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Midterm Psychopharm > Midterm Outline > Flashcards

Midterm Outline Flashcards

1
Q

Outermost layer of cerebrum

A

Cerebral cortex

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2
Q

What does the limbic lobe consist of?

A 
Surrounds upper brainstem
Includes- 
hippocampus 
Amygdala 
Hypothalamus 
Parahippocampal gyrus
Cingulate cortex
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3
Q

Plays a critical role in memory

A

Hippocampus

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4
Q

Important element of fear circuitry

A

Amygdala

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5
Q

Frontal cortex functions

A 
Planning 
Attention 
Abstract thought 
Problem solving 
Judgement 
Inhibition of impulses
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6
Q

Cerebellum function

A

Motor coordination

Cognitive and affective processes

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7
Q

Thalamus role

A

Major rely station for incoming sensory information

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8
Q

Part of the brain that plays a critical role in neuroendocrine Regulation by affecting pituitary hormone release

A

Hypothalamus / mood motivation/ sex drive/ hunger/ temperature/sleep

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9
Q

Neuromodulatory nuclei in the midbrain

A

Dopaminergic ventral tegmental area

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10
Q

Neuromodulatory nuclei in the brainstem

A

Serotonergic raphe nuclei

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11
Q

Neuromodulatory nuclei in the pons

A

Noradrenergic locus coeruleus neurons

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12
Q

Cholinergic neurons are located where?

A

Basal forebrain and brainstem

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13
Q

Neuron doctrine theory

A

Neurons act as psychically discrete functional units within the brain communicating with each other through specialized junctions

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14
Q

Cell soma function

A

Housing the nucleus with its genomic DNA

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15
Q

Support neuronal function by supplying nutrition, maintaining homeostasis, stabilization of synapses, myelinating axons

A

Glia cells- 10x more than neurons

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16
Q

Play a role in synaptic transmission

A

Glia cells

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17
Q

Smal phagocytic cells

A

Microglia

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18
Q

Astrocytes and oligodendrocytes

A

Macroglia

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19
Q

Play a critical role in glutamatergic neurotransmission (function and transport)

A

Astrocytes (macroglia)

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20
Q

Mood disorders are associated with a reduction in the number of _____ in select brain regions

A

Glia

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21
Q

Characteristics of a neurotransmitter

A

Synthesized within presynaptic neuron

Released w:depolarization from pre synaptic neuron to exert an action on post synaptic neuron

Action can be replicated by a drug

Action on synaptic cleft is terminated by a specific mechanism

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22
Q

Amino acid neurotransmitters

A

Glutamate

GABA

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23
Q

Monoamine neurotransmitters

A 
Dopamine 
Serotonin 
Norepinephrine 
Epinephrine 
Histamine
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24
Q

Small molecule neurotransmitter

A

Acetylcholine

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25
Q 
Opioids 
Hypothalamic factors 
Pituitary hormones 
Substance P/VIP
Leptin
A

Peptides

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26
Q

Rapid effect neurotransmitter receptors are either

A

Ion channels (NMDA glutamate receptors) or coupled to ion channels

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27
Q

G protein coupled receptors work —-

A

Via slower second messenger systems - involve multi enzyme cascade

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28
Q

Second messenger systems convert receptor signals into a coordinated set of cellular effects by….

A

Altering the function of multiple target proteins

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29
Q

Second messenger pathway involving glycogen synthase kinase(gsk) may mediate therapeutic efficacy of….

A

Lithium salts in bipolar disorder

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30
Q

By modifying gene expression in the nucleus, _______ can produce persistent changes in neural function

A

Transcription factors

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31
Q

Most widely studied neuronal transcription factor

A

CREB (cAMP response element binding protein)

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32
Q

Upregulated and phosphorylated in neurons in response to antipsychotic meds or drugs of abuse

A

CREB

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33
Q

BDNF and other related neurotrophic factors exert effects by…

A

As a growth factor during embryonic Neuro development and synaptic signaling

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34
Q

BDNF signaling modulates what?

A

CREB activity and gene expression ( neuroplasticity)

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35
Q

Included processes in the brain that continue into adulthood such as neurogenesis

A

Neurodevelopment

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36
Q

The capacity of the neural system to change in response to internal or external stimuli following predetermined rules

A

Neuroplasticity

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37
Q

Nerve fiber that carries away nerve impulses from the cell body

A

Axon

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38
Q

Branched extensions of a nerve cell that propagate the electrical stimulation received from another neuron

A

Dendrite

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39
Q

abnormally high or low concentrations of neurotransmitters in the area between two neurons

A

synapse. Can inhibit neurotransmitter synthesis, inhibit transport, vescicle formation, release/block post synaptic efforts or increase clearance rate from the synapse.

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40
Q

Can induce second messenger cascades that can influence intra-cellular processes, including gene transcription.

A

Enzymes via G proteins embedded within the cell membrane

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41
Q

Most conventional antipsychotic agents are extensively metabolized by the 2D6 isoenzyme of the….

A

Hepatic P450 enzyme system

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42
Q

Neurotransmitter is synthesized where?

A

presynaptic neuron

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43
Q

Biogenic amines

A

Serotonin and Histamine

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44
Q

catecholamines

A

Dopamine
Norepinephrine
Epinephrine

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45
Q

Amino acid neurotransmitters

A

Glutamate
Gaba
Glycine

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46
Q

An enzyme dopamine beta hydroxylase wil convert Dopamine into what?

A

Norepinephrine within the vescicle

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47
Q

Hormone and neurotransmitter synthesized by norepinephrine in the cytoplasm by enzyme

A

Epinephrine

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48
Q

What is innervation

A

The nervous excitation necessary for the maintenance of the life

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49
Q

Involves a multi-enzyme cascade that work via slow messenger systems

A

G-protein-coupled receptors

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50
Q

Linked to cytoplasmic enzymes via proteins embedded within the cell membrane

A

G-protein-coupled receptors

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51
Q

2 G-protein-coupled receptors

A

Glutamate

GABA

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52
Q

transmembrane channel that opens or closes in response to binding

A

Ligand gated ion channel

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53
Q

When a ligand binds to a ligand gated ion channel what happens ?

A

A channel opens and allows ions like K, Ca, CL, NA through)

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54
Q

voltage gated ions rely on???

A

The difference in membrane potential. Not the same as a ligand gated ion channel

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55
Q

Glutamate is a what?

A

Ligand

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56
Q

what alters gene expression?

A

Chromatin. Seen in child abuse - chromatin structure changes

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57
Q

influencing monoaminergic function has been shown to result in several different changes in second-messenger systems and….

A

Gene expression/downstream effects

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58
Q

Gene function may be changed without a specific alteration in the code. This change in function may also be heritable.

A

Epigenetics

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59
Q

Bipolar modification of chromatin is an example of….

A

epigenetics

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60
Q

drug capable of producing a maximum response that the target system is capable of

A

Full agonist

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61
Q

drugs that bind to and activate a given receptor but not fully

A

Partial agonist

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62
Q

Ligand that binds to the same receptor binding site as an agonist and not only antagonizes of the agonist but exerts the opposite effects by suppressing receptor signaling.

A

Inverse agonist

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63
Q

compound that has the opposite effect. Decreases the activation of a synaptic receptor by binding and blocking neurotransmitters from binding or decreasing the ammt of time neurotransmitters are in the synaptic cleft

A

Antagonists

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64
Q

system level treatment adherence

A

mental health care coverage
fragmentation of pt care
distance to care
financial barriers

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65
Q

sociocultural adherence to treatment barriers

A

attitudes and beliefs about psychiatric symptoms and treatment

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66
Q

clinical influence on tx adherence

A

cognitive impairment
substance misuse
psychiatric sx

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67
Q

tx related influences to adherence

A

tx efficacy
side effects
dose timing/frequency
psychotherapy modality

68
Q

SSRI mechanism of action

A

interact with the monoamine neurotransmitter system including the reuptake transporters that terminate the action of NE, SE, DOPAMINE

69
Q

TCA’s and MAOI’s were postulated to work by

A

increasing noradrenergic or serotonergic neurotransmission and compensating for monoamine “deficiency”

70
Q

More recent theory on how antidepressants work is that they help by creating&raquo_space;>?

A

slower adaptive responses within neurons to these initial biochemical changes - downstream effects

71
Q

SSRI’s have effects on what neurotransmitters?

A

Serotonin reuptake and some modest dopamine and norepine reuptake

72
Q

SSRIs have shown to have NON monoaminergic effects including moderate and selective effects on ________receptor expression and editing

A

glutamate

73
Q

SNRI’s inhibit and do what?

A

Inhibit reuptake of Serotonin and NE with minimal to no affinity to muscarinic cholinergic, histaminergic and adrenergic receptors

74
Q

SNRI duloxetine has been shown to

A

provide marked upregulation of BDNF and protein and redistribution of neurotrophin=potential improvement of synaptic plasticity

75
Q

Norepinephrine reuptake inhibitors mechanism of action

A

significant NE reuptake inhibition, weak affinity to serotonin reuptake, with several non-monoaminergic properties

76
Q

Reboxitine

A

NRI that inhibits nicotinic acetylcholine receptors and increasing extracellular levels of ACH
Partial agonist of kappa opioid receptor
ANTIDEPRESSANT THAT AFFECTS GLUTAMATE RECEPTORS WITH A DECREASE OF GLUR3 EXPRESSION

77
Q

mechanism of action of serotonin agonists/antagonists

A

trazodone and nefazodone are weak inhibitors of serotonin and NE reuptake.

They primarily block serotonin 5HT2A receptors and demonstrate partial agonist properties as well

Able to release Serotonin presynaptically

stimulates Mu opioid receptors

may inhibit NMDA induced cyclic GMP elevation

Overall effect in the brain appears to be an increase in extracellular levels of serotonin- possible serotonin syndrome

78
Q

Buspirone

A

full serotonin agonist at 5HT1A and partial agonist at 5TH1A post synaptic receptors

FDA approved for anxiety

79
Q

Vortioxetine

A

Recently approved antidepressant

multiple 5HT receptor antagonist

Increases extracellular SE, NE, DOP in PFC and hippocampus-increases cell proliferation and survival

stimulates maturation of immature granul cells in hippocampus

80
Q

NDRI’s mechanism of action

A

Primarily block reuptake of NE and DOP

Buproprion- dose dependent extracellular dopamine levels and NE

81
Q

Alpha2 Adrenergic receptor antagonists

A

mirtazepine and mianserin

appears to enhance release of serotonin and NE by blocking alpha receptors

Mirtazepine appears to block 5HT receptors as well

Enhance release of NE and serotonergic transmission

First alpha 2 receptor antagonist approved for depression

Also a potent H1 receptor antagonist

82
Q

TCA mechanism of action

A

Inhibit reuptake of NE and more potently than SE

Exhibits effects on glutamatergic system

Doxepine, amytriptyline, Nortriptyline-inhibity glycine

Trimipramine and clomiprimine - affinity for D2 receptors

Fairly potent blockers of HI, SE, ACH and Alpha receptors

83
Q

MAOI mechanism of action

A

Inhibit MAO- enzyme found on outer membrane of the mitochondria= catabolizes(degrades) DOP, NE, SE following reuptake from the synapse

Either loaded into vesicles for subsequent re-release or broken down by MAO

84
Q

MAO catabolizes a number of dietary pressor amines (DOP, Tyramine, triptamine, phenylithiamine.

Whats the concern?

A

Hypertensive crisis when consumption of dietary amines

85
Q

Co-administering of Dopaminergic agents and MAOI’s can

A

cause hypertensive crisis

serotonin syndrome

86
Q

How many days until MAO enzymatic activity is complete?

A

14 days

87
Q

SNRI drugs

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran ER

88
Q

NRI antidepressants

A

Stratera-Atomoxetine

Reboxetine

89
Q

Serotonin receptor antagonists/agonists antidepressants

A 
trazodone
nefazodone
vilazodone(viibryd)
vortioxetine(brintellix)
90
Q

NDRI antidepressants

A

Buproprion

91
Q

alpha 2 receptor antagonist antidepressants

A

Mirtazepine (Remeron)

92
Q

TCA antidepressants

A 
Imipramine
Desiprimine
Amitriptyline
Nortriptyline
Doxepine
Trimipramine
Protriptyline
Maprotyline
Amoxepine
Clomiprimine (Anafranil)
93
Q

MAOI antidepressants

A

Selegiline
phenelzine
Isocarboxazid
Tranylcypromine

94
Q

eldery considerations for antidepressants

A

may have alterations in hepatic metabolic pathways

alteration in demethylation&hydroxylation(involved in metabolism of ssri’s and tca

95
Q

Most common side effects of SSRI’s

A 
nausea
tremor
excessive sweating
flushing
headache
insomnia
activation or sedation
jitteriness
dizzyness
rash
dry mouth
sexual dysfunciton emergence
96
Q

SSRI cognitive symptoms

A

mental slowing
apathy and emotional blunting
motor-bruxism (grind teeth)and akathisia(agitation, restlessness)

97
Q

Less common side effects of ssri’s

A 
diarrhea
tremor
bruxism
rash 
hyponatremia
SIADH
worsening parkinson's tremors- pts needing more levodopa
abnormal bleeding with normal labs
hyperprolactinemia
98
Q

which SSRI has the most research on reproductive safety?

A

Fluoxetine

99
Q

Discontinuation syndrome sx from SSRI’s

A 
Dizzyness
insomnia
nervousness
irritabilty
nausea 
agitation
100
Q

Venlafaxine facts

A

SNRI
several meta analysis show superior to SSRI’s (w/exception to escitalopram)
Often used as a front line tx
Often used for TRD

DC for ECT- study showed asystole

101
Q

Venlafaxine common side effects

A 
nausea
insomnia
sedation
sexual dysfunction
HA
tremor
palpitations 
dizzyness
sweating
tachycardia
102
Q

Desvenlafaxine facts

A 
SNRI
CYP450 3A4/weak 2D6
common s/e- nausea, dry mouth, vomiting, constipation
sweating
tremor
somnolence
nervousness 
abnormal vision
sexual dysfunction
103
Q

Duloxetine facts

A 
SNRI
as effective as SSRI's
primarily excreted in urine
metabolized by CYP 450 2D6
good for somatic sx of depression such as pain
104
Q

Duloxetine side effects

A 
dry mouth
HA
Nausea
somnolence
sweating
insomnia 
fatigue
does NOT cause HTN
105
Q

Atomoxetine facts

A 
Strattera
NE reuptake inhibitor
FDA approved for ADHD
single open trial for tx of depression
s/e- nausea, increased BP, decreased appetite, insomnia
106
Q

Buproprion facts

A 
NDRI
tx of depression and anxiety
lacks anticholinergic properties
CYP 450 2D6- if combined with other 2d6's- can increase levels
lower incidence of gi side effects
lower risk of wt gain
107
Q

Buproprion common side effects

A 
agitation
insomnia
wt loss
dry mouth
ha
constipation
tremor

Major: Sz- more likely with bulimia and head trauma

108
Q

Trazodone facts

A

Serotonin antagonist
shown to be as effective as ssri’s but ordered less frequently
short half life but still sedating
common s/e- sedation, orthostatic hypotension, headaches
should be used with caution with pts with cardiac disease
LOWEST RISK OF ALL ANTIDEPRESSANTS FOR SZ

rare hepatoxicity/
reported overdoses
rare/serious-priapism penis and clitoris

109
Q

Nefazodone facts

A

serotonin receptor agonist
CYP 3A4- serotonin syndrom when combined w/ssri’s
lower risk of wt gain than ssri’s(appetite reducing effects)
lower risk of sexual side effects

rare/serious s/e- priapism male and female
s/e-nausea, dry mouth, constipation, headache,blurred vision
increased risk of hepatoxicity

110
Q

Vilazodone

A 
Viibryd
serotonin 5ht1a partial agonist and ssri
studies show superiority for mdd
possible less sexual side effects than ssri's
GI and insomnia sx
111
Q

Vortioxetine facts

A

Brintellix
serotonin agonist/antagonist
New for depression

112
Q

Mirtazepine facts

A

alpha 2 adrenergic receptor antagonist
more sedation and wt gain than ssris
lower risk of HA or sexual dysfunction

113
Q

TRD tx

A

combine SSRI or SNRI with a DNRI or two meds from different classes

114
Q

Antipsychotic side effects

A

metabolic syndromes
TD
extrapyramidal sx

115
Q

MS patients are at risk for?

A

2X more likely to be bipolar

116
Q

Epidemiology risk factors for BP

A

similar for men and women, may have gender differences in illness features

no difference with race, ethnicity or socioeconomic

strongest established risk factor is family hx

117
Q

Environmental risks for BP

A 
pregnancy and obstetrical complications
stressful life events
TBI
MS
Epilepsy
Decrease in omega fatty acid consumption
118
Q

Clinical features of BP

A

increased activity or agitation for one week or more
If irritable-4 rather than 3 associated sx
If hospitalized, 1 wk criteria is null
Sx must be associated with market impairment-social, occupational or psychotic sx

119
Q

Cyclothymia

A

2 yrs marked by periods of hypomania as well as periods of depressed mood and no more than two months without sx.

120
Q

manic episode criteria

A

1 wk or more of elevated or irritated mood/increase in energy

during mood disturbance 3-4 sx of: inflated self esteem, decreased need for sleep, talkative, flight of ideas, distractibility, increase in goal directed activity, increase in pleasurable activities

Marked impairment in social and occupational functioning
Not attributable to a drug physiological effects

121
Q

rapid cycling

A

patients with at least 4 distinct episodes in a year with switch to other pole or full recovery

122
Q

Bipolar pathophysiology

A 
impairment in inositol signaling
Wnt/Gsk3 pathway abnormality
circadian rhythm disruption
Decreased density of oligodendrocytes
changes in gene expression
Increased volume in striatum and amygdala
increased perfusion in PFC during mania
decrease in perfusion in PFC during depression
Metabolic abnormalities
123
Q

Genetic changes in bipolar

A

Chromatin modification

acute and chronic stress may exert epigenetic effects

124
Q

what drug can modify chromatin expression?

A

Clozapine

125
Q

atypical bipolar depression sx

A 
Reverse neurovegetative signs
overeating
carb craving
hypersomnia 
some say irritability during depression is marked for bipolarity
126
Q

median age of onset for MDD and BP

A

later on for MDD
greater onset of childhood sx is possible indicator for BP
Greater recurrence of bp episodes is indicator for BP

127
Q

personality disorder sx facts

A

more pervasive, less episodic
will not typically remit like a mood episode will
although bpd pt’s have mania or hypomania or depressive sx they don’t meet full criteria for Bipolar

128
Q

secondary mania

A

manic sx in the context of a medical illness
exposure to corticosteroids
late onset in a pt with no prior mood sx
other neurological or systemic sx

129
Q

frequently used tool to assist in bipolar recognition

A

Mood DQ

130
Q

Treatment strategies for bipolar

A

anticonvulsants
antipsychotics
traditional therapy- mood stabilizer (lithium or valproate)
psychoeducation and disease mgmt strategies

131
Q

Mania treatment

A 
Lithium
Valproate
SGA's
combo. therapy may have greater efficacy
start 1, if no improvement in a short period, add another or switch
132
Q

first line for euphoric mania

A 
lithium
quetiapine
valproate
aripiprazole
risperidone
zipprazidone
133
Q

mixed episode bipolar first line tx

A

valproate
aripiprazole
risperidone
ziprasidone

134
Q

mixed state bipolar drug class of choice for first line

A

atypical antipsychotics

135
Q

bipolar depression first line tx

A

Lamotrigine if without severe or recent hx of mania

if severe and or recent mania- antimanic + Lamotrigine

136
Q

antidepressants for Bipolar facts

A

should be avoided

If given, needs to be with a mood stabilizer

137
Q

psychosocial interventions for bipolar

A

cbt
interpersonal/social rhythm therapy (IPSRT)
family focused therapy

138
Q

treatment intervention for bipolar

A

treat the predominant mood type (mania, hypomania, depression or mixed state)

139
Q

other factors that may be contributing to cycling

A

thyroid

substance abuse

140
Q

residual mood symptoms (manic and depressive) following an acute episode appear to be predictive of……

A

earlier recurrence

141
Q

earlier onset of mood symptoms has been associated with?

A

increased severity, greater chronicity and recurrence

142
Q

panic disorder treatment

A

SSRI or SNRI

raise doses a week or so after acclimation

143
Q

quetiapine drug class

A

atypical antipsychotic

144
Q

individuals with social anxiety disorder are more at risk for what?

A

substance abuse

145
Q

treatments for social anxiety disorder

A

SSRI, SNRI first line tx
Possible quetiapine
benzos, tca and maoi’s if necessary
propanolol and atenolol

146
Q

lithium mechanism of action

A

recycling of inositol is inhibited
regulating intracellular ca
protein kinase activation

147
Q

pharmacokinetics and pharmacodynamics of lithium

A 
absorbed in the gut, rapidly distributed
peak plasma in 1-2 hrs after first dose
renal clearance
half life renal clearance-24hrs
steady levels reached in about 5 days
148
Q

meds to avoid on lithium

A

NSAIDs and cox inhibitors (decrease renal flow and increase Li levels)
Thiazide Diuretics

149
Q

lithium for children

A

No RCTs supporting it

150
Q

lithium in psychotic disorders

A

ineffective in the tx of psychosis but has been studied as an adjunct in for schizophrenia and schizoaffective

151
Q

lithium and etoh dependence

A

No proven effects

152
Q

principles of lithium tx

A

labs- bun, cr, thyroid, ekg, electrolytes
check levels after 5 days and on every change in sx.
every 2 mo for first 6 mo for lithium levels
bun, cr and thyroid check every 6 mo

153
Q

lithium dosing

A

0.6-0.8 (used to be 0.8-1.2)
begin at 600 once daily
can divide doses

154
Q

adverse events lithium

A 
hypothyroidism
polyuria but may be helpful to carefully consider a diuretic like amiloride
edema- give spironolactone
decrease in Cr clearance-decrease in GFR
rare sinus arrhythmias
GI sx-give slow release formula
tremor- propanolol or atenolol
psoriasis 
acne
155
Q

lithium toxicity s/s

A 
lethargy 
tremor
nv
confusion
visual changes
vertigo
hyperreflexia

sz
coma
arrythmia

156
Q

lithium toxicity tx

A

Hold
IV fluids
tx electrolyte imbalance

157
Q

anticonvulsants ineffective in tx bipolar

A 
gabapentin
topiramate
oxcarbazepine
pregabalin
zonisamide
tigabine
158
Q

valproate and lithium facts

A

valproate proved to be an effective antimanic
valproate is an anticonvulsant
valproate slightly more tolerable than lithium
may be slightly efficacious than lithium
antipsychotics overall more effective in tx mania than anticonvulsants
valproate not fda approved for bp maintence and not suggested
inadequate data to support valproate as effective for acute bp depression

159
Q

lamotrigine facts

A 
anticonvulsant/mood stabilizer
approved for maintenance tx of bp
lamotrigine may not help with depression
lamotrigine plus lithium effective in small randomized double blind
-limited research
Not efficacious for mania
160
Q

carbamazepine facts

A

anticonvulsant
may be efficacious for mania but no solid data showing it effective for maintenance
significant withdrawal sx

161
Q

oxcarbamazepine and gabapentin and levetiracetam for bp

A

no published placebo controlled studies

levetiracetam may cause sz

162
Q

pregabalin facts

A

binds to voltage gated ca channels
good for fibromyalgia
maybe good for anxiety
not enough evidence to use for bipolar

163
Q

tiagabine, zonisamide and topiramate facts for bp

A

anticonvulsants
Not effective for bp
topiramate (inhibit na gated ion channels)

164
Q

tiagabine mechanism of action

A

inhibitor of gaba transporter

165
Q

3 anticonvulsants that may help with bipolar

A

valproate
lamotrigine
carbamazepine

Midterm Psychopharm (2 decks)

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