Test 2 Flashcards
Differentiate BiPolar I, Bipolar II, and Cyclothymic?
BP I: cycles b/w manic and hypomanic to depresssion and dysthymia
BI II: like BP I but doesn’t get to mania, only gets up to Hypomania
Cyclothymic: cycles b/w Hypomania and Dysthymia
What’s the correct term for “bipolar” in kids?
Kids Bipolar = Disruptive Moods Dysregulation Disorder
Differentiate Mania and Hypomania?
Hypomania: >4d but <1w, w/lighter and milder manic type sxs, w/ less impairment and can be IMPROVED, functioning, “genius” can occur
Manic: >1w of sxs
contrast emotional responses and feelings
Feelings = conscious experience of emotion
Feelings neurology = pattern of activity across insular cortex, secondary somatosensory cortex, cingulate cortex, hypothalamus, and upper brainstem
Emotions: automatic physiological response experienced
What’s the role of the frontal cortex w/emotional responses and feelings?
Frontal Cortex Necessary for emotional responses, esp social emotions and decision making
What are the 3 divisions of the amygdala, and which part is related to feelings/emotions?
Amygdala =
1 basolateral: receives input from assoc cortices and sensory structures
2 Central: projects out to emotional response structure
3 Corticomedial: projects to olfaction and appetite centers
What changes in brain structure size correlates w/depression?
Depression:
Prefrontal cortex, esp orbitofrontal prefrontal cortex, dorsolateral prefrontal cortex, subgenual prefrontal cortex, amygdala, anterior cingulate cortex, Hippocampus
Prefrontal GABA neuron density reduced
Occipital GABA neuron density reduced
Prefrontal, Anterior Cingulate Cortex neurons and Glial cells in general decreased
What changes in neural activity correlates w/depression?
Depression:
Cerebral cortex in general, esp in frontal lobes activity decreases
Anterior cingulate cortex, subgenual prefrontal cortex, hippocampus, striatum have metabolic changes
Which sided lesions generally leads to mania vs depression?
What occurs w/B/L lesions of DorsoLateral prefronal cortex vs Medial OrbitoFrontal cortex?
Lt lesion → depression
Rt lesion → mania
B/L DorsoLateral Prefrontal → flat
B/L medial OrbitoFrontal cortex → elevated
Where are these NTs neurons located? DA NE 5HT Histamine
DA: Mesostriatal (from SNc = substantia nigra), Mesolimbic (from VTa = ventral tegmental area), and Mesocortical (from VTA and around SN)
NE: Locus ceruleus and Lateral Tegmental area
5HT: Raphe nuclei in midbrain, pons, medulla, Rostral raphe of midbrain and rostral pons, Caudal Raphe nuclei of caudal pons and medulla
Histamine: posterior Hypothalamus
Depression is assoc w/ ___ inflammatory markers and ____ cortisol
Depression is assoc w/ INCREASED inflammatory markers and INCREASED cortisol
Differentiate Premsenstrual Dysphoric Disorder vs Post-Partum Depression sxs?
PPD time frame for occurance?
• PDD Symptoms include: ○ decreased concentration ○ feelings of sadness ○ tension ○ anxiety ○ fatigue ○ mood swings ○ panic attacks Seems to be a biochemical deficiency in the neurotransmitter Serotonin
PPD is major depressive or Bipolar w/w/o psychotic features after childbirth >4w but up to 1 yr post
Maybe d/t Progesterone drop?
How to recognize major depression as assoc feature or consequence of medical condition?
• Criteria
○ A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
§ Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities. (-)
§ Elevated, expansive, or irritable mood. (+)
○ B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
○ C. The disturbance is not better accounted for by another mental disorder (as Adjustment Disorder with Depressed Mood in response to the stress of having a general medical condition).
○ D. The disturbance does not occur exclusively during the course of a delirium.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
Which NTs and neurophysiologic changes are implicated in mood disorders?
DA and 5HT implicated in mood disorders
What are types of General Medical Conditions w/mood disorders?
○ With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a Major Depressive Episode.
○ With Depressive- Like Episode: if the full criteria are met for a Major Depressive Episode, except disturbance only occurs exclusively during course of a delirium
○ With Manic Features: if the predominant mood is elevated, euphoric, or irritable.
○ With Mixed Features: if the symptoms of both mania and depression are not present but neither predominates.
Define dx criteria of Major Depressive disorder
Major depressive disorder: 5+ everyday for 2w+
□ 1. Depressed mood.
□ 2. Loss of interest or pleasure in most or all activities.
□ **3. Insomnia or hypersomnia.
□ **4. Change in appetite or weight.
□ **5. Psychomotor retardation or agitation.
□ **6. Low energy.
□ ***7. Poor concentration.
□ **8. Thoughts of worthlessness or guilt.
□ **9. Recurrent thoughts about death or suicide.
List the associated features of MDD:
catatonic
Major depressive disorder: catatonic
• 1. motoric immobility as evidenced by cataplexy or stupor.
□ Catalepsy: immobile position constantly maintained.
□ Cerea flexibilitas (waxy flexibility) can “mold” limb position when moved like wax.
• 2. excessive motor activity (purposeless movement)
• 3. extreme negativism or mutism;
□ Motiveless resistance to instructions or maintenance of a rigid posture against attempts to be moved; mute.
• 4. peculiarities of voluntary movement
□ as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movement, prominent mannerisms, or prominent grimacing).
• 5. *echolalia- psychopathological repeating of words or phrases (may be in a mocking tone) or *echopraxia- pathological imitation of movements of one person by another.
□ Consider *Mirror neurons: may be involved in feelings of empathy (an understanding “from the inside”) or role in specific human abilities.
• 6. Either of the following, occurring during the most severe period of the current episode:
□ 1. loss of pleasure in all, or almost all, activities.
□ 2. lack of reactivity to usually pleasurable stimuli when something “good happens,”) does not feel much better, even temporarily).
List the associated features of MDD:
Melancholic
Major Depressive Disorder-Melancholic
• 1. distinct quality of depressed mood (that is, separate from, say, kind of feeling experienced when your beloved dog died).
• 2. depression regularly worse in the morning.
• 3. early morning awakening (at least 2 hours before usual time of awakening).
• 4. marked psychomotor retardation (-) or agitation (+).
• 5. significant anorexia or weight loss.
• 6. excessive or inappropriate guilt.
List the associated features of MDD:
atypical
Major Depressive Disorder-atypical
• A. Mood reactivity (mood actually brightens in response to positive events).
• B. Two or more of the following features:
○ 1. significant weight gain or increase in appetite.
○ 2. hypersomnia
○ 3. leaden paralysis (arms/legs feel “like lead”)
○ 4. long-standing pattern of interpersonal rejection sensitivity resulting in significant social or occupational impairment.
• C. Criteria that are not met for with melancholic features or with catatonic features during the same episode.
Describe dx characteristics of Dysthymia
Dysthymia:
• A. Depressed mood for most of the day, for more days than not for 2yrs (adult) or 1yr (kid)
• B. Presence, while depressed, of two or more of the following:
□ 1. poor appetite or overeating.
□ 2. insomnia or hypersomnia.
□ 3. low energy or fatigue.
□ 4. low self-esteem.
□ 5. poor concentration or difficulty making decisions.
□ 6. feelings of hopelessness.
Discuss dx and tx options for Bipolar disorders?
Major depression disorder
dysthymia
Cyclothymia
BP: mood stabilizers and antipsychotics w/w/o antidpressants, ECT
Major Depression Disorder: SSRI, SNRI, MAOI, antipsychotic, phototherapy, ECT,
Dysthymia: less pharmacotherapy than MDD if possible
Cyclothymia: Mood stabilizers (Lithium, Valproic Acid > Carbamazepine, Lamotrigine> Gabapentin, Toparamate), Antipsychotics [2st gen Thorazine or 2nd gen Quetiapine], Combo w/w/o antidepressants, and ECT
Diagnostic criteria of Cyclothymia?
Cyclothymia:
hypomanic and depressive sxs for 2yrs (adult), 1 yr( kids), but doesn’t meet criteria for Major Depressive or Bipolar… so more chronic but milder
What’s the MonoAmine theory of depression?
Depression’s d/t decreased monoamines, and w/initial tx you get an acute decrease d/t presynaptic autoreceptors
Takes weeks to get an increase in Monoamines
For SSRIs, what're the MOA TI PK *ADEs
SSRIs (Fluoxetine, Paroxetine, Citalopram)
MOA: SSRI
TI: Depression, bulimia, all major anxiety disorders (GAD, PTSD, OCD)
ADE: *Reduced libido, *teratogen (cardiac malformation 1st trimester exposure), GI, serotonin syndrome, discontinuation syndrome, dizzy, paresthesias
For SNRIs, what're the MOA TI PK ADE
SNRIs (Venlafaxine, Duloxetine)
MOA: SNRI
TI: Depression, pain, urinary incontinence, all major anxiety disorders (GAD, PTSD, OCD)
ADE: decreased libido, GI, noradrenergic HTN and HR increase, insomnia, anxiety, agitation
For TCAs, what're the *MOA TI PK *ADE
TCAs (Amitryptyline, Nortriptyline, Clomipramine)
MOA: SNRI and inhibition of *mACh, H, Da, NE receptors
TI: depression, OCD, peripheral neuropathy, chronic pain, migraine prophylaxis
PK: needs titration bc potential for OD, serious drug interactions
ADE: *Anticholinergic, *Cardiotoxicity, sedation, orthostatic hypotension, discontinuation syndrome
For MAOIs, what're the MOA TI *PK ADE CI/precautions?
MAOI-Selegiline
MOA: MAOI
TI: depression, Parkinson’s, anxiety
PK: *transdermal patch avoides hypertensive crisis w/tyramine ingestion (wine/cheese)
ADE: orthostatic hypotension, wt gain, anorgasmia, discontinuation syndrome, Hypertensive Crisis w/tyramine ingestion
CI: SSRI, TCA, St John’s Wort
For Trazodone, what're the MOA *TI *PK *ADE
Trazodone
MOA: selective 5HT Transporter, metabolite=5HT2A antagonist
TI: DEPRESSION AND INSOMNIA
PK: *Major metabolite is the antidepressant
ADE: *Priapism, sedation, nausea, postural hypotension
For atypical antidepressants, what’re the
MOA
TI
ADE
atypical antidepressants Bupropion and Vilazodone
MOA: Buproprion=DSNRI, VIlazodone DNRI and enhances 5HT and NE release
TI: Depression
ADE: trouble sleeping, GI, nausea, diarrhea
Bupropion-seizures and psychosis
What are the FDA approved mood stabilizers?
FDA approved mood stabilizers: Lithium Lamotrigine Valproic Acid (rapid cyclers) Carbamazepine
what meds can be used off label for Bipolar Disorder?
non-FDA-approved mood stabilizers Oxcarbazepine atypical antipsychotics some typical antipsychotics Olanzapine Benzodiazepine
For Lithium? theorized MOA ADEs drug-drug interaction drug-disease interaction
Lithium
theorized MOA: alters Na and NT transport, and 2nd messenger systems like IP3 and DAG in alpha and muscarinic adrenergic systems
ADEs: prone to high serum levels
Most common nausea, diarrhea, polyuria, polydipsia, weight gain, tremor, fatigue, confusion, somnolence… Hypothyroidism, skin reactions, leukocytosis, cardiac abnormalities, diabetes insipidus
drug-drug interaction: renal elimination, so NSAIDs, diuretics esp thiazides, ACEI or ARB
drug-disease interaction: pregnancy category D
For Valproic Acid theorized MOA ADEs drug-drug interaction drug-disease interaction
Valproic Acid
theorized MOA: enhance GABA and block Na
ADEs:
drug-drug interaction:
Transient: GI effects, sedation, dizziness, tremor, thrombocytopenia
Weight gain, polycystic ovary syndrome (PCOS), menstrual changes, mild alopecia
Rare: agranulocytosis, hepatotoxicity, pancreatitis, SJS
drug-disease interaction: pregnancy category D
How do you prescribe mood stabilizers?
Acute mania/manic
§ Lithium and/or valproic acid
§ +/- Antipsychotic (if psychotic symptoms, severe, or mixed symptoms)
§ Antipsychotic monotherapy (hypomania or milder mania)
§ +/- Adjunctive short term benzodiazepine (select symptoms)
§ Alternatives are carbamazepine, oxcarbazepine
Acute depression/depressive
§ Lithium and/or lamotrigine
§ Consider valproic acid
§ Fluoxetine + olanzapine (co-formulated)
§ Antipsychotics as monotherapy (e.g., quetiapine, lurasidone, olanzapine, select others)
§ Adjunctive antidepressant
□ Often done, but avoid monotherapy with an antidepressant
□ Ideal duration unknown; typically discontinued (tapered) a few months following episode remission
§ Adjunctive antipsychotic (if psychotic symptoms)
• Lithium
○ Best in both states (mania and depression)
○ Limited by monitoring, pregnancy, adverse effects
• Valproate
○ Good for mania/hypomania state
○ Also good for rapid cyclers and mixed features
• Carbamazepine, Oxcarbazepine
○ Good for mania/ hypomania state
○ Limited by drug interactions
• Lamotrigine
Good for bipolar depression
For Lamotrigine theorized MOA ADEs drug-drug interaction drug-disease interaction
Lamotrigine
theorized MOA: Glutamate inhibition
ADEs: Rash; SJS (rare)—titrate slowly! Avoid new medications, foods, products in first few months, Nausea and headache
Somnolence and fatigue
drug-drug interaction: anticonvulsants, so decrease dose for Valporate, increase dose w/Carbamazepine, Phenytoin, Primidone, Phenobarbital, Rifampin
drug-disease interaction: Pregnancy Category C (fine)
For Carbamazepine theorized MOA ADEs drug-drug interaction drug-disease interaction
Carbamazepine
theorized MOA: Na channels, Aspartate and Glutamate
ADEs: Somnolence, confusion, dizziness, blurred vision, GI effects, diplopia, SIADH
Rare: SJS/TENS, blood dyscrasias, hepatic failure
Test those with Asian ancestry for HLA-B*1502 gene since SJS linked to this gene
drug-drug interaction: Inducer of 1A2, 2C9, 2C19, and 3A4; Autoinduction (3A4) Complete after 3-4 weeks; Need 2nd form of birth control; Avoid with MAOIs
drug-disease interaction: can cause SJS
For Oxcarbazepine? theorized MOA ADEs drug-drug interaction drug-disease interaction
Oxcarbazepine
theorized MOA: Na channels, Aspartate and Glutamate; prodrug of 10, 11-epoxycarbamazepine
ADEs: like Carbamazepine but less blood cell effects and more SIADH
drug-drug interaction: maybe d/t 3A4 induction, but NOT autoinducer
drug-disease interaction: pregnancy category C (fine)
Which Benzodiazepine, antidepressant, and atypical antipsychotic can be used for BiPolar?
Benzodiazepine: Lorazepam
Antidepressant
Atypical Antipsychotic: Olanzapine
For Atypical antipsychotics, which is used for BP and what’s the theorized ADE relevant to BP?
Olanzapine for Bipolar interacts w/other drugs
When do you use TCAs for Bipolar?
whatre the possible ADEs relevant to BP?
TCA for BP can theoretically induce mania or rapid cycling
Use as adjunct when getting some response from optimal dose of mood stabilizer
For Benzodiazepines, which is used for BP, when, and what’re the precautions?
Lorazepam for BP can be used for
agitation, insomnia, or anxiety as adjunct, or IM in emergency
avoid chronic use
What’s the tx for Clyclothymia?
Cyclothymia tx
same as BP, mood stabilizers +/- antidepressants
Define personality disorder
enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture
is pervasive and inflexible
has an onset in adolescence or early adulthood
is stable over time
leads to distress or impairment
representative of long-term functioning and are not limited to episodes of illness
Differentiate Paranoid PD, Schizoid, Schizotypal, and Paranoid Schizphrenia
Who seeks tx?
Paranoid PD: paranoia grounded in REALITY
Schizoid: solitary, little interest in sex, emotionless, indifferent, no close friends, FUNCTIONAL
Shizotypal: odd beliefs, magical thinking, excessive social anxiety d/t paranoid fears that they can tell are delusional/apart from reality
Schizophrenia paranoia: paranoia not grounded in reality, that they CAN’T differentiate from reality
Schizotypal seeks tx for stress and anxiety, (+) results w/Haloperidol
Differentiate Antisocial and Borderline personality disorder?
Tx?
Problems when experiencing illness?
Antisocial: fails to conform to social norms of lawful behavior, indifferent and w/o remorse
-complies w/psychotherapy but usually substance abusers so maybe use meds
Borderline: frantically avoiding ‘abandonment’ but alternates b/w extrerme idealizing and devaluing people, HIGH IMPULSIVITY
-psychotherapy + meds
Differentiate Histrionic, and Narcissistic personality disorder?
Tx?
problems while treating?
Histrionic: inappropriately demanding center of attention, shallow, melodramatic, BUT FUNCTIONAL
-psychotherapy +antidepressants if symptomatic
Narcissistic: grandiosity, no empathy, arrogant, requires admiration, less manipulative/impulsive than borderline PD
-long term psychotherapy goals of tolerating disappointments and appreciating others needs, but they usually don’t seek help
Differentiate Avoidant and Dependent personality disorder?
tx?
problems while treating?
Avoidant: avoids interpersonal contact, hypersensitive to rejection and embarrassment, socially awkward and timid,
tx: psychoanalytic therapies, SSRI, MAOIs, beta-blockers for social phobias
tends to abandon tx abruptly
Dependent: starting in early adulthood, dependent on others for everything, difficulty disagreeing w/others or initiating projects
Tx: meds given during crisis, psychotherapy
Differentiate OCD and OCPD?
tx?
problems while treating?
OCD: true obsessions and compulsions, makes them NON-FUNCTIONAL bc deep seated fear/anxiety, and they understand they are abnormal!
-Clomipramine
OCPD: FUNCTIONAL, perfectionism that can interfere w/task completion, over-conscientious/scrupulous/inflexible on morals/ethics/values/rules, excessive hoarding of worthless items, but they think they’re normal!
-SSRIs
What’s found in REM and non-REM stages of sleep? (behavior, EEG)
nonREM
Stage 1: some muscle activity, low V, mixed f
Stage 2: episodic bursts of Sinusoidal waves that’re high V
slow-wave
Stage 3: high a, slow Delta waves
Stage 4: increased slow waves
REM: low V, mixed F, paradoxical sleep, no muscle activity, rapid eye movements
Compare peds to YA to elderly sleep patterns
newborns 50% REM
YA 25% REM, mostly Stage 2 sleep
elderly <25% REM, less nonREM stage 4 sleep
as you age, sleep cycles increase in duration
What’s the neural correlate of Circadian Rhythm
Circadian Rhythm:
Suprachiasmatic nucleus = endogenous clock, releases hormones on 24hr cycle
proteins PER and TIM regulate hormone release
TIM’s degraded by light, so build up occurs at night, allowing PER and TIM to form complex and limit hormone transcription
What are the patterns of sleep cycles?
Cycle: nonREM 1-2-3-4-3-2 to REM (skips 1 on the way back)
REM occurs every 60-90m, increasing in duration and intensity throughout the night
2nd half of night is mostly REM and Stage 2 (very little Stages 3-4 slow wave sleep)
What are the role of the brainstem and thalamic neurons w/regards to sleep?
Midbrain Reticular Formation (part of ascending reticular activating system) above Pons = wakefulness
Medulla = sleep center, inhibits wakefulness
Posterior Hypothalamus = arousal via Histamine
Anterior Hypothalamus = sleep via GABA, inhibiting Post Hypothalamus
What are the monoamine mechanisms for REM and nonREM sleep?
REM (and switching between nonREM and REM) = ACh
non-REM = histamine, NE, 5HT… get shut off between waking to stage 1 through stage 4; GABA cells in Nucleus Reticularis oscillate d/t VgCaCh, inhibiting Thalamocortical relay cells
