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Year 4 - 2. Psychiatry > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

State some common side effects from adrenergic/noradrenergic drugs

A
  • Sweating
  • Tremor
  • Nausea
  • Headaches
  • Dizziness
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2
Q

State some common side effects from muscarinic (ACh) drugs

A
  • Dry mouth / thirst
  • Dry skin
  • Hot / flushed skin
  • Urinary retention
  • Difficulty swallowing
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3
Q

State some common side effects from histamine drugs

A
  • Dry mouth
  • Drowsiness
  • Dizziness
  • N&V
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4
Q

State main mechanism of action of most antidepressants

A

Act on serotonin activity, aim to increase activity at postsynaptic receptors

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5
Q

Explain the mechanism of action of selective serotonin reuptake inhibitor (SSRI) drugs

A

Increase serotonin activity
- Reduces reuptake of serotonin at the presynaptic membrane
- More serotonin remains in the synapse
- Leads to a downregulation of serotonin receptions on the postsynaptic membrane

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6
Q

State some common side effects of selective serotonin reuptake inhibitor (SSRI) drugs = STRESS

A

Sweating
Tremor
Rash
Extrapyramidal side effects (uncommon)
Sexual dysfunction
Somnolence = drowsiness

  • Restlessness
  • GI disturbance e.g. nausea, diarrhoea/constipation
  • Headache
  • Bleeding
  • Hypomania
  • Suicidal ideation
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7
Q

State how long antidepressants take to:
1. Start to have an effect
2. Substantial benefit

A
  1. Start to have an effect in 1 week
  2. Substantial benefit by weeks 4-6
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8
Q

List some examples of selective serotonin reuptake inhibitor (SSRI) drugs

A
  • Sertraline
  • Citalopram
  • Fluoxetine
  • Paroxetine
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9
Q

State the safest SSRI drug to use in cardiac disease

A

Sertraline

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10
Q

State the main side effect of Citalopram to be concerned about

A

QT prolongation

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11
Q

State the main side effect of Fluoxetine to be concerned about

A

Serotonin syndrome (occurs when switching to another drug and there is a cross over as Fluoxetine has a long t1/2)

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12
Q

State the main side effect of Paroxetine to be concerned about

A

Discontinuation syndrome (occurs when suddenly stopping SSRI, due to short t1/2)

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13
Q

Outline how SSRIs (selective serotonin reuptake inhibitors) are different to SNRIs (serotonin and NA reuptake inhibitors)

A

SSRIs block serotonin reuptake receptors on presynaptic membrane
SNRIs act in a similar way, but ALSO block noradrenaline reuptake receptors as well

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14
Q

State some side effects for serotonin and NA reuptake inhibitors (SNRIs)

A
  • GI disturbance e.g. nausea
  • Headache
  • Dry mouth
  • Hypertension
  • Sexual dysfunction
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15
Q

List 2 examples of serotonin and NA reuptake inhibitors (SNRIs)

A
  • Duloxetine
  • Venlafaxine
    (can be used for neuropathic pain)
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16
Q

State the target receptors for Mirtazapine (class of its own)

A

Serotonin receptor (5HT receptor) antagonist - acts at 5HT-2 and 5HT-3 receptors
Also strong histamine activity (at H1 receptors) = sedation

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17
Q

State the main 2 side effects of Mirtazapine (class of its own)

A
  • Sedation
  • Weight gain

only drug where side effects don’t reduce by reducing dosage of drug

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18
Q

List some examples of tricyclic antidepressants (TCAs)

A
  • Amitriptyline (older)
  • Nortriptyline (newer)
  • Lofepramine (newer)

Used at lower doses for neuropathic pain

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19
Q

State some side effects of tricyclic antidepressants (TCAs)

A

Muscarinic effects:
- Dry mouth / thirst
- Nausea
- Urinary retention
- Dry / flushed skin
- Difficulty swallowing

Histaminic effects:
- Dry mouth
- Sedation
- Dizziness
- N&V

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20
Q

Outline the fatal side effect from tricyclic antidepressant (TCA) overdose

A
  • QT prolongation
  • Arrhythmias
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21
Q

For monoamine oxidase inhibitors (MAOi) - state the amino acid it can react with and what it can lead to

A

Tyramine
- Tyramine reaction can lead to a hypertensive crisis

Tyramine products: cheese, wine, pickled meats

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22
Q

State the new antidepressant which can be used for difficult to treat cognitive symptoms

A

Vortioexetine

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23
Q

For the following scenarios, suggest which antidepressant to consider:
- New case with no previous treatment
- Depression with major weight loss
- Depression with major sleep difficulty
- Depression with neuropathic pain

A

New case with no previous treatment = SSRI

Depression with major weight loss = Mirtazapine

Depression with major sleep difficulty = Mirtazapine

Depression with neuropathic pain = SNRI

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24
Q

Outline the rough pathway / order for trying antidepressants

A

SSRI first
- If no effect, try different SSRI
- No effect, switch to SNRI (Venlafaxine or Duloxetine)
- Mirtazapine

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25
Q

Outline when discontinuation syndrome happens and list some symptoms

A

Can happen if antidepressant medication is stopped, especially suddenly

  • Sweating
  • Tremor
  • Agitation / irritability
  • Insomnia
  • Headaches
  • N&V
  • Paraesthesia
  • Clonus
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26
Q

State the SSRI drug and SNRI drug which have the highest risk of discontinuation syndrome and why

A
  • Paroxetine (SSRI)
  • Venlafaxine (SNRI)

Short t1/2

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27
Q

List some symptoms of serotonin syndrome, including:
- Cognitive
- Autonomic
- Somatic

A

Cognitive:
- Hypomania
- Confusion
- Agitation
- Coma

Autonomic:
- Sweating
- Hyperthermia
- Nausea
- Diarrhoea

Somatic:
- Headache
- Myoclonus (muscle jerking)
- Tremor
- Hyperreflexia

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28
Q

Briefly state why serotonin syndrome occurs and how is treated

A

Caused by abrupt increase in serotonin, can occur if started on a high dose or switching one antidepressant to another which creates a cross over

Generally supportive management
- Stop/reduce offending drug
- Fluids
- Monitoring
- May consider stopping/changing dose

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29
Q

State how antipsychotic drugs aim to work

A

Reduce level of dopamine activity
- Act at D2 receptors
- Target dopaminergic pathways

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30
Q

State the 4 dopaminergic brain pathways and which ones are the target for anti-pscyhotics

A

Targets:
- Mesocortical
- Mesolimbic
Unwanted effects:
- Nigrostriatal
- HPA axis (tuberoinfundibular)

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31
Q

State some generic side effects of antipsychotics

A
  • Sedation
  • Extrapyramidal side effects
  • Weight gain
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32
Q

State the difference between typical and atypical antipsychotics,
- Pharmacological target
- Tolerability
- Likely side effects

A

Typical = older
- High affinity to block D2/D3 receptors in the brain = reduce Dopamine transmission
- Less tolerable
Likely side effects
- Extrapyramidal side effects e.g. tardive dyskinesia
- High prolactin

Atypical = newer
- Target serotonin receptors more
- More tolerable
Likely side effects
- Metabolic syndrome (diabetes and weight gain)
- Stroke in elderly

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33
Q

List the typical and atypical antipsychotics

A

ALL D2 receptor antagonists except Aripiprazole

Typical = older
- Haloperidol
- Chlorpromazine
- Flupenthixol
- Zuclopenthixol
- Sulpiride

Atypical = newer
- Clozapine
- Olanzapine
- Quetiapine
- Risperidone
- Aripiprazole D2 partial agonist
- Amisulpride
Efficacy is similar

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34
Q

State some extrapyramidal side effect features

A
  • Akathisia (urge to move)
  • Dystonia (muscle contractions/spasms)
  • Parkinsonisms (tremor and/or rigidity, bradykinesia)
  • Tardive dyskinesia
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35
Q

State the frequency of monitoring required for antipsychotics and what should be monitored

A

Frequency:
- Baseline
- 3 months after starting treatment
- Then yearly

Monitoring:
- Weekly weights
- FBC, lipids, LFTs, HbA1c, ECG, blood pressure and pulse

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36
Q

Outline some main side effects of atypical antipsychotics and also typical antipsychotics

A

Atypical antipsychotics:
- Weight gain and hypergylcamia (metabolic syndrome)
- QT prolongation
- Lesser risk of extrapyramidal side effects e.g. rigidity, tremor

Typical antipsychotics:
- Extrapyramidal side effects e.g. rigidity, tremor
- Tardive dyskinesia
- Weight gain
- Constipation
- Dizziness / drowsiness
- Dry mouth
- Gynaecomastia
- Hyperglycaemia

For both: risk of neuroleptic malignant syndrome

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37
Q

Outline neuroleptic malignant syndrome (including which drugs cause it) and including symptoms of the syndrome

A

Rare life threatening reaction in patients taking antipsychotics
Onset of symptoms in first 10 days after starting/changing treatment

Symptoms (like malignant hyperthermia):
- Fever
- Autonomic instability e.g. tachycardia
- Sweating
- Muscle rigidity
- Confusion

Death usually occurs due to:
- rhabdomyolysis
- renal failure
- seizures

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38
Q

State some risk factors for developing neuroleptic malignant syndrome

A
  • Young male
  • High doses
  • High potency drugs in antipsychotic naive patients
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39
Q

List some investigations to consider in a patient with neuroleptic malignant syndrome

A
  • FBC (leukocytosis / infection)
  • Creatine Kinase (markedly elevated)
  • U&Es (renal function)
  • LFTs (liver function)
40
Q

Outline some basic management steps for neuroleptic malignant syndrome

A
  • Emergency referral to A&E
  • Stop antipsychotics / causative medication
  • Fluid resuscitation
  • Benzodiazepine for behavioural disturbance
  • Oxygen if necessary
  • Cool temp with cooling blankets

Rhabdomyolysis - fluids and sodium bicarbonate
Relax muscles: Dantrolene or Lorazepam

41
Q

Outline the difference in presentation between neuroleptic malignant syndrome and serotonin syndrome

A

NMS is very similar to serotonin syndrome, but the main difference is that serotonin syndrome is associated with serotoninergic medications

Both present with hyperthermia, autonomic dysregulation and altered mental status

42
Q

State a drug that can be used to treat extrapyramidal side effects of antipsychotic drugs (except tardive dyskinesia)

A

Procyclidine (anticholinergic)

43
Q

Briefly explain acute dystonia and how to manage it

A
  • Sustained and painful muscular spasms
  • Can occur after antipsychotics

Management:
- Stop antipsychotic immediately, could restart later on
- IM Procyclidine (anticholinergic) and continue for 1-2 days after, consider long term

44
Q

State what drug class Clozapine belongs to and roughly how it works

A

Antipsychotic
D2 and 5HT-2 antagonist (both dopamine and serotonin receptor blocker)

45
Q

State the main risks of Clozapine and how they are mitigated against

A
  1. Agranulocytosis
    - Weekly / fortnightly / monthly FBC monitoring at clinic
  2. Bowel obstruction / toxic megacolon (untreated constipation)

Also
- Hypersalivation
- Urinary incontinence

Dose titrated very slowly over 2 weeks and monitor for autonomic dysregulation (postural hypotension)

46
Q

State the required monitoring for Clozapine (antipsychotic)

A

FBC - weekly for first 18 weeks (risk of agranulocytosis, esp. neutrophils)

Then 2 times a month for up to a year
After a year, can be done monthly

Also monitor risk of constipation (ask about symptoms)

47
Q

Briefly explain how agranulocytosis secondary to Clozapine is treated

A
  • STOP CLOZAPINE
  • Stop other bone marrow suppressing drugs e.g. Sodium Valproate
  • Avoid other antipsychotics where possible
  • Contact consultant haematologist
  • Avoid sources of infection
  • May use Lithium or G-CSF
48
Q

State the 2 antidepressants that are safest in pregnancy

A

Sertraline
Fluoxetine
Some TCAs e.g. Amitriptyline

Should be used with caution, at the lowest effective dose

49
Q

State the 2 antidepressants that are safest in breastfeeding

A

Sertraline
Paroxetine

Should be used with caution, at the lowest effective dose

50
Q

State drug classes that be used in the management of anxiety

A
  • Beta blockers
  • Antidepressants
  • Benzodiazepines
  • Pregabalin
51
Q

State indications for use of Benzodiazepines

A
  • Delirium tremens
  • Alcohol detoxification
  • Acute psychosis (sedation)
  • Violent behaviour

Advised against:
- Insomnia (short term)
- Anxiety (short term)

52
Q

Outline the management steps for delirium tremens

A

Benzodiazepines: Oral Lorazepam

(if unable, offer it as IV or offer Haloperidol)

53
Q

State 2 most commonly used Benzodiazepines in anxiety and how they work

A
  1. Diazepam
  2. Lorazepam

Potentiate GABA receptors and reduce excitability of GABA neurones
- Allosteric modulators which change structure of GABA receptors and makes GABA more potent when it binds (more inhibition)

54
Q

State 1 example of a short acting benzodiazepines and 2 examples of long acting benzodiazepines

A

Short acting: Lorazepam (< 12 hours)

Long acting: Diazepam (< 12 hours)

55
Q

Explain the potential paradoxical disinhibition in use of Benzodiazepines

A

Paradoxical disinhibition can occasionally occur in Benzodiazepine use
- Commonly occurs if low dose of drug is used
- Inhibition of frontotemporal lobe without inhibition of amygdala = erratic behaviour

56
Q

State some side effects for Benzodiazepines

A
  • Drowsiness (next day)
  • Light-headedness (next day)
  • Confusion
  • Ataxia
  • Amnesia
  • Dependence
  • Muscle weakness
  • Respiratory depression
57
Q

Outline how Pregabalin works for anxiety

A
  • Binds to voltage gated Ca channels and alters threshold potential
  • Makes Ca channels harder to stimulate
    = reduces neuronal activity
58
Q

State 2 side effects of Pregabalin

A
  • Weight gain
  • Sedation
59
Q

State the 2 classes of hypnotics (sleeping tablets) that can be used and a two examples of each

A

Benzodiazepines:
- Temazepam
- Lormetazepam

Non-benzodiazepines (z-drugs):
- Zopiclone
- Zolpidem

60
Q

State 3 types of mood stabilisers and examples of drug names

A
  1. Lithium (own class)
  2. Anticonvulsants
    - Carbamazepine
    - Lamotrigine
    - Sodium valproate
  3. Antipsychotics
    - Haloperidol
    - Olanzapine
    - Quetiapine
    - Risperidone
61
Q

suState Lithium monitoring frequency, including what is monitored

A

Monitor Lithium levels, U&Es and thyroid levels

Lithium levels:
- Every week until therapeutic level is stable for a month
- Once stable, 3 monthly monitoring

U&Es:
- Every 6 months

Thyroid function:
- Every 12 months

62
Q

State 2 long term complications of Lithium to be aware of

A
  1. Hypothyroidism (reversible - should resolve on stopping Lithium)
  2. Renal impairment (irreversible)
63
Q

List some side effects of Lithium AND symptoms of Lithium toxicity ‘TOXIC’

A

Side effects:
- Metallic taste / dry mouth
- GI disturbance
- FINE tremor
- Excessive thirst and urination
- Weight gain
- Thyroid dysfunction

Symptoms of toxicity:
- Tremor (coarse)
- Oliguric renal failure
- AtaXia
- Increased reflexes
- Convulsions / coma / reduced consciousness

64
Q

List 3 medications that can increase Lithium levels in the body (through nephrotoxic effects)

A
  • NSAIDs
  • ACEi
  • Loop diuretics
65
Q

Outline the management steps for Lithium toxicity (>1mmol/L)

A

No specific antidote to lithium toxicity.

Supportive treatment
- Regularly check Lithium levels every 6–12 hours
- May require diuresis, or peritoneal dialysis haemodialysis if very high levels

66
Q

State how long antipsychotics should be used for after a psychotic episode

A

Continue antipsychotics for at least 1-2 years after a psychotic episode

Some recommend use for 5 year after to prevent relapse

67
Q

State the antipsychotics that CAN be give orally and as a depot (and those that can only be given orally)

A

Oral and depot:
- Haloperidol (short acting IM and depot)
- Chlorpromazine
- Olanzapine
- Risperidone
- Aripiprazole

Just oral:
- Quetiapine
- Clozapine

68
Q

State the first line atypical antipsychotic that can be used to treat bipolar disorder

A

Quetiapine
Can use other atypical or typical antipsychotics

69
Q

State some anticonvulsants that can be used for bipolar disorder treatment

A
  • Sodium valproate
  • Carbamazepine
  • Lamotrigine (risk Stevens Johnson syndrome)
70
Q

State some side effects of anticonvulsants used for bipolar disorder treatment

A
  • Weight gain
  • Sedation
  • Risk of thrombocytopenia
  • Lamotrigine: additional risk Stevens Johnson syndrome
71
Q

State 3 drugs used in the treatment of ADHD

A

Stimulants:
- Methylphenidate
- Dextroamphetamine
SNRI:
- Atomoxetine

72
Q

State the advantages of SSRIs compared to TCAs

A
  • SSRIs generally have slightly less adverse effects
  • SSRIs are associated with lower rates of anticholinergic side effects, weight gain and sedation, compared to TCAs
73
Q

State the disadvantages of SSRIs compared to TCAs

A
  • SSRIs appear to be slightly less efficacious, compared to TCAs
  • SSRIs are less good for treating neuropathic pain, compared to TCAs
74
Q

State the purpose of rapid tranquillisation and some associated risks

A

Purpose:
- Emergency measure
- Used to quickly calm a person down and reduce the risk of further violence / harm to themselves and others
- Not intended to treat
underlying mental illness or induce sleep or unconsciousness, but to
promote a calmer state

Risks:
- Hypotension
- Loss of consciousness / airway obstruction
- Cardiac arrest
- Seizures
- Coma / death
- Neuroleptic malignant syndrome

75
Q

What is psychotherapy?

A

Systematic use of a relationship between a patient and a therapist to produce changes in feelings, thoughts and behaviour (as opposed to physical and social methods)

76
Q

List some qualities that make a patient a good candidate for psychotherapy

A
  • Takes responsibility for resolution of their difficulties
  • Psychologically minded
  • Patients are able to verbalise their problems
77
Q

Outline the management steps for Wernicke’s encephalopathy

A

Offer prophylactic oral thiamine to those at risk e.g. dependent drinkers

Mainstay treatment:
- IV Thiamine for a minimum of 5 days
- Oral thiamine should continue after parenteral therapy

78
Q

State some common side effects of Haloperidol and Chlorpromazine (same)

A
  • Hypotension
  • Constipation
  • Dry mouth
  • Drowsiness
  • Insomnia
  • Blurred vision
79
Q

List some indications for antipsychotic medications

A

First line for Schizophrenia (and other conditions where psychosis can present)

  • Schizoaffective disorder
  • Drug-induced psychosis
  • Acute mania
  • Major depressive disorder with psychosis
  • Delusional disorder
  • Severe agitation
  • EUPD (if psychotic symptoms are present)
80
Q

List some indications for mood stabiliser medications

A

First line: bipolar affective disorder

  • Acute manic episode (if atypical antipsychotic ineffective)
  • Depression (adjunct only)
81
Q

Outline the role of mood stablisers

A
  • Help to stabilise mood
  • Reduce incidence of hypomania/mania and depressive symptoms
  • Most effective for bipolar disorder
82
Q

State some common side effects of mood stabilisers e.g. Lithium = LITHIUM

A

Low WCC
Impaired renal function
Tremor / teratogenic
Hypothyroidism / hair loss
Increased weight / fluid retention
Urine increased
Metallic taste

83
Q

Briefly explain the concept of cognitive behavioural therapy (CBT)

A
  • Based on idea that disorder is influenced by the patient’s thoughts and feelings
  • Explores the interaction between thoughts, feelings and behaviours
  • Aims to identify and challenge automatic negative thoughts
84
Q

Suggest some conditions for which CBT psychotherapy can be used

A

Mood:
- Mild to moderate depression
- Bipolar disorder

Neurotic:
- Anxiety disorders e.g. GAD, PTSD, OCD

Psychotic:
- Psychosis disorders
- Schizophrenia

Other:
- Eating disorders
- Substance misuse
- Chronic medical conditions e.g. chronic fatigue syndrome

85
Q

State the concept behind behaviour therapies

A

Based on learning theory, especially operant conditioning (behaviours are reinforced if positive consequences)

86
Q

List 2 examples of behavioural therapies and state what conditions they are used in

A

Exposure and response prevention = in phobias and OCD

Systemic desensitisation = in phobias

87
Q

Briefly explain the concept of psychodynamic therapy

A
  • Based on concept that childhood experiences / unresolved conflicts / previous relationships significantly influence a current situation
  • Uses free association (patient says whatever they want) and therapist interprets these statements
  • Huge emphasis on relationship between patient and therapist
  • Explores conflicts and defence mechanisms and development of insight
88
Q

Suggest some conditions for which psychodynamic therapy can be used

A
  • Recurrent depression (chronic dysthymia)
  • Dissociative disorders
  • Somatoform disorders
  • Psychosexual disorders
  • Some personality disorders
89
Q

Briefly explain the concepts of transference and counter-transference in psychodynamic therapy

A

Transference - patient experiences strong emotions from early important relationships, which is reflected within their relationship with the therapist

Counter-transference - therapist is affected by powerful emotions from the patient and reflects what the patient is feeling

90
Q

Outline the concept of family (systemic) therapy

A
  • Involves family members being seen together (family system)
  • Focusses on family system’s ability to help family problems and individual mental illness
  • Corrects any impaired communication or dysfunctional relationships
91
Q

Suggest some conditions for which family (systemic) therapy can be used

A

Paediatric disorders:
- Eating disorders
- Conduct disorder

Adult disorders:
- Bipolar affective disorder
- Schizophrenia
- Depression

92
Q

State how dialectical behavioural therapy is used in emotionally unstable (borderline) personality disorder

A
  • Uses components of CBT
  • GROUP skills training
  • Provides individuals with alternative coping strategies (other than self-harm) to deal with emotional instability
93
Q

State the first line medication for ADHD

A

Methylphenidate or Dexamfetamine/Lisdexamfetamine

94
Q

List some side effects of the stimulants used to treat ADHD (Methylphenidate or Dexamfetamine/Lisdexamfetamine)

A
  • Stunted growth
  • Tachycardia, arrythmias or hypertension
  • Tics
  • Sexual dysfunction (Atomoxetine)
  • Seizures
  • Worsening of behaviour
  • Stimulant misuse
95
Q

State the management of acute dystonia

A

Treatment centres re-balancing disrupted dopaminergic-cholinergic levels

  • Discontinuation of the offending agent
  • IV anticholinergic drugs e.g. Diphenhydramine and Benztropine

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Year 4 - 2. Psychiatry (12 decks)

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