Psych exam 2 Flashcards
Mania
essential feature, abnormally elevated, expansive, or irritable mood
DSM-V for bipolar disorder
3 or more present for at least 1 wk
inflated self esteem, decreased sleep, talkative
flight of ideas, distractibility, increased goal-directed activity, involvement with high risk/pleasure activities
What is bipolar disorder
cyclic disorder with periods of euthymia between episodes
What is hypomania
less severe mania present for shorter time periods (4 days)
What is rapid cycling
more than 4 moods w/in 12 months timeframe
What is bipolar 1
manic episodes
may be psychotic/delusional and require hospitalization
may have other mood episodes (hypomania, depressive)
What is bipolar 2
recurrent major depressive episodes
hypomanic episodes (NO MANIA or psychosis)
dose not affect social/work
What are acute mania treatments
mood stabilizers (lithium)
anticonvulsants (VPA, carbamazepine)
second gen antipsychotics
First and second step for acute mania
1: lithium, divalproex, or SGA, or 2-drug combo
2: 2 or 3 drug combo
+: BZD prn for short-term adjunctive tx of agitation or insomnia
What is lithium the first line tx for
acute mania, acute bipolar depression, and maintenance tx for bipolar 1 and 2 disorders
Acute and Maintenance therapeutic level for lithium
0.6-1.2 acute
0.6-1.0 maintenance
Time to steady state for drug level
3-5 days
may take 1-2 wk to see full effect of drug
combo with BZD or antipsychotics may be needed
When to get lithium levels
5-7 days after initiation
need 2 consecutive therapeutic serum concentrations during acute phase, then monitor q3-6months
draw 12 hours after evening dose (just before morning dose)
Lithium side effects early in therapy (dose dependent)
GI upset, nausea, diarrhea
fine hand tremor
polyuria/polydipsia
Lithium side effects long-term (dose independent)
cognitive effects (memory, concentration, learning)
hypothyroidism
derm
wt gain
Lithium cause polyuria/polydipsia
may decrease in intensity over time as kidneys compensate for this effect
mechanism: changes in the collecting tubules decrease sensitivity to ADH, leading to decreased concentrating ability and production of dilute urine
increases thirst
Baseline monitoring for lithium
CBC w/ diff
TSH, T3, T4
Electrolytes
Specific gravity
BUN, SCr
EKG
wt/glucose
pregnancy test
Risk factors for acute lithium toxicity
advanced age, renal insufficiency or fatigue, dehydration or malnutrition, insufficient drug monitoring, drug interactions that decrease lithium clearance
Mild lithium toxic effects
1.0-1.5 mEq/L
tremor, slurred speech, lethargy, nausea, muscle weakness, decreased concentration
Moderate lithium toxic effects
1.6-2.5 mEq/L
confusion, disorientation, drowsiness, restlessness, unsteady gait, coarse tremor, vomiting, dysarthria
Severe lithium toxic effects
> 2.5 mEq/L
poor consciousness, delirium, ataxia, EPS, convulsions, impaired renal function, coma, death
Management of acute lithium toxicity
disc lithium
disc drugs that decrease lithium concentration
decrease intestinal absorption using activated charcoal
IV fluids
Hemodialysis for lithium toxicity
goal <1 mEq/L 6-8 hours post-dialysis
li levels >2.5 mEq/L + marked sx
li levels >4
li levels btw 2.5-4, pt asymptomatic but level not expected to be <0.6 at 36 hours
Lithium drug interactions
NSAIDs, diuretics, ACE-I increase lithium levels
Sodium decreases lithium levels
Lithium in pregnancy
1st trimester associated with ebstein’s anomaly (displacement of tricuspid valve)
use in later pregnancy associated w/ fetal cardiac arrythmias, hypoglycemia, thyroid fx
What to do if you use lithium in pregnancy
use minimum dose, close monitoring levels, glomerular fx, renal perfusion
do not use in first trimester
Distribution for lithium
not protein bound
Vd=0.7 L/kg
Lithium kinetics
not metabolized (no CYP interactions)
~25% of creatine clearance
li follows Na
Factors that increase and decrease clearance of Lithium
increase: acute mania, pregnancy, Na loading
decrease: dehydration, NSAID, ACE, thiazides
Anticonvulsants for bipolar
may start at lower doses
ADE: GI and CNS
best when combined with li or divalproex
VPA ade
increase LFT
elevated ammonia levels
Carbamazepine ade
hyponatremia
BBW: agranulocytosis, SJS
reserved for tx failure w/ li or valproate
Oxcarbazepine (3rd acute mania, 4th maintenance) ade
diplopia, hyponatremia
Lamotrigine used for
only for maintenance
not in acute mania
Maintenance of bipolar disorder tx
lithium, divalproex, lamtrigine, quetiapine
2nd: carbamazepine, paliperidone, asenapine
combo w/ lithium, divalproex
Bipolar depression vs Unipolar depression
Bi: hypersomnia, hyperphagia
Uni: insomnia, decreased appetite
Tx for bipolar depression
lithium, quetiapine
lurasidone
olanzapine/fluoxetine
lamtrigine, valproate
No antidepressant monotherapy in bipolar depression
adj antidepressants for acute bipolar depression
permissible if h/o positive response w/ antidepressant
avoid if >2 manic sx, psychomotor agitation, rapid cycling
Adj therapy for bipolar maintenance
permissible if depressive relapse after stopping antidepressant
Antidepressant monotherapy for acute bipolar depression
avoid in bipolar 1 disorder
avoid in bipolar 1 & 2 depression if >2 manic sx
Lithium MOA
block hydrolysis of inositol phosphate
inhibit 5-HT1A and 5-HT1B
enhance glutamate uptake
What is lithium indicated for
acute and chronic tx of bipolar
only approved drug for maintenance therapy
Reduction in renal Na+ reaborption results in what
dehydration concentrated blood levels
What is the only anticonvulsant used for acute mania
valproic acid
valproic acid MOA
inhibitor of GABA transaminase, prevents metabolism of GABA and blocks voltage-gated Na+ and T-type Ca2+ channels
What three anticonvulsants block voltage-gated Na+ channels
carbamazepine, lamotrigine, topiramate
Chronic medical conditions associated with anxiety disorders
arrythmias, HF, diabetes, thyroid, IBS, seizures, asthma, COPD, cancer, anemia
Meds/substances associated with anxiety symptoms
albuterol, antipsychotics, antidepressants, bupropion, caffeine, decongestants, illicit drugs, levothyroxine, steroids, stimulants
GAD DSM-5
unrealistic/worry lasting for at least 6 months
3 of the follwoing:
restlessness, fatigue, difficulty concentrating, irritability, sleep disturbances, muscle tension
Common physical complaints of GAD
lump in throat, irritable bowel, numbness, headahce
Treatment goals for GAD
reduce severity and duration of anxiety sx
improve overall conditioning
long term: remission w/ minimal anxiety sx, no fx impairment, and QOL
First line therapy for GAD
antidepressants (start at low doses to develop anxiety)
TCAs or imipramine second line
Second line therapy for GAD
BZD
buspirone (partial serotonin agonist, can not be taken PRN needs 4-6 wk to work)
What properties does BZD have
anxiolytic, anticonvulsant, muscle relaxant, sedative/hypnotic properites
BZD place in therapy for GAD
rapid anxiety relief
2-4 wk as adjunct agents until antidepressants work
ADE of BZD
sedation
cognitive impairment
problems with balance, coordination
delayed reaction times
hostility, anger
respiratory depression
BZD withdrawal
anxiety, insomnia, irritability, muscle aches, tremor, nausea, depression
rare: seizures, delirium, confusion, psychosis
BZD who is at risk for use
pt with active or history of alcohol or substance use disorders
misuse is rare
How to minimize risk of BZD abuse
length of tx
contracts: duration, directions for use, follow-up, not absolute contraindication
Third line for GAD
hydroxyzine (sedative effects, used prn)
quetiapine, pregabalin
Length of tx for anxiety
12 months
risk of relapse is common if disc early
Which short acting BZD has a metabolite
xanax
Which short acting BZD do not have a metabolite
oxazepam
lorazepam* (preferred)
temazepam
What long acting BZD have a metabolite
diazepam
clonazepam
chlordiazepoxide
What is panic disorder
recurrent or unexpected panic attacks
1 attack with 1 month of 1 of the following:
concern about another attack, worry about implication of attack, significant change in behavior
Classification of panic disorder
4 of the following develop within minutes:
depersonalization, derealization, fear of losing control
ab distress, nausea, chest pain, tachycardia, palpitations, chills, sweating…
People who have panic disorder have a higher risk of what
HTN, peptic ulcer disease, depression, alcohol abuse
General issues with panic disorder therapy
anxiety responds after the actual panic attack
last to respond to tx is agoraphobia
long-term results poor
First line for panic disorder
antidepressants
start low and go slow
Second line for panic disorder
switch to another SSRI or to venlafaxine
Third line for panic disorder
imipramine, venlafaxine, or another SSRI
What happens if there is no relief after 3rd line panic disorder
add BZD for rapid relief (clonazepam, alprazolam)
beta blocker or atypical antipsychotic
Acute phase length of tx for panic disorder
1-3 months
follow up q1-2wk then q2-4wk
response is a 40% decrease in rating scale score
Maintenance phase length of tx for panic disorder
12-24 months
if med is disc taper over 4-6 months
What are the 7 dimensions of panic disorder
frequency of attack, distress during attack, anticipatory anxiety, agoraphobic, fear/avoidance, impairment of work, impairment of social
-remission s defined by a score of ≤5
Symptoms of social anxiety disorder
blushing is main symptom
trembling, sweating, tachycardia, diarrhea
more prevalent but least recognized
What is social anxiety disorder
intense, irrational, persistent fear of being negatively evaluated r scrutinized while in a social situation
exposure to the feared situation leads to panic attack
social anxiety disorder DSM-5
last 6 or months, interferes with normal routine
-persistent fear of one or more social situation
-exposure to the feared situation provokes anxiety
-person recognizes that fear is unreasonable
-feared situations are avoided or else endured w/ intense anxiety and distress
First line for social anxiety disorder
antidepressants (not fluoxetine)
What happens if there is no response or partial response to first line social anxiety disorder
no: different SSRI, venlafaxine
partial: augmentation w/ buspirone or clonazepam
other options: phenelzine, quetiapine, gabapentin, pregabalin
What to use for performance anxiety
propranolol 10-80 mg
atenolol 25-100 mg
Acute phase length of tx for performance anxiety
4-12 wk
reduce sx, phobic avoidance, social anxiety
adequate trial: 8-12 wks
Continuation phase length of tx for performance anxiety
3-6 months
improve ability to participate in social activities and QOL
dose may be increased at 6-8 wk if only partial response
Duration of maintenance tx for performance anxiety
12 months
obsessive compulsive and related disorder
OCD
hoarding
hair pulling
body dysmorphic disorder
skin picking
High comorbidities of obsessive compulsive and related disorders
depression, eating disorders, phobias, tourettes
Etiologies for obsessive compulsive and related disorder
twins
tourettes
hypoxia at birth, breech birth
encephalitis, head injury
PANDAS
DSM-5 for obsessive compulsive and related disorder
severe enough to cause marked distress to be time consuming or cause significant impairment in social or occupational functioning
-obsessions, compulsions, chronic illness
What is a good response for obsessive compulsive and related disorder
≥25% reduction in score
First line for OCD
antidepressants
-SSRI dose may exceed those in depression
-concurrent psychotherapy reduces risk of relapse
3rd line and augmentation for OCD
3: clomipramine (after failure of 2 SSRIs +/- physchotherapy)
Augmentation: low doses of risperidone or aripiprazole
Length of tx for OCD
adequate trial 8-12 wk
maintenance tx: 1-2 yr for first episode, 2-4 severe relapses, lifelong tx
What is PTSD
exposure to traumatic event one witnessed, experiences, or was confronted w/ actual or threatened death, serious injury, sexual violence, or possible harm to self or others
DSM-5 criteria for PTSD
re-experience: memories, dreams, flashbacks (at least 1)
avoidant behavior: people, convo, place, thought, activity, feeling (at least 1)
negative alterations: anhedonia, estrangement from others, inability to recall important aspects of trauma, negative mood, negative beliefs of oneself (at least 2)
hyperarousal: insomnia, irritability, poor concentration, outbursts, flashbacks, startled (at least 2)
Symptoms for PTSD category must be present for how long
at least 1 month
acute: 1-3 months
chronic: >3 months
PTSD TRAUMA
T: traumatic event
R: re-experience
A: avoidance
U: unable to fx
M: month (at least)
A: arousal
First line therapy for PTSD
antidepressants (not for combat PTSD)
FDA indication: sertraline, paroxetine
Second and third line for PTSD
2: TCA (imipramine, amitriptyline), mirtazapine
3: MAO-I
Other drugs used in PTSD
prazosin (reduce nightmares, improve sleep)
augmentation: atypical antipsychotics (risperidone, olanzapine, quetiapine)
What drug are ineffective in PTSD
bupropion and BZD
Length of tx for PTSD acute and continuation phase
acute and continuation phase: 3-4 wk after exposure to event if no improvement of symptoms
3 months response is a good long-term outcome
6-12 weeks adequate trial
Length of tx for PTSD maintenance phase
12-24 moths
some have chronic symptoms and qill require life-long tx
Non-pharm options for anxiety
CBT (1st line in mild)
Exposure therapy (exposure to triggers in safe environment)
Relaxation Techniques (deep breathing, meditation)
Non-pharm management strategies of anxiety
sleep
stay active, exercise
good nutrition
avoid or limit alcohol and other substances
reduce caffeine intake
Digital health for anxiety
mind shift (CBT)
uses management strategies based on CBT
Pt education for antidepressants
time to respond 6-8 wk
length 1 yr to life-long
reason for starting low doses
tx are not addicting (BZD short-term)
access to written info and instructions essential
BZD MOA
modulate ongoing GABA activity
increase the frequency of channel opening
BZD CNS effects enhanced when taken with other drugs
ethanol
barbiturates
antihistamines
BZD detoxification
beta blockers
treatment with antidepressants
flumazenil
hydroxyzine MOA
antihistamine
Buspirone MOA
partial 5-HT1A agonist and weak D2 mixed agonist/antagonist
What is insomnia
trouble falling and/or staying asleep
What is sleep apnea
partial or complete closure of upper airway during inspiration
signs: gasping, snoring, daytime sleepiness
Management and risk factors for sleep apnea
management: wt loss, surgery, CPAP
risk factors: obesity, FH, HTN
Type 1 vs Type 2 narcolepsy
1: with cataplexy
2: without cataplexy
Narcolepsy and treatment
excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis
tx: modafinil, armodafinil, stimulants, SSRI/SNRI, sodium oxybate
Risk factors for insomnia
increasing age, female, comorbid conditions, shift work
possibly unemployment, lower socioeconomic status
What causes insomnia
crossing time zones
blue light
stress
alcohol, smoking, or caffeine
heavy food
medicines
environmental factors
uncomfortable bed or pillow
Assessment for insomnia
primary complaint
pre sleep conditions
sleep wake patterns
Supporting information for insomnia
detailed psychiatric and med history
rating scales, questionnaires, sleep diaries
actigraphy and polysomnography
Insomnia classifications
primary (unidentifiable cause) vs comorbid (secondary to a condition)
episodic (,3 months) vs persistent (≥3 months)
recurrent (≥2 episodes within 1 year)
Digital Health for insomnia
Nox A1 PSG system
-fully wireless and portable polysomnography system that can be used in-lab and in ambulatory
easy hookup for pt comfort
What is the epworth sleepiness scale
assesses likelihood of falling asleep in a given situation
used in clinical practice and in clinical trials
DSM-5 criteria for insomnia
at least 1: difficulty initiating sleep, difficulty maintaining sleep, waking in the early morning and not being able to return to sleep
sx occur ≥3 nights per week and are present for ≥3 months
Cognitive behavioral therapy (CBT) for insomnia
1st line tx option
-combines behavioral and cognitive therapy components
goal: change faulty beliefs and unrealistic expectations about sleep
Sleep restriction therapy for insomnia
time someone spends in bed leads to negative beliefs
do not lay down, take a nap until next bedtime
goal: decrease time spent in bed; induces mild, temp sleep deprivation
if in bed for 20 minutes get up and move around
Sleep hygiene for insomnia
sleep in dark, quite place, avoid heavy meals before sleep, limit electronic devices at night, avoid caffeine
goal: change in lifestyle and environmental factors to improve sleep
Relaxation Training for insomnia
meditation, progressive muscle relaxation, imagery training
goal: reduce somatic tension, control thought patterns impairing sleep
Digital Health for insomnia
Breethe: sleep and meditation app
start your day, take a break, and go to sleep
