Psych Flashcards
Clinical Presentation of Generalized Anxiety Disorder
Excessive anxiety and uncontrolled worry Feeling on edge poor concentration Restlessness, fatigue, muscle tension Difficulty sleeping, irritability Impairment in social or occupational functioning
Clinical Presentation of Obsessive-Compulsive Disorder
Obsessions: Recurrent thoughts, imags, and/or impulses
Compulsions: Repetitive activities and/or mental acts that reduce the anxiety caused by the obsessions.
Clinical Presentation of Panic Attack/Disorder
Physical symptoms: Chest pain or discomfort, dizziness, SOB, tachycardia, tremor, nausea, palpitations, sweating.
Psychological: Fear of losing control or dying, fear of ability to escape from fearful situations.
Agoraphobia may result from repeated panic attacks.
Clinical Presentation of Posttraumatic Stress Disorder
Triad of symptom complexes:
Reexperiencing: Flashbacks of the event, recurring and disturbing memories or dreams
Avoidance: Avoiding thoughts, feelings, conversations, people, or activities related to the event; inability to recall the event, avoiding others (isolating); sense of foreshortened furture.
Hyperarousal: Decreased concentration, insomnia, irritability, easily startled, hypervigilance.
Social Anxiety Disorder
Fear of being embarrassed, humiliated, or evaluated by others
Fear of situations: Speaking, eating, or interacting in a group of people or with authority figures; public speaking; talking with strangers.
Physical symptoms: GI upset-Diarrhea, sweating, flushing, tachycardia, tremor.
HAM-A Scale
The Hamilton Anxiety Scale (HAM-A) is the gold standard scale for anxiety disorders used in clinical trials and requires a traind rater. A score of 18-20 is significant anxiety.
A clinical response is 50% decrease in Ham-A score, recovery is a score less than 7.
Beck Anxiety Inventory
Is a brief, patient-rated scale that can distinguish anxiety symptoms from depression.
Non-pharm treatment for anxiety
CBT (Cognitive-behavioral therapy)
Most effective psychotherapy with or without drug therapy in clinical trials.
Underused because of cost, time commitment of patient, and lack of readily available trained providers.
Pharmacological Tx of Anxiety
SSRIs (1st line), SNRI, TCA, MAOI (reserved for 3rd or 4th line therapy)
Other Treatments:
Pregabalin- effective for GAD, not FDA approved
Gabapentin, not FDA approved either but can be used for GAD
Topiramate- mixed results for PTSD
Atypicals: limited evidence in augmenting therapy for GAD
Buspirone: FDA approved for GA (takes 2 weeks to see onset)
Hydroxyzine: FDA approved for anxiety
B-blockers: most often used in performance-related social anxiety.
Prazosin/Clonidine: most often used in PTSD to treat nightmares
BZD: all are effective see BZD slide.
SSRI anxiety doses initial doses should be lower than doses used for depression.
Benzodiazepines
Alprazolam shows the greatest efficacy for panic attacks and panic disorder
Overall should be avoided in elderly and PTSD population. PTSD d/t high substance abuse potential.
Limited efficacy in OCD
Discontinuation can cause rebound anxiety as well as withdrawal seizures.
If therapy lasts longer than 1 year, taper over 2-4 months. Consider changing to a longer acting BZD diazepam, clonazepam, chlordiazepoxide during the taper.
Short acting LOT
lorazepam, oxazepam, temazepam
FDA Approved Indications for Anxiolytics
Paroxetine approved for all indications.
Sertraline approved for all except GAD
Others see table 3 on page 1-8.
True or False. In clinical tries drug therapy is more effective thatn CBT for insomnia.
False, CBT is more effective long term than drugs alone.
Pharmacologic Therapy for Insomnia-BZD
- Can induce and maintain sleep
- Typical BZD used: flurazepam, triazolam, temazepam, estazolam, quazepam.
- Tolerance can delevelop
- Rebound insomnia reported with abrupt D/C
- Avoid use in elderly
Pharmacologic Therapy for Insomnia- Z hypnotics
Zolpidem, zaleplon, eszopiclone
Bind selectively to the GABA-A receptor. Thought to be less disruptive to normal sleep parameters than the BZD class.
Zaleplon (sonata) more rapid onset and shorter duration, may be repeated during the night if the patient has 4 hours left before needing to awaken.
Less hangover than BZD.
Sleep eating and sleep driving have sometimes been reported with this class.
CYP3A4 substrates except zaleplon
Rebond insomnia and tolerance less likely with zaleplong
ADRs: Amnesia, dizziness, HA, GI (Eszopiclone (lunesta) can cause metallic taste)
Pharmacologic Therapy for Insomnia- Ramelteon
Melatonin agonists
No abuse potential, not a controlled substance
Improves sleep latency-time to fall asleep; may not affect duration of sleep.
Dose: 8 mg po 30 min before bedtime. Doses above 8mg have no greater efect.
ADRs. Daytime sleepiness, hyperprolactinemia, dizziness, and stomach upset.
Ramelteon is CYP1A@ substrate. (caution with fluvoxamine)
Anticoagulant and this med may inc risk of bleeding.
Brand Name Rozerem (not available in generic)
ONSET MAY TAKE 3 WEEKS.
Pharmacologic Therapy for Insomnia-Trazodone
Serotonergic antidepressent commonly used for sleep induction.
Usual doses are much lower than those used for depression.
Starting dose 50 mg QHS
Onset of action slower, duration of action longer..more daytime hangover.
Priapism is possible with higher doses (more than 200mg) (incidence less than 1%)
Pharmacologic Therapy for Insomnia-Doxepin
TCA
Recently FDA approved under the brand name Silenor for those with insomnia and problems with sleep maintenance.
Usual dose 3-6 mg orally 30 min before sleep on an empty stomach.
Warmings include suicidal thinking and sleep-driving.
Pharmacologic Therapy for Insomnia-Antihistamines
Diphenhydramine/Doxyolamine
Tachyphylaxis to sedative effects is common, drug is usually effective for a few weeks than wears off, drug holiday is needed for continued effect.
Anticholinergic ADRs limit its usefulness.
Pharmacologic Therapy for Insomnia-Alternative Therapies (Herbal)
Melatonin (only useful for jet lag, elderly, and shift-work disorders)
Chamomile: theorized to affect the BZD receptor. Caution ragweed allergy.
Valerian: thought to inhibit breakdown of GABA or increase GABA release. no benefit in clinical trials but seems safe. case reports of hepatic toxicity.
Treatment for Sleep Apnea
Weight loss
Changing position while sleeping
surgical correction of obstruction
CPAP- continuous positive airway pressure
Modafinil/Armodafinal for excessive daytime sleepiness (does not replace CPAP)
Use sedative-hypnotic agents with caution.
Treatment Restless Leg Syndrome
Dopamine agonists are mainstay of therapy (ropinirole and pramipexole)
Ropinirole 0.25 mg 1-3 hours before bedtime, may increase slowly up to 1 mg.
Pramipexole 0.125 mg orally 1-3 hours before bedtime, can increase up to max 0.5 mg/day.
Rotigotine patch (Neupro) RLS dose intially 1 mg/day up to 3 mg day.
ADRs symptom augmentation, insomnia, dizziness, nausea, sleep attacks, psychosis.
Shift Work Sleep Disorder
Short acting BZD or Z-hypnotic can be considered to reduce lost sleep time.
Modafinil and armodafinil are FDA approved to treat the daytime sleepiness associated with work sleep disorder.
Modafinil dosing 200mg daily 1 hour before starting shift work.
Armodafinil dosing 150 mg oraly once daily 1 hour before starting shift work.
Both are substrates of CYPE 3A4 and moderately induce 3A4 induce CYP 2C19.
Major Depression Dx
Five or more Depression sx present during the same 2 week period and represent a change from previous functioning, at least one of the symptoms is either depressed mood or loss of interest or pleasure.
a. Depressed mood
b. Diminished interest
c. Weight loss
d. Insomnia or hypersomnia
e. Psychomoter agitation
f. Fatigue
g. Feelings of worthlessness
h. Diminished ability to think or concentratie
i. recurrent thoughts of death.
Scales to Measure Depression Sx
PHQ- useful in primary care to indentify depression and monitor response. (5=mild sx, 10=moderate, 15= mod-severe, 20=severe)
HAM-D, higher the score more severe depression, gold standard for trials.
Montgomery-Asberg DepressioN Rating Scale (MADRS) (another one used in clinical trials)
Beck Depression Inventory
Pharmacologic Treatment of Depression
SSRIs- generally first line.
Other options SNRIs TCA Bupropion Mirtazapine Trazodone Vilazodone
SSRIs
ADRs anxiety, irritability, sedation, sinsomnia, sexual dysfunction (10-30%), HA, seating, abnormal bleeding, hyponatremia, and GI effects.
Sertraline- may cause false positive in BZD urine drug screen.
Citalopram- not recommended in congenital long QT syndrome; should not be dosed above 40mg/day.
Fluvoxamine/Fluoxetine, paroextine (lots of drug interactions)
SNRIs
Venlafaxine (only dual inhibitor if doses >150mg/day otherwise primarily Seratonin): May elevate BP
Desvenlafaxine (doses above 50mg/day generally do not confer a greater antidepressant efficacy..just more ADRs, also concern with HTN.
Duloxetine: (monitor for hepatotoxicity)
Milnacipran(only approved for fibromyalgia in US) but studied for depression extensively in europe.
TCA
ADRs sedation, anticholinergic and cardiobascular effects.
Weight gain and sexual dysfunctioN ADRs limit toleratiblity and adherence.
Use caution in elderly
Amitriptyline, Imipramine, Doxepin, Clomipramine, Nortriptyline, Desipramine, Protriptyline, Amoxapine, Maproltiline
Often used for seation, fibromyalgia
MOA-I
Irreversible enzyme inhibitors (take 2 weeks after therapy for new enzymes to form)
Do not combine with other antidepressive agents)
Must washout for 2 weeks before switching to other drugs like fluoxetine
ADRs orthostatic hypotention, HA, GI effects, dry mouth, sexual dysfunction, HTN
Avoid Tyramine Foods
Avoid decongestants, amphetamines, Dextromethorphan, epinephrine, meperideine.
Drugs: isocarboxazide, phenelzine, tranylcypromine, selegiline.
Bupropion
weak inhibitor of dopamine and norepi, active metabolite that is a norepi reuptake inhibitor.
ADRs (insomnia, anorexia, HA, GI upset, dry mouth)
CI in seizure disorders.
May be “activating” and should be given in the morning or early afternoon to avoid insomnia.
