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Therapeutics 2 > psychiatric disorders > Flashcards

psychiatric disorders Flashcards

1
Q

When was the DSM-5 published?

A

May 2013

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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

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3
Q

what does the anxiety disorder chapters of the DSM-5 include?

A

generalized anxiety disorder, social anxiety disorder, panic disorder

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4
Q

What are the clinically useful depression rating scales?

A

the PHQ-9 and Beck Depression Inventory

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5
Q

Considerations of the PHQ-9?

A

patient rated and screens for depression and suicidal thinking

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6
Q

Considerations for the Beck Depression Inventory

A

patient rated

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7
Q

What is the screening tool for bipolar?

A

the Mood Disorders Questionnaire (MDQ)

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8
Q

Considerations for the MDQ (Mood disorders questionnaire)

A

patent rated, screens for bipolar I (mania and depression)

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9
Q

What are the two depression research screening tools

A

Hamilton Depression (HAM-D) and Montgomery Asberg Depression Rating Scale (MADRS)

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10
Q

HAM-D considerations

A

clinician rated, gold standard

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11
Q

MADRS considerations

A

Montgomery Asberg Depression Rating Scale (MADRS) clinician rated, used in clinical trials, gold standard

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12
Q

what is the bipolar disorder rating scale

A

Young mania rating scale (YMRS)

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13
Q

YMRS considerations

A

young mania rating scale (clinician rated by patient report)

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14
Q

generalized anxiety rating scale

A

Hamilton Anxiety Rating Scale (HAM-A)

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15
Q

Rating scales for schizophrenia clinical trials

A

Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale

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16
Q

PANSS considerations

A

Positive and negative syndrome scale, gold standard and clinician rated for schizophrenia

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17
Q

BPRS considerations

A

Brief psychiatric rating scale, clinician-rated gold standard

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18
Q

What are the movement side effects ratings scales

A

Simpson-Angus (SAS) and Barnes Akathisia Scale (BARS)

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19
Q

SAS considerations

A

Simpson Angus, evaluates drug-induced parkinsonian symptoms, clinician rated

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20
Q

BARS considerations

A

Barnes Akathisia Scale, clinician rated for akathisia

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21
Q

scale for tardive dyskinesia

A

Abnormal Involuntary Movement Scale (AIMS) clinician rated for tardive dyskinesia

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22
Q

what is ESRS scale

A

Extrapyramidal Symptoms Rating Scale (ESRS), Clinician Rated for parkinsonian symptoms, akathesia, dystonia, and tardive dyskinesia

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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

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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

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25
Q

what are the positive symptoms of schizophrenia

A

hallucinations, delusions, bizarre behavior, thought disorders

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26
Q

what are the negative symptoms of schizophrenia

A

blunted emotion, poor self care, social withdrawal, poverty in speech

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27
Q

what are the cognitive symptoms of schizophrenia

A

decrease in cognitive function involving D1 and glutamate receptors

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28
Q

Serotonin Hypothesis of Schizophrenia

A

5HT2A receptor is mediator of hallucinations, antagonism and inverse agonism linked to antipsychotic activity

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29
Q

Glutamate hypothesis of schizophrenia

A

phencyclidine and ketamine are NMDA (glutamate receptor) inhibitors, exacerbate psychosis and cognitive deficits***

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30
Q

Dopamine hypothesis of schizophrenia

A

Dopamine receptor antagonists - D2 binding affinity = clinically effective
Dopaminergic agents exacerbate schizophrenia symptoms, increased D2 receptor density in schizophrenia patients

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31
Q

What are the 5HT2A receptor antagonists

A

clozapine, olanzapine, and risperidone

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32
Q

a1 receptor blockade effects

A

hypotension and sedation

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33
Q

a2 receptor blockade effects

A

beneficial in therapy

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34
Q

Muscarinic receptor blockade effects and drugs

A

anticholinergic effects, clozapine thioridazine

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35
Q

H1 receptor antagonists effects

A

sedation and weight gain

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36
Q

D2 antagonist effects in basal ganglia (nigrostriatal pathway)

A

motor effects and EPS (parkinsonian symptoms)

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37
Q

D2 antagonist effects in mesolimbic pathway

A

primary therapeutic effects

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38
Q

d2 antagonist effects in medulla

A

anti-emetics

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39
Q

EPS - what is it and occurance

A

Extrapyramidal symptoms (dystonia, pseudo parkinsonism, tremor, akathisia)
Occur early and is reversible

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40
Q

Drug therapy for EPS

A

anticholinergics (benztropine) and antihistamines (benadryl), and dopamine releasing agents (amantadine), and propanolol

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41
Q

what is tardive dyskinesia

A

super sensitivity of receptors to dopamine, rhythmic involuntary movement, jerky-random movement, occurs months to years and is irreversible

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42
Q

how to monitor for tardive dyskinesia

A

AIMS (abnormal involuntary movement scale)

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43
Q

tardive dyskinesia treatment

A

VMAT inhibitors

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44
Q

VMAT inhibitors names

A

tetrabenazine, valbenazine, deutetrabenazine

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45
Q

VMAT2 inhibitors treatment

A

Add-on treatment for tardive dyskinesia

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46
Q

what is NMS

A

neuroleptic malignant syndrome (rare)
EPS symptoms with fever, impaired cognition, and muscle rigidity (fatal)

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47
Q

neuroleptic malignant syndrome treatment

A

DA agonist, diazepam, dantrolene (skeletal muscle relaxant)

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48
Q

what antipsychotic is used for tourettes?

A

Orap (pimozide)

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49
Q

muscarinic receptor blockade effects

A

dry mouth, difficulty urinating, constipation (SSPS)

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50
Q

alpha blockade effects

A

hypotension, impotence

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51
Q

dopamine blockade effects

A

parkinsons symptoms, akathesia, dystonia

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52
Q

supersensitivity of dopamine receptor effects

A

tardive dyskinesia

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53
Q

muscarinic blockade effects in CNS

A

toxic-confusional state

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54
Q

H1 blockade effects in CNS

A

sedation, weight gain

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55
Q

hyperprolactinemia effects

A

amenorrhea, infertility,, impotence

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56
Q

H1 and 5HT2 blockage

A

sedation and weight gain

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57
Q

Contraindications for antipsychotics

A

cardiovascular disease, parkinsons, epilepsy (clozapine), and diabetes (newer agents)

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58
Q

what does high 5HT2A/D2 ratio cause?

A

weight gain/metabolic effects

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59
Q

what does high clinical potency/D2 cause?

A

more risk for EPS

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60
Q

What are sedative properties caused by?

A

H1 block

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61
Q

what are hypotensive properties caused by?

A

A1 block

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62
Q

side effects of the typical first generation antipsychotics

A

more movement and EPS problems, strong D2 block, higher risk for tardive dyskinesia

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63
Q

Alphiatic phenothiazine drug

A

chlorpromazine (thorazine) and promethazine (phenergan)
promethazine also has H1 block, used for N/V

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64
Q

piperidine phenothiazine

A

thioridazine (mellaril), sedation, hypotension, anticholinergic, many SE

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65
Q

piperazine phenothiazines

A

Fluphenazine (permitil), strong EPS
Prochlorperazine (Compazine) - antiemetic
Perphenazine (Trilafon)

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66
Q

Thioxanthines

A

thiothixene (Navane) EPS

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67
Q

Butyrophenones

A

Haloperidol (Haldol) - EPS

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68
Q

Misc antipsychotics

A

Molindone (Moban)
- Moderate EPS, use with anticholinergic
Pimozide (Orap)
- use for tourettes

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69
Q

Chlorpromazine key points

A

1st antipsychotic, antihistamine side effects

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70
Q

Promethazine key points

A

antihistamine, antiemetic

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71
Q

thioridazine key points

A

Many SE: anticholinergic, sedation, sexual dysfunction, cardiovascular

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72
Q

Fluephenazine key points

A

EPS

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73
Q

prochlorperazine key points

A

anti-emetic

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74
Q

perphenazine key points

A

Catie studies, use with anticholinergic

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75
Q

thiothixene, haloperidol, and molindone key points

A

Modest EPS, EPS, Modest EPS

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76
Q

Pimozide (orap) key points

A

Tourette’s disease, suppresses motor and vocal tics

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77
Q

Side effects of the second generation antipsychotics

A

Reduced EPS, dual 5HT2A and D2 blockers, more metabolic problems, linked to diabetes (olanzapine and clozapine)

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78
Q

Clozapine about

A

Clozaril, 1st atypicical (most effective)
causes agranulocytosis (weekly blood monitoring)
anticholinergic and antihistamine side effects, less movement disorders

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79
Q

Olanzapine about

A

Zyprexa; Weight gain but less N/V, less EPS, diabetes risk

80
Q

Loxapine about

A

Loxitane; inhibits NET (also used as antidepressant)

81
Q

Quetiapine about

A

Seroquel; metabolite w/ antidepressant activity, 5HT2A and D2, low EPS, hypotension (a1), sedation (h1), diabetes risk

82
Q

risperidone about

A

5HT2A and D2 antagonist, low EPS, weight gain and some sedation

83
Q

paliperidone

A

Invega 9-hydroxyrisperidone

84
Q

Iloperidone

A

Fanapt
very potent a1

85
Q

Ziprasidone

A

5HT2A, D2, a1
prolongs QT interval

86
Q

Asenapine

A

5HT2a and D2

87
Q

Lurasidone

A

Latuda; 5HT2a and D2
Less weight gain and metabolic effects, fast onset

88
Q

Pimavanserin (nuplazid)

A

inverse agonist (5HT2A) parkinson disease psychosis

89
Q

aripiprazole

A

Abilify, 5HT2 and D2, partial agonist at 5HT1a, moderate affinity for D4, a , and histamine receptors
Side effects: weight gain

90
Q

What are the D2/D3 partial agonists

A

Brexiprazole (Rexulti), Cariprazine (vraylar), and Lumateperone (Caplyta)

91
Q

clozapine key points

A

1st atypical, agranulocytosis, diabetes risk, superior efficacy

92
Q

olanzapine key points

A

weight gain, diabetes risk

93
Q

quetiapine key points

A

metabolite with antidepressant activity, hypotension, sedation

94
Q

risperidone key points

A

5HT2A/D2 antagonist

95
Q

Ziprasidone

A

5HT2a/D2, A1, prolongs QT interval

96
Q

Lurasidone

A

5HT2A/D2, reduced metabolic effects

97
Q

Aripiprazole

A

5HT2A/D2 affinity, partial agonist activity

98
Q

what is KarXT

A

dual M1/M4 agonist with peripheral muscarinic antagonist

99
Q

psychotic disorders features

A

delusions, hallucinations, disorganized thinking and speech, disorganized or abnormal motor behavior

100
Q

negative symptoms

A

relate to long term functioning

101
Q

1A2 substrate antipsychotics

A

olanzapine, asenapine, clozapine, loxapine

102
Q

marijuana, cocaine, and amphetamines

A

exacerbate symptoms, may cause earlier onset

103
Q

typical antipsychotics about

A

older agents, primarily D2 receptor antagonists, good efficacy for positive symptoms, may worsen negative symptoms

104
Q

typical antipsychotic clinical pearls

A
  • haloperidol most common (routine and PRN)
  • more EPS with higher potency typicals
105
Q

atypical antipsychotics general about

A

D2 + 5HT2A antagonists
less EPS but more metabolic effects

106
Q

what are the partial agonists

A

aripiprazole, brexiprazole, cariprazine

107
Q

aripiprazole, brexiprazole, cariprazine about

A

more akathesia than other atypicals, all are adjunct depression treatments

108
Q

Aripiprazole about

A

2D6 and 3A4 substrate, moderate akathesia, low weight gain

109
Q

brexiprazole about

A

2D6 and 3A4 substrate, moderate akathesia, low to moderate weight gain

110
Q

cariprazine about

A

3A4 substrate, moderate akathesia, low to moderate weight gain

111
Q

the pines medications

A

asenapine, clozapine, olanzapine, quetiapine

112
Q

the pines counseling

A

all cause weight gain

113
Q

Asenapine about

A

comes in SL and patch formulation, 1A2 substrate, QTC prolongation

114
Q

Clozapine about

A

1A2 substrate, boxed warnings, caused the most weight gain, QTc prolongation, 3rd line but very effective

115
Q

Olanzapine about

A

1A2 substrate, weight gain and sedation, metabolic syndrome, DRESS warning

116
Q

Quetiapine about

A

3A4 substrate, QTC prolongation, weight gain and sedation, boxed warning for suicidal ideation

117
Q

Asenapine patch about (Secuado)

A

QTC prolongation, apply every 24 hours, UGT and 1A2 substrate

118
Q

clozapine REMS

A

weekly x6 months, biweekly x 6months, then monthly

119
Q

Lybalvi (Olanzapine/Samidorphan)

A

samidorphan- opioid antagonist (reduces weight gain)

120
Q

What are the dones?

A

Iloperidone, lurasidone, ziprasidone, risperidone, paliperidone

121
Q

Iloperidone about

A

high risk dizziness and syncope, QTC prolongation, 2D6

122
Q

Lurasidone about

A

3A4 substrate, akathesia risk, adjunct for bipolar depression, take with food (low weight gain risk)

123
Q

Ziprasidone about

A

QTC prolongation C/I, DRESS warning, take with food,

124
Q

Risperidone

A

2D6 substrate, EPS hyperprolactinemia, weight gain, sedation, orthostasis

125
Q

paliperidone

A

renally eliminated, EPS hyperprolactinemia, weight gain, sedation, orthostasis, QTC prolongation

126
Q

lumateperone (Caplyta)

A

low risk weight gain or other metabolic effects, low risk EPS or akathesia, 3A4 substrate

127
Q

typical LAI

A

haloperidol decanoate

128
Q

risperdal consta (risperidone)

A

weekly injection; must supplement orally for 3 weeks

129
Q

Perseris (risperidone)

A

abdominal SQ injection; use higher dose with 3A4 inducers

130
Q

Rykindo (risperidone)

A

Q2W IM injection; must do oral overlap for one week

131
Q

Uzedy (risperidone)

A

Abdominal or upper arm SQ injection (once monthly or every 2 months)

132
Q

Invega sustenna (paliperidone)

A

loading dose, booster after 1 week, then every 4 weeks, must be given in deltoid, no oral overlap, renally eliminatd

133
Q

invega trinza (paliperidone Q3M)

A

only for patients who have done invega sustenna for four months, deltoid administraton, not recommended CrCl<50

134
Q

invega hafyera (paliperidone Q6 months)

A

only for patients who have done invega sustenna for four months, gluteal injection

135
Q

zyprexa relprevv (olanzapine)

A

REMS, post dose delirium sedation syndrome

136
Q

abilify maintena (aripiprazole)

A

overlap with oral aripiprazole for 14 days, deltoid or gluteal injection

137
Q

abilify maintena dose adustments

A

dose adjust if taking 2D6 or 3A4 inhibitor or inducers

138
Q

abilify asimtufii (aripiprazile)

A

every 2 month dosing, gluteal injection only, oral aripiprazole for 2 weeks

139
Q

Aristada (aripiprazle lauroxil)

A

prodrug, overlap with oral for 3 weeks

140
Q

Aristada Initio

A

use to forgo 3 weeks oral overlap with aristada, avoid with 2D6 or 3A4 inhibitors

141
Q

Immediate release injections

A

haloperidol most common (chlorpromazine, fluphenazine)

142
Q

immediate release antipsychotics with benzos?

A

Olanzapine cannot be given with IR benzos

143
Q

Adasuve

A

Loxqapine IR nasal spray

144
Q

dystonia and drug-induced parkinsons treatment

A

benztropine and diphenhyramine, trihexphenidyl (parkinsosn)

145
Q

akathesia treatment

A

propanolol and lorazepam

146
Q

tardive dyskinesia treatment

A

VMAT inhibitors

147
Q

VMAt inhibitors drugs

A

Valbenazine (2D6/3A4 and QTC prolongation) and Deutrabenazine (2D6 substrate and QTC prolongation)

148
Q

Neuroleptic Malignant Syndrome

A

Emergency; tachycardia labile blood pressure, muscle rigidity, muscle breakdown

149
Q

drugs causing anxiety

A

albuterol, caffeine, decongestants, levothyroxine, steroids, stimulants

150
Q

benzos without long acting metabolite

A

alprazolam, lorazepam, clonazepam, and oxazepam

151
Q

benzos with long acting metabolite

A

diazepam, chlorazepate, chlordiazepoxide

152
Q

which benzos are preferred in the elderly?

A

LOT, lorazepam, oxazepam, and temazepam

153
Q

hydroxyzine

A

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
Q

propanolol

A
  • acute physiological anxiety symptoms, perdormance and situational anxiety
155
Q

what natural products can be used for anxiety

A

Kava, St. John’s Wort, Passionflower, Valerian, Chamomile

156
Q

first line for anxiety?

A

SSRIs and SNRIs & Buspar

157
Q

when can antipsychotics be used?

A

treatment resistant OCD (aripiprazole and risperidone)

158
Q

When are SNRI meds used for anxiety?

A

when the patient also has a pain syndrome (Duloxetine)

159
Q

When are benzos used?

A

generally not first line, can be bridge therapy

160
Q

Hydroxyzine use?

A

typically as needed

161
Q

Social anxiety disorder first line?

A

SSRIs, then SNRIs, the beta blockers (propanolol)

162
Q

Panic disorder treatment

A

SSRIs, then SNRIs (benzos not first line)

163
Q

OCD treatment

A

SSRIs are first line, 25-50% reduction in symptoms

164
Q

PTSD treatment

A

SSRIs/SNRIs (prazosin for sleep or nightmares)

165
Q

SSRIs/SNRIs anxiety clinical pearl on exam

A

Jitteriness syndrome; initial doses should be lower than depression doses.
- SSRI onset in 2-4 weeks
- Abrupt d/c of benzos is bad

166
Q

Disease states/medications associated with insomnia

A

anxiety, caffeine, modafinil, amphetamines, beta-agonists, beta-blockers, nicotine, thyroid meds, mood disorders, bupropion, decongestants, methylphenidate

167
Q

insomnia criteria

A

3 nights per week for at least 3 months

168
Q

insomnia first line treatment

A

non-pharmacologic; sleep hygeine

169
Q

z-hypnotics info

A

zolpidem (5mg in women and elderly), eszopiclone, zaleplon (all are 3A4 substrates) (somnolence, dizziness, ataxia, headache) (parasomnia) (CNS depressants)

170
Q

benzos for sleep

A

temazepam (drowsiness, dizziness, cognitive impairment, fall risk)

171
Q

Melatonin receptor agonists

A

Ramelteon and Tasimelteon, both are 1A2 substrates

172
Q

ramelteon info

A

contraindicated with fluvoxamine, GI upset, next day drowsiness, prolactinemia

173
Q

tasismelteon info

A

FDA approved for sleep wake disorder; melatonin receptor antagonist

174
Q

What are the orexin receptor antagonists

A

Suvorexant, Lemborexant, Daridorexant

175
Q

orexin receptor antagonists counseling

A

take with at least 7 hours to sleep, contraindicated in narcolepsy, all are 3A4 substrates

176
Q

Doxepin info for insomnia

A

TCA, H1 receptor antagonist, anticholinergic side effects

177
Q

trazodone for insomnia info

A

not FDA approved 25-100g, long half life

178
Q

mirtazapine for insomnia info

A

Clinically used as a sleep agent in patients with depression

179
Q

Quetiapine for insomnia info

A

can be used for insomnia with co-morbid psychiatric disorders

180
Q

benadryl/unisom

A

not recommended by AASM, anticholinergic side effects

181
Q

Natural products for sleep

A

melatonin- used for jet lag and in patients with low melatonin levels
1A2 substrate
Chamomile - allergy in patients with daisy or ragweed allergy.

182
Q

treatment algorithm - insomnia

A

lifestyle mods first

183
Q

Obstructive sleep apnea

A
  • 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
Q

when is polysomnography indicated?

A

cardiorespiratory disease, respiratory muscle weakness, hypoventilation, opioid medication use, history of stroke, severe insomnia

185
Q

Sleep apnea treatment

A

weight loss, smoking cessation, avoid alcohol and CNS depressants, CPAP, modafinil/armodafinil

186
Q

narcolepsy tetrad

A

EDS, cataplexy, hallucinations, sleep paralysis

187
Q

Cataplexy treatment

A

sodium Oxybate (Xyrem) or Xywav (adults and children 7+)
Lumryz (adults only, once nightly dosing)

188
Q

excessive daytime sleepiness treatment

A

modafinil/armodafinil treatment (rash possible), sodium oxybate, pitolisant and solriamfetol

189
Q

Pitolisant (Wakix)

A

H3 receptor agonist/inverse agonist, prolongs QT interval, C/I with hepatic impairment, avoid with otc antihistamines, 3A4 inducer, 2D6/3A4 substrate

190
Q

Solriamfetol (Sunosi)

A

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
Q

Shift work Sleep Disorder treatment

A

Modafinil and Armodafinil

192
Q

Restless Leg Syndrome treatment

A

gabapentin enacarbil, dopamine agonists (pramipexole/ropinirole), iron supplementation

193
Q

what medication is contraindicated in eating disorders?

A

bupropion

194
Q

binge eating disorder treatment

A

lisdexamfetamine

195
Q

bulimia treatment

A

fluoxetine

196
Q

what is the low-end of normal BMI?

A

18.5kg/m2

197
Q

what is re-feeding syndrome

A

fat metabolism–> glucose metabolism. Cause hypokalemia, water retention, and severe edema resulting in multiple organ failure.

Therapeutics 2 (9 decks)

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