Psychiatry Pharmacology Flashcards
What are the two types of antipsychotics?
typical and atypical
What are typical antipsychotics and how do they work?
1st generation drugs
Block D2 receptors
What causes a large number of psychotic symptoms?
overactivity of dopamine pathways
2 examples of typical antipsychotics?
Haloperidol
Chlorpromazine
What are atypical antipsychotics and how do they work?
2nd generation drugs
Antagonists to D2 receptors and 5HT2a (serotonin receptor)
3 examples of atypical antipsychotics?
rispiridone
olanzapine
clozapine
First line drug in schizophrenia?
rispiridone
Why are atypical antipsychotics preferred?
less likely to produce extrapyramidal side effects
What are the main extrapyramidal side effects?
parkinsonism
akathisia (severe restlessness)
dystonia (uncontrollable contraction of muscles)
dyskinesias (abnormality of voluntary movement)
What are positive symptoms of schizophrenia?
psychosis- delusions and hallucinations
What drug do you give for psychosis in parkinsons?
clozapine
What effect does D2 blockade have?
decreases psychotic symptoms
What effect does 5HT2a blockade have?
decreases negative symptoms
What are the main side effects of typical antipsychotics?
drowsy
anticholinergic, antihistamine and antisympathetic (blockade of M1, H1, alpha1)
EPSE
What is the main side effect of clozapine?
agranulocytosis (leukopenia and neutropenia)
When can you give cloazapine?
resistant schizophrenia
after trial of 2 other drugs
Depression 1st 2nd and 3rd line line treatment?
SSRI- fluextetine, citalopram
TCAs- amitryptiline, clomipramine
MAOIs- pheelzine, moclobemide
What antidepressant is indicated for young and why?
fluoxetine- safest for suicide risk
Give 2 examples of tricyclic antidepressants?
amitryptiline and clomipramine
How do TCAs work?
block serotonins and noradrenaline transporters
(SERT & NET) inhibiting the reuptake of Na and 5-HT to increase its availability in the synapse
What causes depression?
imbalance (usually deficiency) of monoamine neurotransmitters- dopamine (DA), noradrenaline (NA), serotonin (5HT)
What does monoamine oxidase do?
catalyses breakdown of monoamine neurotransmitters
Give an example of monoamine oxidase inhibitors?
phenelzine
moclobemide
How do MAOIs work?
inhibit the breakdown of monoamine neurotranmitters- DA, 5HT, NA increasing their availability in synapse
Depression with anxiety treatment?
SSRI
MAOIs
Panic disorder treatment?
SSRI
TCAs
MAOIs
Atypical depression treatment?
SSRI
MAOIs
Schizophrenia treatment?
rispiridone olanzapine (ass with metabolic syndrome dont use in diabetics) clozapine
Triad in ADHD?
inattention, hyperactivity, impulsivity
Triad in Autism?
social impairment
impairment of language and communication
ritual and compulsive phenomena
Acute management of agitation and anxiety?
respiredone
Acute management in autism?
respiredone
Drug for difficult sleep problems?
melatonin
Pharmacological management of ADHD?
1st line- stimulants: methylphenidate (ritalin), dexamfetamine
2nd line- atomoxetine
Alcohol relapse prevention treatment?
naltrexone
acamprosate
disulfiram (antabuse)
Give examples of benzodiazepines?
diazepam
How do benzodiazepines achieve the anxiolytic effects?
increase the inhibitory effects of GABA at GAPA-A receptor. calming effect
When are benzodiazepines used?
short term relief of severe disabling and distressing anxiety and insomnia symptoms
alcohol withdrawal
status epilepticus
What is the maximum use of benzodiazepines and why?
4 weeks
addictive with increasing tolerence
when do you never give benzodiazepines and why?
delirium- makes it worse
respiratory depression
sleep apnoea
when do you never give benzodiazepines and why?
respiratory depression
sleep apnoea
caution in delirium as can make it worse (only use if alcohol dependence/benzodiazepine withdrawal)
What is disinhibition?
impulsivity and disregard for social norms and authority
physiological management of ADHD?
1- parent training, classroom behaviour strategies
2- social skills training, sleep and diet
When is peak onset for delirium tremens in alcohol withdrawal?
2 days abstinence
When do symptoms typically resolve for alcohol withdrawal?
5-7 days
How does naltrexone achieve its affects?
opiod antagonist
mechanism of acamprosate?
reduces cravings by acting on glutamate and GABA systems
mechanism of disulfiram (antabuse)?
blacks the effect of acetaldehyde dehydrogenase. Normally when alcohol is ingested enzymes in the liver convert it into acetaldehyde which is then broken down by acetaldehyde dehydrogenase into harmless acetic acid. When this is stopped build up of acetaldehyde causes hangover like symptoms.
mechanism of disulfiram (antabuse)?
blacks the effect of acetaldehyde dehydrogenase. Normally when alcohol is ingested enzymes in the liver convert it into acetaldehyde which is then broken down by acetaldehyde dehydrogenase into harmless acetic acid. When this is stopped build up of acetaldehyde causes hangover like symptoms.
Treatment of alcohol withdrawal?
benzodiazepines- diazepam
titrate depending on severity of symptoms and reduce over 7 days
paraentral thiamine as prophylaxis to wernickes
triad in wernickes and what is it?
opthomaplagia (weakness of eye muscles)
ataxia (lack of volunary muscle control)
confusion
vitamin B1/thiamine deficiency
What effects do prolonged alcohol use have?
alcohol inhibits excitatory glutamate NMDA ion channels and chronic use leads to upregulation of receptors
increases the inhibitory effect of GABA and chronic use leads to down regulation of receptors
alcohol withdrawal leads to excessive glutamate activity (which is toxic to nerve cells) and reduced GABA activity causing CNS excitability and neurotoxicity
What are the hallmarks of delirium?
acute and fluctuating
inattention
altered level of consciousness
change in cognition
pharmacological management of uncomplicated delirium?
haloperidol- typical antipsychotic
pharmacological management of PD/LB dementia with delirium?
quetiepine- atypical antipshychotic
pharmacological management of delirium if seizure/alcohol or benzodiazepine withdrawal?
lorazepam- benzodiazepines
Cause of velocardiofacial/ di george syndrome?
deletion of segment on chromosome 22
AD
Key features of di george syndrome?
congenital heart defects
learning disabilities
facial features
recurrent infections
Cause and genetics of Prader willi syndrome?
deletion segment on chromosome 15
Features of prader willi syndrome?
newborns- weak muscles, feeding difficulties and delayed growth
childhood- constant hunger and overeating- obesity and diabetes
learning difficulties and behavioural problems
cause of angelman syndrome?
deletion of segment from maternal chromosome 15
What are the features of angelman syndrome?
intellectual and developmental disability sleep disturbance seizures happy/excitable demeanour short attention span jerky movements especially hand flapping
cri du chat syndrome genetics?
deletion of short arm on chromo 5
Features of cri du chat syndrome?
microcephaly
severe learning disabilities
high pitched cry (usually lost at about 2yrs)
wide eyes
learning disabilities categories?
borderline >70
mild 50-70 mental age 9-12
moderate 35-50 6-9, delayed self care and motor skills, physical disability and epilepsy common
severe 20-35 3-6, epilepsy
profound <20 <3, severe mobility restriction
antisocial personality disorder treatment?
group based therapy
borderline personality disorder treatment?
dialectibal behavioural therapy
Cluster A personality disorders?
(odd & eccentric) WEIRD
Paranoid- distrust and suspicious od others and their motices ACCUSATORY
Schizoid- detachment from social relationships and restricted emotional range ALOOF
Schizotypal- social anxiety and paranoia AWKWARD
Cluster B personality disorders?
(dramatic and emotional) WILD
Antisocial- disregard for others BAD
Borderline- instability in interpersonal relationships, self image, impulsive BORDERLINE
Histrionic- very emotional and attention seeking BULLSHIT
Cluster C personality disorders?
(anxious and fearful) WORRIED
Avoidant- social inhibition, hypersensitive to negative evaluation COWARD
Dependent- need to be taken care of CLINGY
Obsessive- Compulsive- order and perfectionist COMPULSIVE
1st rank symptoms of schizophrenia?
auditory hallucinations (commentary, thought echo, third person) thought disorder (thought withdrawal, insertion, broadcasting) passivity phenomena (senses controlled by external) delusions
atypical antipsychotics in the elderly increase risk of what?
stroke and VTE
What is conversion disorder?
typical loss of motor and sensory function with no apparent cause
patient indifferent to their condition
post MI antidepressant?
sertraline
main side effects with antidepressants?
GI
transient increased anxiety
increased suicide risk
emergency schizophrenia treatment?
im lorezepam 1-2mg
long term treatment of schizophrenia?
typical antipsychotics- risperidone, olanzapine, clozapine
non pharmacological treatment of PTSD?
CBT
eye movement desensitisation and reprocessing
pharmacological treatment in PTSD?
SSRI- paraxoitine
NASSAs- mirtazapine
Treatment for OCD?
CBT, exposure and response prevention
SSRI
TCA- clomipramine
What is a NASSAs?
noradrenaline and specific serotonergic antidepressants
Depression treatment?
SSRI
NASSA or TCAs
First line depression treatment in individual with history of CVD?
SSRI- Sertraline
What else should you provide if a patient is on an NSAID/ aspirin and about to start an SSRI and why?
PPI
SSRI and NSAID increase risk of GI bleeding
What is the first line SSRI in adolescents?
fluoxetine
What are the main SE of SSRIs?
GI symptoms
Increased risk of GI bleed with NSAID
increase suicidality
transient anxiety
What do you give a patient on warfarin/heparing and depression?
NaSSA: mirtazapine
What SSRI doesnt need to be decreased gradually?
fluoxetine
What effect do antipsychotics have on PD?
worsening of symptoms
What is the pharmacological treatment of delirum- 3 main scenarios?
first line sedative: Typical antipsychotic-
haloperidol
alcohol withdrawal or benzodiazepine dependence: low dose benzodiazepines-
chlordiazepoxide or diazepam
parkinsons or LB dementia: benzodiazepine-
lorazepam
How long to symptoms have to be present for diagnosis of depression?
2 weeks with no manic or hypo manic episodes
What are the core symptoms of depression?
low mood
anhedonia
anergia
What is anhedonia?
inability to feel pleasure in normally pleasurable activities
What are the the classifications for mild, mod and severe depression?
mild- 2 core total 4
mod- 2 core total 6
severe- 3 core total 8
What are some other common symptoms of depression?
loss of confidence guilt thoughts of death/suicide reduced concentration early morning wakening decreased appetite
When do you prescribe antidepressants for sub threshold/mild depressive symptoms?
present for > 2 yrs
history of mod or severe depression
if no improvement with other interventions
other chronic health problem
What is first line treatment for sub threshold/mild depression?
CBT
do not use antidepressants routinely
mod to severe depression general management?
CBT or interpersonal therapy and antidepressants
What class are first line antidepressants?
SSRIs
SSRI post MI or previous CVD?
sertraline
SSRI in younger patients?
fluoxetine
first line SSRI?
citalopram
Adverse effects of SSRIs?
GI symptoms
increased risk of GI bleed
transient anxiety
SSRI with least drug interactions?
sertraline?
What should also be prescribed with an SSRI if patient is already on NSAIDs?
PPI
What is citilopram associated with?
dose dependent QT interval prolongation
What should be given instead of an SSRI if patient on warfarin/heparin?
mirtazapine
How long should patients continue on SSRI after remission?
6 months
When should patients be reviewed after starting SSRI?
after 2 weeks
if < 30 or increased suicide risk after 1 week
How do you stop SSRIs and what is the exception?
reduce dose over 4 weeks
not needed in fluoxetine that has a long half life
what are some common SSRI discontinuation symptoms?
restless sleeping problems unsteady sweating increased mood change GI parathesia
What are the features of atypical depression?
mood reactivity >2 of: weight gain/increased appetite hypersomnia leaden paralysis interpersonal rejection sensitivity
How do monoamine oxidase inhibitors work?
inhibit monoamine oxidase to prevent breakdown of monoamine neurotransmitters (5HT, NA, DA)
Give some examples of MAOIs?
Phenelzine
Tranylcypromine
When are MAOIs inhibitors used?
2nd line depression with anxiety
2nd line atypical anxiety
How long must you be off a TCA or SSRI before starting an MAOI?
2-3 weeks
What foods must you avoid on MAOIs and why?
soft cheese, pickled herring, wine, chocolate
inhibitors prevent the breakdown of dietary tyramine which increases NE release and causes blood vessels to constrict (binds to alpha recepors) leading to hypertensive crisis
treatment of MAOI induced hypertensive crisis?
alpha blocker
What is somatic symptom disorder?
multiple physical symptoms but no underlying cause
patient worried about symptoms
What is dysthymia?
chronic low mood but not fulfilled criteria for depression
usually able to cope with demands of life
baby blues key features?
3-7 days post birth
anxious tearful irritable
key features of postnatal depression?
1-3 months
Treatment of postnatal depression?
CBT
SSRI- paroxetine
What SSRI to avoid in breast feeding mothers and why?
fluoxetine
long half life
key features of puerperal psychosis?
onset 2-3 weeks
severe mood swings similar to bipolar
disordered perception
treatment for puerperal psychosis?
hospital referral
What differentiates mania from hypomania?
presence of psychotic symptoms
What are two common psychotic symptoms in mania?
delusions of granduer
third person auditory hallucinations
what are the features of mania and hypomania?
Mood predominately elevated irritable Speech and thought pressured flight of ideas poor attention Behaviour insomnia loss of inhibitions: sexual promiscuity, overspending, risk-taking increased appetite
Acute management of mania?
olanzapine with valproate or lithium
What are the main SE of typical antipsychotics?
hyperprolactinaemia
metabolic syndrome
agranulocytosis (clozapine)
increased stroke risk
Diagnosis of bipolar?
two or more episodes of mania +/- depression
How long is an average untreated episode in bipolar?
3 months
What is bipolar 1?
mania or a mixed episode of mania and depression
what is bipolar 2?
hypomania and depression
What is cyclothymia?
hypomania and mild depression
What is meant by rapid cycling in bipolar disorder?
> /=4 mood episodes in a year
What is lithium?
mood stabiliser
What are the main side effects of lithium?
nephrotoxicity, weight gain, fine tremor, N,V,D, hypothyroid (+/- goitre)
When should lithium blood levels be checked?
weekly at first then every 3 months when stable aim for 0.4-1
12hrs post dose
What should be routinely checked with lithium use?
blood levels every 3 months
thyroid and renal function every 6 months (U&Es, LFTs, TFTs)
When does lithium toxicity occur?
> 1.5mmol/L
What are the features of lithium toxicity?
coarse tremor hyperreflexia confusion seizure coma
how do you treat lithium toxicity?
saline volume resus
haemodialysis
sodium bicarbonate
prophylactic treatment in bipolar?
lithium
What must be checked before starting someone on lithium?
U&Es
ECG
T4
