy or anger
- > if you are anxious about your cancer, this might be a defense to make yourself feel like you’re in good hands
What is altruism and when can it be used negatively?
Committing oneself to the needs of other over and above one’s own needs
- > alleviate negative feelings via unsolicited generosity
- > can be used negatively in narcissism (want to win big prize) and guilt (remorse for bad actions)
How does graded exposure differ from systematic desensitization?
Graded exposure = doing systematic desensitization in real life.
i.e. moving through the hierarchy when you have a fear of flying by looking at pictures, then going to airport, flying on plane short trip, etc
What is reaction formation vs sublimation?
Reaction formation -> doing the opposite of an unacceptable wish or impulse. I.e. going to a monastery when you feel like having sex, overcompensating but not being genuine.
Sublimation -> channeling those feelings into something positive / something that does not conflict with your value system -> i.e. former cocaine addict works for a substance abuse hotline to help others after he feels like smoking da crack
What is implosion?
Carrying out flooding in imagined scenarios
-> Implosion is to systematic desensitization as flooding is to graded exposure
What type of therapy is indicated specifically for borderline personality disorder and how does it work? What is the goal?
Dialectical Behavioral Therapy (DBT)
Individual and group therapy which draws from CBT and supportive psychotherapies.
- > see individuals weekly for 1 year. Taught to be mindful of present, regulate their emotions, and accept negative feelings
- > goal is to reduce self destructive / self harm behaviors and improve interpersonal skills
What is the domino effect of interpersonal relationships in depression?
Depressive episodes are triggered, which leads to negative interpersonal encounters, which further lowers mood and social functioning
-> IPT (interpersonal therapy) can be useful to reverse this and improve mood
What is Milieu therapy?
A type of group therapy used on inpatient psych wards to help increase patients’ ability to relate to world and others
How does family therapy differ from individual therapy and what are its main goals?
Focuses on family as a unit rather than individual, knowing that the family unit attempts to maintain homeostasis
Goals:
Change maladaptive roles in the house
Improve communication
Decrease blaming / scapegoating
What is psychodynamic psychotherapy / what is it based on?
Based on Freud’s psychoanalytic theory
- > symptoms result from early experiences with buried conflicts
- > uncovering the unconscious results in improved self-understanding and conflicts can be resolved
- > uncover the conflicts, repressed feelings, and issues from early life
->psychoanalysis is the more intense form of this 3-6 times per week
What is the typical thought process in MDD? What is the most dangerous thought content?
Typical -> poverty of ideation - slowed thinking and low or no thoughts, often with negative ruminations and hopelessness / helplessness
Most dangerous: psychotic depression with perceptual disturbances / command hallucinations = “you should kill your wife then yourself”
How does the dexamethasone suppression test for MDD work? What does it indicate?
Give dexamethasone
- > in non-depressed people, coristol production is suppressed
- > in depression, cortisol production is unchanged (increased cortisol levels in depression)
That person with positive test + diagnosed depression is more likely to have melancholia, psychotic features, and at greater risk for suicide
What medical condition is depression a risk factor for?
Cardiac events / CAD in patients with pre-existing heart condition
-> same risk for MI as LV dysfunction
How is full remission defined for MDD?
A return to patient’s baseline level of symptom severity and functioning, which correlates with a HAMD score of <7 for greater than 2 months
What sleep abnormalities are present in MDD?
Increased sleep latency
Decreased REM latency and greater proportion of REM sleep
How long should patient be treated in continuation phase? How often should patient be seen in continuation / maintenance phase?
6 months to a year on pharmacotherapy
- > goal is to prevent relapse
- > requires monthly visits (can go to quarterly in maintenance)
Acute phase is the time it takes to get a >50% reduction in MDD symptoms via HAMD
What is dysthymia now called and what are its diagnostic criteria? What is the time table?
Persistent depressive disorder (PDD) Depressed mood and 2+ of HCASES H: Hopelessness C: Concentration decrease A: Appetite change S: Sleep change E: Energy decrease S: Self esteem reduction
Must be for MOST days x2 years, never without symptoms for >2 months
Not enough symptoms for MDD
When must symptoms be present for PMDD?
Premenstrual dysphoric disorder
-> in most menstrual cycles over the last year (>2 cycles), with at least 5+ symptoms during week before menses, with improvement within a few days of menses, and minimal / no symptoms a week post menses
What are the AT LEAST 1 required symptoms of PMDD?
Affective lability (i.e. mood swings)
Irritability / anger / conflict
Depressed mood
Anxiety / tension
Anxiety, Depression, Anger, Lability
What are the additional symptoms of PMDD?
Depression symptoms
Overwhelmed / out of control feeling
Physical symptoms - include breast tenderness, joint / muscle pain, bloating / weight gain
What are the diagnostic criteria for a manic episode? Include time scale.
At least 1 week of:
Distinct period of abnormally / persistently elevated or irritable mood
AND
Persistently increased goal-directed activity or energy
PLUS 3+ of:
DIGFAST
Distractibility
Indiscretion - excessive pleasurable activities
Grandiosity
Flight of ideas / racing thoughts
Activity increase
Sleep deficit only (decreased need for sleep)
Talkativeness
So, goal-directed activity/energy + a elevated mood + DIGFAST
What are the nonspecific brain findings in MDD? With regards to activity
Reduced activity in dorsolateral prefrontal cortex -> seat of reasoning = associated cognitive decline
Increased activity in amygdala and ventromedial prefrontal cortex -> leads to depressed mood and anxiety
- > hypoactivity of the cortex overall on PET scan
- > also has increased ventricle:brain ratio, with overall atrophy and decreased size of hippocampus (size also decreased in PTSD)
How does a hypomanic episode differ from a manic episode?
Identical to manic episode except:
- Lasts at least 4 days (instead of one week)
- Less significant impairment in functioning -> just noticeable and uncharacteristic change
- NO associated psychotic symptoms
What is the nonspecific brain finding for BPD?
Enlarged third ventricles
How are substance induced depressive and bipolar disorders diagnosed?
Same criteria as medical-illness induced, except symptoms develop within 1 month of starting or withdrawing from a substance
+
evidence of association with intoxication or withdrawal and the diagnostic mood symptoms
How are MDE criteria changed for children?
Depressed mood may be changed to include irritability
Weight loss may be replaced with growth retardation / lack of expected weight gains
- > same change for PDD, and also can be >1 year
- > same change with cyclothymia
Guess these kids’ lives are two short for >2 year diagnoses
What are the criteria for the “anxious distress” modifier?
2+ during majority of time patient is MDE or manic: A. Keyed up or tense B. Unusually restless C. Concentration issues due to worry D. Fear of something awful happening E. Fear of losing control
tense, restless, fear of bad things / loss of control, concentration problems
-> puts you at risk of suicide and treatment nonresponse
What are the criteria for the “seasonal pattern” modifier?
Association between onset of symptoms and time of year.
During past 2 years, 2+ episodes demonstrate a pattern, with NO nonseasonal episodes. Seasonable episodes outweigh non-seasonal episodes throughout the patient’s lifetime.
What two modifiers can only be applied to MDE, and not BPD1/2?
Atypical features (MAOI), melancholic features (dexamethasone risk factor)
What are the diagnostic criteria for atypical features?
MDE only:
High mood reactivity
Significant weight gain / increase of appetite with hypersomnia
Leaden paralysis - feeling stiff / heavy
Oversensitivity to rejection
What are the diagnostic criteria for melancholic features?
Opposite of atypical: Low mood reactivity / complete anhedonia, significant anorexia / weight loss, early morning awakening / insomnia, worse in the morning.
Marked psychomotor abnormalities.
What is the peripartum onset modifier?
MDE or BPD with symptoms starting during pregnancy or within 4 weeks of delivery
What two modifiers can be applied to BPD 1 and MDE, but not BPD2?
Psychotic features, catatonic features
What are the diagnostic criteria groups for panic disorder?
- Recurrent panic attacks
or - At least 1 month of persistent concern of having another panic attack, causing behavioral change
Typical other DSM criteria
What part of the brain is responsible for anticipatory anxiety? What types of anxiety manifestations do the following brain areas cause: prefrontal cortex? brain stem?
Amygdala / limbic system
Prefrontal cortex is responsible for avoidance behaviors
Brain stem: autonomic symptoms
What, in general, are the diagnostic criteria for agoraphobia?
Fear of public spaces where escape might be difficult or help unavailable for greater than 6 months.
Anxiety is out of proportion to the actual threat posed, and thus these situations are avoided or endured with extreme anxiety
How are agora and specific phobias treated with therapy? OCD?
Agora / specific phobias - Exposure with graded desensitization
OCD - Exposure plus response prevention
What, in general, is social anxiety disorder? What is the normal age of onset?
A fear or avoidance of social / interactional situations which lasts more than 6 months, can be as small as eating / using bathroom in public
Typically in teen years
-> frequently cormorbid with depression and alcohol dependence (gotta drink to talk to people)
What, in general, is generalized anxiety disorder?
Excessive anxiety and worry more days than not for at least 6 months
-> Requires associated physiological / psychological symptoms
What types of diseases are typically on the differential diagnosis for anxiety / panic disorders?
Cardiovascular / respiratory dysfunction to cause the physiological symptoms, endocrine dysfunction for stress hormones, etc
What are the four core features of PTSD? How long must they be present?
More than 1 month
- Intrusive symptoms -> i.e. memories, nightmares, physiologic response
- Avoidance behavior -> avoidance of triggers
- Negative mood / cognitions -> includes forgetting important aspects / distorted cognition
- Hyperarousal symptoms -> exaggerated startle, irritable behavior, sleep problems
- > treat symptoms with pharmacotherapy
What are two important specifiers of PTSD?
- With dissociative symptoms -> i.e. depersonalization
2. With delayed expression -> does not start until 6 months after event (i.e. holocaust victims until retirement)
What area of the brain which regulates affect is found to be hypoactivated in PTSD?
medial prefrontal cortex, including orbitofrontal cortex and anterior cingulate cortex
What are the criteria for an adjustment disorder?
Emotional or behavioral symptoms in response to a stress occurring within 3 months of a stressor, which will not persist for more than 6 months after stress is removed.
- > cause marked distress out of proportion to severity / intensity of stressor
- > cause significant impairment
- > often comorbid with personality disorders and substance abuse
- > treat with therapy or short-term anxiety meds
What conditions are commonly co-morbid with OCD, and one unique one?
Anxiety disorders or mood disorders
Unique - up to 30% have co-morbid tic disorders, and with Tic can be used as a specifier for the OCD
What are the noradrenergic and HPA findings in PTSD?
Noradrenergic - increased epinephrine concentrations in urine + downregulation of platelet alpha-2 receptors
HPA - low plasma / urinary cortisol, which cannot be stimulated easily with CRF and is enhanced suppression by dexamethasone (opposite of depression), overly-suppressed
What is one OCD-related disorder when the prevalence in men is more than women and its diagnostic criteria basically?
Hoarding disorder
- > holding onto items regardless of value, accumulating as clutter in living areas which prevents their intended use.
- > Causes distress to discard the items
- > think of Mr. McLeroth not being able to use the basement
Why does hairpulling in trichotillomania continue and when does it start?
Typically starts in 11-13 year olds and is lifelong
-> response to negative emotions and is positively reinforced because it feels good
What two neurosurgeries can be used for OCD?
Cingulotomy - bilateral lesioning of the anterior cingulate gyrus between orbitofrontal cortex (seat of wisdom) and limbic system
Capsulotomy - anterior limb of internal capsule - relay between cortical structures and thalamus
What dirty drug is good for treating trichotillomania and OCD?
Clomipramine - a tricylic antidepressant
-> highly serotonergic
What is PANDAS?
Abrupt onset of OCD in children following Streptococcus infection (Group A Strep)
-> analogous to Syndenham’s chorea, due to autoimmune condition
How does acute distress disorder differ from PTSD? What is the treatment?
Acute stress disorder is from 3 days to 1 month after trauma, although it has the same symptoms
-> becomes PTSD after 1 month
Possible beta-blockers to prevent memory consolidation, but mostly just CBT
What three psychiatric comorbidities are very common with anorexia nervosa?
- Depression
- OCD - anorexia was once thought to be part of OCD spectrum
- Personality disorders - Avoidant & OCD
What personality disorders are associated with bulimia nervosa?
Avoidant & Borderline Personality Disorder
What reproductive / hormonal changes occur in anorexia?
Low LH / FSH / TSH leads to hypothyroid symptoms as well as amenorrhea
-> Low TSH / hypothyroidism explains the comorbid depression
What are the DSM general criteria for AN?
- Restriction of energy intake leading to low body weight or less than minimally expected for children
- Intense fear of gaining weight
- Disturbed view of own weight / shape
What are the two subtypes of AN?
- Restricting type -> no binging and purging for last 3 months, just calorie restriction
- Binge-eating / Purging type -> engage in binge-eating / purging during last 3 months
People can alternate between these two
How does Binge-eating / purging subtype of AN differ from bulimia?
Bulimia is not associated with a decreased overall weight and an intense fear of weight gain (just preoccupation with weight)
What metabolic effects are seen from vomiting in bulimia and purging-type anorexia?
Hypokalemic, hypochloremic alkalosis
- > increased HCl excretion in vomit leads to increased bicarbonate uptake in the kidney to compensate for loss of Cl-
- > less H+ is able to be exchanged for K+, so not as much K+ can be reabsorbed
What is the initial treatment for AN and what should be avoided? After recovery?
Gradual weight restoration -> try to return to normal weight before discharge
+
Cyroheptadine - antihistamine and anti-5HT to increase apetite
Avoid:
Refeeding syndrome - increased insulin upon introduction of carbohydrates in feeding leads to hypophosphatemia (glucose-6-phosphate formation) and cardiac arrhythmias. GO SLOWLY
SSRIs - until weight is restored
After recovery, use:
SSRIs
Cyproheptadine (for appetite)
Atypical antipsychotics
What are the diagnostic criteria for bulimia nervosa?
- Recurrent binge eating with lack of self control
- Recurrent inappropriate compensatory behavior
- > could be vomiting, but often only laxatives, enemas, diuretics, meds, or even excessive exercise - Behavior must average at least 1x per week for 3 months
- Negative self-evaluation on body shape / weight gain
What are the subtypes of BN?
- Purging type -> self-induced vomiting or use of laxatives as compensatory behaviors
- Nonpurging type -> Other inappropriate compensatory behaviors like fasting and excessive exercise are used
How is management of bulimia nervosa different than anorexia nervosa?
- Most patients can be managed as outpatients rather than inpatients, with same emphasis on therapy and SSRI / antipsychotic use.
- Bulimia patients should NOT be given cyproheptadine since their appetite is normal (vs AN)
What is purging disorder? What are they at risk for developing?
Recurrent purging after consuming only a SMALL amount of food in persons with normal weight and a distorted body image
At risk for developing bulimia
-> note that there is also a binge eating disorder
Other than bupropion, what other class of medication is relatively contraindicated in eating disorders?
Stimulants (i.e. methylphenidate)
-> abuse potential + cause weight loss / decreased appetite
What features of depression might make you want to learn more towards psychotherapy than pharmacotherapy?
- Presence of personality disorders
2. Psychosocial stressors -> medication cannot fix this
What are some of the withdrawal symptoms of SSRIs?
Dizziness, nausea, paresthesias, anxiety, insomnia
-> must be tapered over 2-4 weeks
Which SSRI has the most CYP interactions, and which SSRIs are known to interfere with opiates?
Fluvoxamine - most interactions
Fluoxetine (most activating) and paroxetine (most sedating) - interferes with effectiveness of opiates like codeine via CYP2D6 interference blocking conversion to active form
What is the mechanism of action of mirtazapine? Include all relevant receptors and their effects
Noradrenergic and specific serotonergic antagonist (NaSSA)
- blocks 5-HT2 and 5-HT3 receptors (increases 5-HT1 agonism overall), with fewer sexual / GI side effects
- blocks alpha2 receptors - increases NE in the synapse
- histamine antagonism - increases weight gain and sedation
What is the mechanism of action of Vilazodone? What is its increased side effect?
SPARI - Serotonin partial agonist / reuptake inhibitor
SSRI + 5HT1A agonist -> possible increased efficacy for anxiety / depression
May make GI side effects worse
What is the mechanism of action of trazodone?
SARI - Serotonin antagonist / reuptake inhibitor
- SSRI plus antagonizes 52 - 5HT-2 receptors
- also has anti alpha-1 (lighter) and anti-histamine (beeswatting on the bench) effects
What syndromes might TCAs be particularly useful for?
Pain syndromes: migraines / neuropathy, due to NRI effects
Enuresis: Due to anticholinergic effects
What cardiac side effects does a patient need to look out for when starting a TCA? What should be done when starting a patient?
Look out for chest pain / shortness of breath
Need baseline EKG if older than 40 or history of CVD
-> can cause tachycardia / prolonged QT / ST depression even at therapeutic doses
What are the common side effects of MAOIs?
Edema
Insomnia
Sexual dysfunction and orthostatic hypotension (alpha1 blockade)
Weight gain (think of eating too much cheese)
What are the tricyclic compounds, opioids, and migraine medications which can precipitate serotonin syndrome when taken with MAOIs?
Tricyclic compounds
- > cyclobenzaprine
- > carbamazepine
Migraines
-> triptans (5HT1b/d)
Opioids (4 M’s + 1 other)
- > tramodol
- > methadone
- > dextromethorphan (oh god memo)
- > mepiridine
- > Propoxyphene
What is the definition of a hypertensive crisis and what is the treatment? What are a few symptoms?
Diastolic blood pressure is greater than 120 mmHG
Alpha-antagonist phentolamine is treatment
Symptoms: Occipital headache, neck stiffness, dilated pupils, and abnormal heart rate
What are the contraindications of ECT and side effects of concern?
Contraindications:
Recent MI (causes SANS / PANS discharge)
Space occupying / hemorrhagic cranial lesion (increases ICP)
Side effect:
Memory problems
Can you summarize the therapeutic uses of lithium, anticonvulsants, atypical / typical antipsychotics for BPAD?
Lithium: Good for all three
Anticonvulsants (carbamazepine / valproic acid) -> sedating, good for mania and maintenance (with the except of lamotrigine, which is good for depression and not mania)
Atypical antipsychotics - good for all three, often as adjunct
Typical antipsychotics - only used in acute bipolar mania
What levels of lithium are considered deadly and when should hemodialysis begin?
> 2.5 mEq/L
>2.0 = acute renal failure, need to begin hemodialysis. Seizures can occur far before this point
What drugs increase lithium levels? Where is it cleared?
NCAT - think MCAT but NCAT N - NSAIDs C - Calcium channel blockers A - ACE inhibitors T - Thiazide diuretics
N/A - reduce GFR via reduced blood flow or volume
T - reduce sodium levels, thus increasing reabsorption of lithium in PCT
It is 95% kidney-cleared, 80% is reabsorbed so 20% of lithium clearance approximates GFR
What drugs / conditions decrease lithium levels?
Theophylline / caffeine (increase GFR)
High sodium (larger Vd, less reabsorption of lithium)
Pregnancy (large Vd)
List the minor CNS, cardiovascular, dermatological, endocrine / metabolic, fetal, GI, hematologic, and renal side effects of lithium?
CNS - hand tremor / cognitive blunting
Cardiovascular - Edema (like MAOIs)
Dermatologic - alopecia, acne, psoriasis
Endocrine / metabolic - weight gain
Fetal - Ebstein’s anomaly
Hematologic - Benign leukocytosis
Renal - Polyuria, polydipsia, nephrogenic diabetes insipidus
What are the more medically serious side effects of lithium?
Hypothyroidism is common
Irreversible kidney disease
ECG changes - SA node blockade and sick sinus syndrome
What is the most likely drug-drug interaction of valproic acid, and should plasma concentration be monitored?
Most likely to interact with highly protein-bound meds like warfarin, digitalis, and other anticonvulsants (i.e. lamotrigine)
Should be monitored and held to 50-100 mg/mL
What blood-related and toxicity-related side effects differentiate valproic acid from lithium toxicity?
Valproate - will cause leukopenia / thrombocytopenia (vs lithium increases leukocytes), possible agranulocytosis
Valproate can also cause hemorrhagic pancreatitis (hemorrhagic sponge) and hepatotoxicity
What tests should be ordered for valproate which are not ordered for lithium?
Liver function tests (metabolized by liver, can cause hepatotoxicity)
Platelets (agranulocytosis is a concern)
Lithium is more thyroid / kidney oriented since it is metabolized by kidney
What are some of the more common and rarer side effects of carbamazepine?
Common:
Diplopia, ataxia, nausea
Less common but serious: Stevens-Johnson syndrome (along with lamotrigine), pancytopenia, hepatic / pancreatic failure (like valproate)
What phases of bipolar disorder is lamotrigine indicated for? Its mechanism of action?
Inhibition of Na+ channels / glutamate channels
Approved for maintenance of BPAD, and sometimes treatment of bipolar DEPRESSION
What are the common and severe side effects of lamotrigine? who is most susceptible?
Common - Headache, nausea, dry mouth, ataxia, diplopia
Severe: SJS (toxic epidermal necrolysis) -> beningn rash is common early, but can be serious, titrate slowly especially if with valproic acid.
Kids more susceptible to SJS
What are the side effects of benzos, especially as they relate to the elderly?
Cognitive problems / falls in elderly
Decreased respiration in prexisting pulmonary dysfunction
Anterograde amnesia
What is the teratogenicity of benzos?
Has been associated with cleft palate in first trimester
-> also use only oxazepam and lorazepam in the elderly since they only need Phase 2 metabolism
What beta-blocker is used in anxiety, what for, and how does it work?
Propanolol - for social anxiety disorder / social phobia, right before meeting that situation
Works by reducing peripheral manifestations of anxiety (tachycardia, tremor, sweating) to prevent conscious thought of it
Buspirone - 5HT-1a agonist
Buspirone - 5HT-1a agonist
- > causes drowsiness, dizziness, and GI distress
- > can cause serotonin syndrome (is a serotonin agonist)
What characterizes borderline personality disorder?
Instability of interpersonal relationships, self-image, affect, and marked impulsivity.
Person will chronically feel empty and fear abandonment.
Splitting makes their interpersonal relationships very intense.
How should a patient with histrionic personality disorder be managed?
Prepare for overly-dramatic complaints, and set clear boundaries.
Like Schizotypal and Schizoid -> avoid close relationship, may be misinterpreted as sexual.
How should you manage a patient with dependent personality disorder?
Schedule more frequent, brief appointments, recognizing the patient gains from your attention.
Set firm limits and watch for your own burnout, and realize that they may be overly-eager to accept treatment and this makes them susceptible
