psychiatric disorders Flashcards
1
Q
When was the DSM-5 published?
A
May 2013
2
Q
What was different between the DSM-4 and DSM-5?
A
reorganized to reflect disorders across a continuum based on developmental and lifespan considerations
3
Q
what does the anxiety disorder chapters of the DSM-5 include?
A
generalized anxiety disorder, social anxiety disorder, panic disorder
4
Q
What are the clinically useful depression rating scales?
A
the PHQ-9 and Beck Depression Inventory
5
Q
Considerations of the PHQ-9?
A
patient rated and screens for depression and suicidal thinking
6
Q
Considerations for the Beck Depression Inventory
A
patient rated
7
Q
What is the screening tool for bipolar?
A
the Mood Disorders Questionnaire (MDQ)
8
Q
Considerations for the MDQ (Mood disorders questionnaire)
A
patent rated, screens for bipolar I (mania and depression)
9
Q
What are the two depression research screening tools
A
Hamilton Depression (HAM-D) and Montgomery Asberg Depression Rating Scale (MADRS)
10
Q
HAM-D considerations
A
clinician rated, gold standard
11
Q
MADRS considerations
A
Montgomery Asberg Depression Rating Scale (MADRS) clinician rated, used in clinical trials, gold standard
12
Q
what is the bipolar disorder rating scale
A
Young mania rating scale (YMRS)
13
Q
YMRS considerations
A
young mania rating scale (clinician rated by patient report)
14
Q
generalized anxiety rating scale
A
Hamilton Anxiety Rating Scale (HAM-A)
15
Q
Rating scales for schizophrenia clinical trials
A
Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale
16
Q
PANSS considerations
A
Positive and negative syndrome scale, gold standard and clinician rated for schizophrenia
17
Q
BPRS considerations
A
Brief psychiatric rating scale, clinician-rated gold standard
18
Q
What are the movement side effects ratings scales
A
Simpson-Angus (SAS) and Barnes Akathisia Scale (BARS)
19
Q
SAS considerations
A
Simpson Angus, evaluates drug-induced parkinsonian symptoms, clinician rated
20
Q
BARS considerations
A
Barnes Akathisia Scale, clinician rated for akathisia
21
Q
scale for tardive dyskinesia
A
Abnormal Involuntary Movement Scale (AIMS) clinician rated for tardive dyskinesia
22
Q
what is ESRS scale
A
Extrapyramidal Symptoms Rating Scale (ESRS), Clinician Rated for parkinsonian symptoms, akathesia, dystonia, and tardive dyskinesia
23
Q
Overall psychiatric functioning assessments
A
Clinical Global impressions (CGI)
CGI-S (severity)
CGI-I (improvement)
observer rated, used to assess change over time
Global Assessment of Functioning (GAF)
Clinician rated, variable results based on clinician evaluation and experience
24
Q
what are the key etiologies of schizophrenia?
A
neurodevelopmental/anatomical (increased ventricle size and changes in white and grey matter), genetics, environmental, gene-environment interaction, and neuro-development environment interaction
25
what are the positive symptoms of schizophrenia
hallucinations, delusions, bizarre behavior, thought disorders
26
what are the negative symptoms of schizophrenia
blunted emotion, poor self care, social withdrawal, poverty in speech
27
what are the cognitive symptoms of schizophrenia
decrease in cognitive function involving D1 and glutamate receptors
28
Serotonin Hypothesis of Schizophrenia
5HT2A receptor is mediator of hallucinations, antagonism and inverse agonism linked to antipsychotic activity
29
Glutamate hypothesis of schizophrenia
phencyclidine and ketamine are NMDA (glutamate receptor) inhibitors, exacerbate psychosis and cognitive deficits***
30
Dopamine hypothesis of schizophrenia
Dopamine receptor antagonists - D2 binding affinity = clinically effective
Dopaminergic agents exacerbate schizophrenia symptoms, increased D2 receptor density in schizophrenia patients
31
What are the 5HT2A receptor antagonists
clozapine, olanzapine, and risperidone
32
a1 receptor blockade effects
hypotension and sedation
33
a2 receptor blockade effects
beneficial in therapy
34
Muscarinic receptor blockade effects and drugs
anticholinergic effects, clozapine thioridazine
35
H1 receptor antagonists effects
sedation and weight gain
36
D2 antagonist effects in basal ganglia (nigrostriatal pathway)
motor effects and EPS (parkinsonian symptoms)
37
D2 antagonist effects in mesolimbic pathway
primary therapeutic effects
38
d2 antagonist effects in medulla
anti-emetics
39
EPS - what is it and occurance
Extrapyramidal symptoms (dystonia, pseudo parkinsonism, tremor, akathisia)
Occur early and is reversible
40
Drug therapy for EPS
anticholinergics (benztropine) and antihistamines (benadryl), and dopamine releasing agents (amantadine), and propanolol
41
what is tardive dyskinesia
super sensitivity of receptors to dopamine, rhythmic involuntary movement, jerky-random movement, occurs months to years and is irreversible
42
how to monitor for tardive dyskinesia
AIMS (abnormal involuntary movement scale)
43
tardive dyskinesia treatment
VMAT inhibitors
44
VMAT inhibitors names
tetrabenazine, valbenazine, deutetrabenazine
45
VMAT2 inhibitors treatment
Add-on treatment for tardive dyskinesia
46
what is NMS
neuroleptic malignant syndrome (rare)
EPS symptoms with fever, impaired cognition, and muscle rigidity (fatal)
47
neuroleptic malignant syndrome treatment
DA agonist, diazepam, dantrolene (skeletal muscle relaxant)
48
what antipsychotic is used for tourettes?
Orap (pimozide)
49
muscarinic receptor blockade effects
dry mouth, difficulty urinating, constipation (SSPS)
50
alpha blockade effects
hypotension, impotence
51
dopamine blockade effects
parkinsons symptoms, akathesia, dystonia
52
supersensitivity of dopamine receptor effects
tardive dyskinesia
53
muscarinic blockade effects in CNS
toxic-confusional state
54
H1 blockade effects in CNS
sedation, weight gain
55
hyperprolactinemia effects
amenorrhea, infertility,, impotence
56
H1 and 5HT2 blockage
sedation and weight gain
57
Contraindications for antipsychotics
cardiovascular disease, parkinsons, epilepsy (clozapine), and diabetes (newer agents)
58
what does high 5HT2A/D2 ratio cause?
weight gain/metabolic effects
59
what does high clinical potency/D2 cause?
more risk for EPS
60
What are sedative properties caused by?
H1 block
61
what are hypotensive properties caused by?
A1 block
62
side effects of the typical first generation antipsychotics
more movement and EPS problems, strong D2 block, higher risk for tardive dyskinesia
63
Alphiatic phenothiazine drug
chlorpromazine (thorazine) and promethazine (phenergan)
promethazine also has H1 block, used for N/V
64
piperidine phenothiazine
thioridazine (mellaril), sedation, hypotension, anticholinergic, many SE
65
piperazine phenothiazines
Fluphenazine (permitil), strong EPS
Prochlorperazine (Compazine) - antiemetic
Perphenazine (Trilafon)
66
Thioxanthines
thiothixene (Navane) EPS
67
Butyrophenones
Haloperidol (Haldol) - EPS
68
Misc antipsychotics
Molindone (Moban)
- Moderate EPS, use with anticholinergic
Pimozide (Orap)
- use for tourettes
69
Chlorpromazine key points
1st antipsychotic, antihistamine side effects
70
Promethazine key points
antihistamine, antiemetic
71
thioridazine key points
Many SE: anticholinergic, sedation, sexual dysfunction, cardiovascular
72
Fluephenazine key points
EPS
73
prochlorperazine key points
anti-emetic
74
perphenazine key points
Catie studies, use with anticholinergic
75
thiothixene, haloperidol, and molindone key points
Modest EPS, EPS, Modest EPS
76
Pimozide (orap) key points
Tourette's disease, suppresses motor and vocal tics
77
Side effects of the second generation antipsychotics
Reduced EPS, dual 5HT2A and D2 blockers, more metabolic problems, linked to diabetes (olanzapine and clozapine)
78
Clozapine about
Clozaril, 1st atypicical (most effective)
causes agranulocytosis (weekly blood monitoring)
anticholinergic and antihistamine side effects, less movement disorders
79
Olanzapine about
Zyprexa; Weight gain but less N/V, less EPS, diabetes risk
80
Loxapine about
Loxitane; inhibits NET (also used as antidepressant)
81
Quetiapine about
Seroquel; metabolite w/ antidepressant activity, 5HT2A and D2, low EPS, hypotension (a1), sedation (h1), diabetes risk
82
risperidone about
5HT2A and D2 antagonist, low EPS, weight gain and some sedation
83
paliperidone
Invega 9-hydroxyrisperidone
84
Iloperidone
Fanapt
very potent a1
85
Ziprasidone
5HT2A, D2, a1
prolongs QT interval
86
Asenapine
5HT2a and D2
87
Lurasidone
Latuda; 5HT2a and D2
Less weight gain and metabolic effects, fast onset
88
Pimavanserin (nuplazid)
inverse agonist (5HT2A) parkinson disease psychosis
89
aripiprazole
Abilify, 5HT2 and D2, partial agonist at 5HT1a, moderate affinity for D4, a , and histamine receptors
Side effects: weight gain
90
What are the D2/D3 partial agonists
Brexiprazole (Rexulti), Cariprazine (vraylar), and Lumateperone (Caplyta)
91
clozapine key points
1st atypical, agranulocytosis, diabetes risk, superior efficacy
92
olanzapine key points
weight gain, diabetes risk
93
quetiapine key points
metabolite with antidepressant activity, hypotension, sedation
94
risperidone key points
5HT2A/D2 antagonist
95
Ziprasidone
5HT2a/D2, A1, prolongs QT interval
96
Lurasidone
5HT2A/D2, reduced metabolic effects
97
Aripiprazole
5HT2A/D2 affinity, partial agonist activity
98
what is KarXT
dual M1/M4 agonist with peripheral muscarinic antagonist
99
psychotic disorders features
delusions, hallucinations, disorganized thinking and speech, disorganized or abnormal motor behavior
100
negative symptoms
relate to long term functioning
101
1A2 substrate antipsychotics
olanzapine, asenapine, clozapine, loxapine
102
marijuana, cocaine, and amphetamines
exacerbate symptoms, may cause earlier onset
103
typical antipsychotics about
older agents, primarily D2 receptor antagonists, good efficacy for positive symptoms, may worsen negative symptoms
104
typical antipsychotic clinical pearls
- haloperidol most common (routine and PRN)
- more EPS with higher potency typicals
105
atypical antipsychotics general about
D2 + 5HT2A antagonists
less EPS but more metabolic effects
106
what are the partial agonists
aripiprazole, brexiprazole, cariprazine
107
aripiprazole, brexiprazole, cariprazine about
more akathesia than other atypicals, all are adjunct depression treatments
108
Aripiprazole about
2D6 and 3A4 substrate, moderate akathesia, low weight gain
109
brexiprazole about
2D6 and 3A4 substrate, moderate akathesia, low to moderate weight gain
110
cariprazine about
3A4 substrate, moderate akathesia, low to moderate weight gain
111
the pines medications
asenapine, clozapine, olanzapine, quetiapine
112
the pines counseling
all cause weight gain
113
Asenapine about
comes in SL and patch formulation, 1A2 substrate, QTC prolongation
114
Clozapine about
1A2 substrate, boxed warnings, caused the most weight gain, QTc prolongation, 3rd line but very effective
115
Olanzapine about
1A2 substrate, weight gain and sedation, metabolic syndrome, DRESS warning
116
Quetiapine about
3A4 substrate, QTC prolongation, weight gain and sedation, boxed warning for suicidal ideation
117
Asenapine patch about (Secuado)
QTC prolongation, apply every 24 hours, UGT and 1A2 substrate
118
clozapine REMS
weekly x6 months, biweekly x 6months, then monthly
119
Lybalvi (Olanzapine/Samidorphan)
samidorphan- opioid antagonist (reduces weight gain)
120
What are the dones?
Iloperidone, lurasidone, ziprasidone, risperidone, paliperidone
121
Iloperidone about
high risk dizziness and syncope, QTC prolongation, 2D6
122
Lurasidone about
3A4 substrate, akathesia risk, adjunct for bipolar depression, take with food (low weight gain risk)
123
Ziprasidone about
QTC prolongation C/I, DRESS warning, take with food,
124
Risperidone
2D6 substrate, EPS hyperprolactinemia, weight gain, sedation, orthostasis
125
paliperidone
renally eliminated, EPS hyperprolactinemia, weight gain, sedation, orthostasis, QTC prolongation
126
lumateperone (Caplyta)
low risk weight gain or other metabolic effects, low risk EPS or akathesia, 3A4 substrate
127
typical LAI
haloperidol decanoate
128
risperdal consta (risperidone)
weekly injection; must supplement orally for 3 weeks
129
Perseris (risperidone)
abdominal SQ injection; use higher dose with 3A4 inducers
130
Rykindo (risperidone)
Q2W IM injection; must do oral overlap for one week
131
Uzedy (risperidone)
Abdominal or upper arm SQ injection (once monthly or every 2 months)
132
Invega sustenna (paliperidone)
loading dose, booster after 1 week, then every 4 weeks, must be given in deltoid, no oral overlap, renally eliminatd
133
invega trinza (paliperidone Q3M)
only for patients who have done invega sustenna for four months, deltoid administraton, not recommended CrCl<50
134
invega hafyera (paliperidone Q6 months)
only for patients who have done invega sustenna for four months, gluteal injection
135
zyprexa relprevv (olanzapine)
REMS, post dose delirium sedation syndrome
136
abilify maintena (aripiprazole)
overlap with oral aripiprazole for 14 days, deltoid or gluteal injection
137
abilify maintena dose adustments
dose adjust if taking 2D6 or 3A4 inhibitor or inducers
138
abilify asimtufii (aripiprazile)
every 2 month dosing, gluteal injection only, oral aripiprazole for 2 weeks
139
Aristada (aripiprazle lauroxil)
prodrug, overlap with oral for 3 weeks
140
Aristada Initio
use to forgo 3 weeks oral overlap with aristada, avoid with 2D6 or 3A4 inhibitors
141
Immediate release injections
haloperidol most common (chlorpromazine, fluphenazine)
142
immediate release antipsychotics with benzos?
Olanzapine cannot be given with IR benzos
143
Adasuve
Loxqapine IR nasal spray
144
dystonia and drug-induced parkinsons treatment
benztropine and diphenhyramine, trihexphenidyl (parkinsosn)
145
akathesia treatment
propanolol and lorazepam
146
tardive dyskinesia treatment
VMAT inhibitors
147
VMAt inhibitors drugs
Valbenazine (2D6/3A4 and QTC prolongation) and Deutrabenazine (2D6 substrate and QTC prolongation)
148
Neuroleptic Malignant Syndrome
Emergency; tachycardia labile blood pressure, muscle rigidity, muscle breakdown
149
drugs causing anxiety
albuterol, caffeine, decongestants, levothyroxine, steroids, stimulants
150
benzos without long acting metabolite
alprazolam, lorazepam, clonazepam, and oxazepam
151
benzos with long acting metabolite
diazepam, chlorazepate, chlordiazepoxide
152
which benzos are preferred in the elderly?
LOT, lorazepam, oxazepam, and temazepam
153
hydroxyzine
approved for generalozed anxiety disorder, used prn for anxiety and insomnia, sedation and anticholinergic side effects, QTC prolongation, do not use in the elderly
154
propanolol
- acute physiological anxiety symptoms, perdormance and situational anxiety
155
what natural products can be used for anxiety
Kava, St. John's Wort, Passionflower, Valerian, Chamomile
156
first line for anxiety?
SSRIs and SNRIs & Buspar
157
when can antipsychotics be used?
treatment resistant OCD (aripiprazole and risperidone)
158
When are SNRI meds used for anxiety?
when the patient also has a pain syndrome (Duloxetine)
159
When are benzos used?
generally not first line, can be bridge therapy
160
Hydroxyzine use?
typically as needed
161
Social anxiety disorder first line?
SSRIs, then SNRIs, the beta blockers (propanolol)
162
Panic disorder treatment
SSRIs, then SNRIs (benzos not first line)
163
OCD treatment
SSRIs are first line, 25-50% reduction in symptoms
164
PTSD treatment
SSRIs/SNRIs (prazosin for sleep or nightmares)
165
SSRIs/SNRIs anxiety clinical pearl on exam
Jitteriness syndrome; initial doses should be lower than depression doses.
- SSRI onset in 2-4 weeks
- Abrupt d/c of benzos is bad
166
Disease states/medications associated with insomnia
anxiety, caffeine, modafinil, amphetamines, beta-agonists, beta-blockers, nicotine, thyroid meds, mood disorders, bupropion, decongestants, methylphenidate
167
insomnia criteria
3 nights per week for at least 3 months
168
insomnia first line treatment
non-pharmacologic; sleep hygeine
169
z-hypnotics info
zolpidem (5mg in women and elderly), eszopiclone, zaleplon (all are 3A4 substrates) (somnolence, dizziness, ataxia, headache) (parasomnia) (CNS depressants)
170
benzos for sleep
temazepam (drowsiness, dizziness, cognitive impairment, fall risk)
171
Melatonin receptor agonists
Ramelteon and Tasimelteon, both are 1A2 substrates
172
ramelteon info
contraindicated with fluvoxamine, GI upset, next day drowsiness, prolactinemia
173
tasismelteon info
FDA approved for sleep wake disorder; melatonin receptor antagonist
174
What are the orexin receptor antagonists
Suvorexant, Lemborexant, Daridorexant
175
orexin receptor antagonists counseling
take with at least 7 hours to sleep, contraindicated in narcolepsy, all are 3A4 substrates
176
Doxepin info for insomnia
TCA, H1 receptor antagonist, anticholinergic side effects
177
trazodone for insomnia info
not FDA approved 25-100g, long half life
178
mirtazapine for insomnia info
Clinically used as a sleep agent in patients with depression
179
Quetiapine for insomnia info
can be used for insomnia with co-morbid psychiatric disorders
180
benadryl/unisom
not recommended by AASM, anticholinergic side effects
181
Natural products for sleep
melatonin- used for jet lag and in patients with low melatonin levels
1A2 substrate
Chamomile - allergy in patients with daisy or ragweed allergy.
182
treatment algorithm - insomnia
lifestyle mods first
183
Obstructive sleep apnea
- need 5 obstructive apneas per hour of sleep (confirmed by polysomnography)
- symptoms: daytime sleepies, snoring, headache, irritability, sore throat, ED, memory impairment, GERD, mood disturbances, pauses in breathing during sleep.
184
when is polysomnography indicated?
cardiorespiratory disease, respiratory muscle weakness, hypoventilation, opioid medication use, history of stroke, severe insomnia
185
Sleep apnea treatment
weight loss, smoking cessation, avoid alcohol and CNS depressants, CPAP, modafinil/armodafinil
186
narcolepsy tetrad
EDS, cataplexy, hallucinations, sleep paralysis
187
Cataplexy treatment
sodium Oxybate (Xyrem) or Xywav (adults and children 7+)
Lumryz (adults only, once nightly dosing)
188
excessive daytime sleepiness treatment
modafinil/armodafinil treatment (rash possible), sodium oxybate, pitolisant and solriamfetol
189
Pitolisant (Wakix)
H3 receptor agonist/inverse agonist, prolongs QT interval, C/I with hepatic impairment, avoid with otc antihistamines, 3A4 inducer, 2D6/3A4 substrate
190
Solriamfetol (Sunosi)
Dopamine norepinephrine reuptake inhibitor, wakefulness for adults, renal dose adjustment 37.5mg, BP and HR increases (avoid in unstable CV disease arrythmias, caution in uncontrolled psychosis.
191
Shift work Sleep Disorder treatment
Modafinil and Armodafinil
192
Restless Leg Syndrome treatment
gabapentin enacarbil, dopamine agonists (pramipexole/ropinirole), iron supplementation
193
what medication is contraindicated in eating disorders?
bupropion
194
binge eating disorder treatment
lisdexamfetamine
195
bulimia treatment
fluoxetine
196
what is the low-end of normal BMI?
18.5kg/m2
197
what is re-feeding syndrome
fat metabolism--> glucose metabolism. Cause hypokalemia, water retention, and severe edema resulting in multiple organ failure.
