Mood 1 Emotional Regulation Flashcards
Emotional Regulation
ability to mange emotional responses to environmental stimuli perceived as aversive or negative
Emotional regulation involves
neurotransmitters associated w/ anxiety & depressive states
immunologic responses/inflammation
Emotional states influence
immunologic responses
risk for maladaptive emotional responses
manifest clinically through bodily symptoms
Anxiety Types
generalized anxiety disorder
social anxiety disorder
panic disorder
Fear-centered anxiety disorders
panic disorders & social anxiety disorder
situation associated w/ overwhelming negative consequences
neural structures to process threat aren’t functioning well
Worry-centered anxiety disorders
GAD
functional disruptions in neuronal circuitry
increased activity in cortical-striatal-thalmic pathway
Anxiety comorbidities
depression
panic disorder: respiratory disease, vestibular dysfunction, thyroid problems, cardiac disease
GAD: chronic pain, unexplained somatic symptoms, sleep disorder
Genetic vulnerability to anxiety
variation of 5-ht transporter geene
SSRIs
Classic fear conditioning (consolidation/reconsolidation)
amygdala/long-term memory
stronger fear memory
meds disrupt chemicals involved in this process
Neuroanatomic Pathways in Anxiety
Conditioned stimulus (read by thalamus > amygdala/visual cortex) Amygdala (confers significance on stimuli [thalamus/hypothalamus], holds emotional memories/threat asessment, controls autonomic responses) Prefrontal cortex (fear learning/extinction, registers/assigns meaning to emotions, weighs pros/cons, balances emotion/thought/controlling attention) Caudate Nucleus (orchestrates action-reward sequencing, drives behavior w/ recall of past successful outcomes)
Anxiety chemical systems
GABA-BZD-receptor system
[gaba/benzodiazepines/glutamate]
GABA
primary inhibitory amino acid neurotransmitter
Benzodiazepines
partners w/ gaba in maintaining mind-body homeostasis
Glutamate
immediate precursor to GABA
extinction
Norepinephrine
increases during states of anxiety
results in downregulation of auto receptor (increased autonomic arousal)
r/t BDZ receptors
Serotonin
(5-HT)
decreased during states of anxiety
action related to fear learning
Dopamine
DA
increased during acute stress
impairs DA reward pathways
phobic responses
Hypothalamic-pituitary-adrenal axis
threatening stimulus (fight or flight) corticotropin-releasing hormone (ACTH/glucocorticoids)
Specific phobia s/s
unreasonable or excessive/persistent fear of specific objects or siuations
Social anxiety disorder s/s
fear generated by social or performance situations w/ exposure to unfamiliar or scruntity
GAD s/s
excessive worry; difficult to control
worry generates restlesssness, fatigue, difficulty concentrating, irritability, tension, sleep disturbance
Anxiety Meds
SSRIs Selective norepinephrine reuptake inhibitors (SNRIs) Tricyclics (TCAs) monoamine oxidase inhibitors (MAOIs) Benzodiazepines Combination therapy Caution in elderly
Escitalopram (lexapro), Sertaline (zoloft) [class/moa/uses/se/bbw/contra/intxtions/preg]
antidepressant
increases availability of serotonin
tx: gneralized anxiety & depression
sexual dysfunction, dizziness, nausea, insomnia, somnolence, confusion, seizures, takes weeks to effect
increased risk of suicidal thinking (notapproved for <12 years)
no breast feeding/MAOI
w/ MAOIs cause serotonin syndrome, hypertensive crisis, hyperthermia and autonomic instability
do not give with St. John’s Worst (serotonin syndrome)
Preg Cat C
Serotonin Syndrome (HARMFUL)
hyperthermia anticognitive (delirium, confusion) reflexes (hyper) myoclonus (jerking/twitching) fast HR unconsciousness loss of GI control
Duloxetine (Cymbalta), Venlafaxine (effexor) [class/moa/uses/se/contra/bbw/intx]
serotonin-norepinephrine reuptake inhibitor (antidepressant anxiolytic)
inhibits reuptake of serotonin & norepinephrine
elevates mood
SE: abnormal dreams, sweating, constipation, dry mouth, loss of appetite, weight loss, tremor, abnormal vision, HA, n/v, dizziness, loss of sexual desire
use w/ caution in underlying CV disease, bupropion = no bueno w/ seizures
risk for suicidal actions
bupropin & levodopa increases adverse effects
impaired platelet aggregation
imipramine (Tofranil) [class/moa/uses/se/vvvw/contra/interx/preg]
TCA (antidepressants)
blocks reuptake of norepinephrine/serotonin
tx major depression off label anxiety/bedwetting in kids
se: dry mouth, blurred vision, urine retention, HTN, orthostatic hypotension, sedation, anticholinergic effect, cardiac dysrhythmias
don’t give if history of MI/heart block/arrhythmia
contra: narrow: angle glaucoma/severe renal/hepatic disease
intx: MOAIs = neuroleptic malignant syndrome, don’t give w/ oral contraceptives, phenothiazines, St. John’s wort
C
Neuroleptic Malignant Syndrome (FEVER)
fever enephalopathy vitals unstable elevated enzymes (CPK) rigidity of muscles
Phenelzine (Nardil) [class/uses/se/bbw/contra/interx/preg]
MAOIs (antidepressant)
tx: depression/panic disorder (anxiety off label)
se: orthostatic hypotension, diarrhea, HA, insomnia, rebound HTN if discontinued abruptly, overdose: seizures, resp depression, circulatory collapse, coma
increased risk of suicidal thinking, nt approved in peds
contra: CV disease, hepatic/renal impairment, pheocrhomocytoma
INtx: SSRIs (serotonin syndrome), avoid food w/ tyramine (HTN crisis), avoid caffiene for heart, avoid ginseng (HA) ma huang, ephedra, st. john’s wort (HTN crisis)
c
Do not give MOAIs w/
barbiturates TCAs antihistamines CNS depressants antihypertensives OTC cold meds cheese wine pickled foods
Tyramine Containing Foods
avocados bananas raisins papaya products canned figs cheese sour cream yogurt beer wines beef/chicken liver pate meat extracts pickled pepperoni salami sausage hotdogs soy sauce yeast chocolate
Lorazepam (Atiavn) [class/uses/SE/contra/interx/overdose/preg]
Benzodiazepines (sedative-hypnotic)
primary tx for anxiety disorders/insomnia
se: drowsiness, dizziness, resp depression, amnesia, ataxia, vision changes, n/a, physical dependence (assess airway)
contra: acute narrow-angle glaucoma, closed-angle glaucoma, liver disease, impaired brain fx, suicidal ideations
interx: can decrease anti-parkinsonism effects of levodopa, don’t admin with kava/valerian/chamomile/hops
overdose: flumazenil reverses CNS depressant
D
Nonpharmacologic TX of anxiety
CBT exposure therapy/counseling progressive muscle relaxation psychoeducation cognitive approaches for automatic thoughts/shcemas biofeedback techniques meditation
Depression
persistent feelings of sadness/lack of interest in life
Depression Classifcations
major depressive disorder persistent depressive disorder premenstrual dysphoric disorder substance/medication-induced depression post-partum depression seasonal affective disorder depression due to another medical disorder
Major Depressive Disorder def
> 1 depressive episodes of >2 weeks over lifetime
w/out history of manic/mixed/hypomanic episodes
Major Depressive Disorder s/s
depressed mood significantly less interest in activities changes in weight insomnia/hypersomnia feelings of worthlessness/guilt diminished ability to think/concentrate recurrent thoughts of death or suicide
Major Depressive Episode
last for 2 weeks +
major symptom: anhedonia (lack of interest)
at least 4 DSM-5 symptoms
Persistent Depressive Disorder s/s
depressed mood occurring on more days than not for >2 years increased overeating or decreased appetite sleeping too much or too little lower energy, fatigue low self-esteem poor concentration difficulty making decisions feelings of hopelessness
Premenstrual dysphoric Disorder
severe form of PMS resulting in depression or anxiety
s/s: mood swings, irritability, depressed mood, anxiety, lack of interest, difficulty concentrating
Chronic Depression
major depression lasting 2 years or longer
no more than a 2 month period of remission
Post-partum depression
rapid decline of estrogen
PP Psychosis = medical emergency
Depression Pathogenesis
insufficient firing of key neural networks
noradrenergic pathway, orbitofrontal complex, prefrontal cortex
Neurotransmitters r/t depression
serotonin (5-HT) regulates obsessions/compulsions
Dopamine (DA) regulates motivation, pleasure and reward
Norepinephrine (NE) regulates alertness, energy
Norepinephrine & Depression
works with dopamine
responsible for interest and energy
provides sense of hope/purpose in life
deficiency results in negative emotions
Serotonin & Depression
mediates positive mood/optimism/impulsivity
essential for keeping norepinephrine at appropriate level
projects widely to several areas of brain
pathway to hippocampus/septum/amygdala are inhibitory
other pathways control somatic fx (to hypothalamus = appetite, to brainstem = sleep)
balance maintains mood
Dopamine & Depression
reward system/deficiency r/t anhedonia
mesolimbic pathway
Stress cascade
stress response > activates hypothalamic-pituitary adrenal axis (HPA) > increased cortisol > chronic leads to decreased immunity & hippocampus atrophy
Effects of hippocampal atrophy
deficits in learning/memory formation
mood & emotion
Stress Reduction Methods
group/social support meditation yoga biofeedback self-hypnosis creative imagery thought stopping breathing exercises regular exercises proper nutrition relaxation response time management
Anterior Cingulate Cortex
emotional control, volume loss & fx alterations w/ depression
Basal Ganglia
limbi-cortical-striatel-pallidal-thalamic tract
hypoactive dorsal section of tract
lack of norepinephrine or dysfunction of monoamine pathways
overactive ventral tract
w/ depression
Hippocampus
excessive prolonged stress & overactivation of HPA axis damages hippocampal neurons = volume loss w/ dpression
Amygdala
function increased in depression = volume increases
Depression TX
TCAs
MOAIs
SSRIs
CBT
Bipolar Disorders
group of mood disorders characterized by mani, hypomanic and depressive episodes
I and II
r/disorder cyclothymic disorder (but not significant enough)
Bipolar Disorder Rapid Cycling
> 4 depressive and/or manic episodes w/in 12 months
at least 1 week for manic
2 weeks for depressive
periods of remission between
Mania
abnormal, persistently elevated, expansive or irritable mood
increased energy present every day for one week or longer
flight of ideas
pressured speech
increased participation of goal-directed activities
Hypomania
feelings of euphoria
mood and behavior changes
Depressive episodes
do not always manifest
alternate w/ mania/hypomania in bipolar I and II
Cyclothymic Disorder
reoccuring episodes of hypomanic symptoms alternating with depression over 2 years +
Manic Attack s/s (DIG FAST)
distractibility indiscretion grandiosity flight of ideas activity increase sleep deficit talkativeness
Bipolar Disorders About
no definitive cause/specific pathophysiology
idiopathic
unusual patterns of inflammation/glial cell activation
Bipolar Disorders RF
stressful life events
heritability factors
Bipolar Disorder Manic DX
must occur most of the day for a week or more (less if hospitalization required)
Bipolar Type I DX
at least one manic episode
Bipolar Type 2 DX
at least one hypomanic episode
Children Bipolar DX
must assess on basis of personal baseline
Bipolar TX
mood stabilizers: lithium
antipsychotics/anticonvulsants: valproic acid, risperiodone
lithium (Eskalith) [class/moa/use/se/intx/bbw/preg]
mood stabilizers
affects sodium transport across cell membranes
tx bipolar for purely manic or depressive episodes
se: HA, lethargy, fatigue, recent memory loss, n, v, anorexia, abdominal pain, diarrhea, dry mouth, muscle weakness, hand tremors, reversible leukocytosis, nephrogenic diabetes insipidus
intx: diuretics, NSAIDS, COX-2 Inhibitors, methyldopa, phenytoin, SSRIs, SNRIs, MOAI (
trazodone, refazodone (class/se/bbw/preg)
SARI (acute antidepressant) SE: orthostatic hypotension, constipation, diarrhea, nausea, vomiting, confusion, dizziness, HA, insomnia, blurred vision, prolonged QT, torsades, seizure, priapism, dysrhythmias BBW: suicide risk w/ MOAIs = serotonin syndrome never with saquinavir, ritonavir never admin if pregnant
buproprion (class/se/bbw/contra/interx/preg)
norepinephrine/dopamine reuptake inhibitor
helps w/ smoking cessation
antidepressant
SE: hepatoxic, mild amphetamine effect if prior drug abuse
BBW: suicidal ideation
Contra: bulimia/anorexia (seizures), zyban (same ingredient, seizure disorder, alcohol/drug withdrawal,
Interx: zyban, MOAIs
C
