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A3 ME3034 SPECIALTIES > W01 - PSYCH: Anxiety Disorders; Psychopharmacology > Flashcards

W01 - PSYCH: Anxiety Disorders; Psychopharmacology Flashcards

1
Q

To define the symptoms of anxiety disorders.

A

brought on by perception of a threat that may or may not be present

Psychological arousal

Autonomic Arousal

Muscle Tension

Hyperventilation

Sleep Disturbance

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2
Q

Anxiety Disorders

A
  • particular stimulants or generalised anxiety
  • F>M, but cultural and alcohol factors

Phobic Disorders

Anxiety Disorders

Obsessive Compulsive Disorders

PTSD

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3
Q

Phobic Disorders

A

Core symptoms of GAD but specific and particular stimuli

  • phobic avoidance
  • Sufferer also experiences anxiety if there is a perceived threat of encountering the feared object or situation “anticipatory anxiety”

*Phobic
* Social = tremor and blushing pre-dominant
* Agoraphobic

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4
Q

Anxiety Disorders

A

+ Fear-related disorders

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5
Q

OCD

A

intrusive, egodistonic (unwanted and unpleasant)
= result in compulsion = physical action or mental effort as a result of the obsession

*M=F
* aetiology = 5HT receptor and functionning

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6
Q

PTSD

A

associated with stress
*F>M (USA)
* Vulnerability factors; genetic susceptibility

*delayed/protracted reaction to stressor or exceptional severity

*Hyperarousal

Re-experiencing phenomena

Avoidance of reminders

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7
Q

Mgmt of Phobic Disorders

A

Social Phobia mgmt
> Cognitive Behavioural Therapy

> Education and advice

> Medication SSRI antidepressants

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8
Q

Mgmt of OCD

A

> education and planning; involving close contacts

> Serotonergic: SSRI Fluoxetine,
Clomipramine

> CBT: exposure and response prevention, examination and weakening convictions

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9
Q

Mgmt of PTSD

A

> screening of survivors at 1mos

> watchful waiting, review
trauma-focussed CBT
eye movement desensitisation reprocessing
sedatives (risk of dependence)

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10
Q

Models of Stress

A

Balance between processing perceived threat and perceived ability to cope

= problem focussed coping

= emotion focussed coping

*yerkes dodson curve = bell curve of stressXperformance

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11
Q

DDx of Anxiety Disorders

A

1) Psychiatric Conditions
Depression
Schizophrenia
Dementia
Substance Misuse

2) Physical Conditions
Thyrotoxicosis
Phaeochromoctoma
Hypoglycaemia
Asthma and or Arrhythmias

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12
Q

Generalised Anxiety Disorder

A

“In general terms GAD for instance is caused by a stressor acting on a personality predisposed to the disorder by a combination of genetic factors and environmental influences in childhood.”

  • pretty common, F>M
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13
Q

Mgmt of GAD

A

> Counselling
Clear Plan of Management
Explanation and education
Advice re caffeine, alcohol, exercise etc.

> Relaxation training
Group or individual
DVDs, tapes or clinician led

Medication
!Sedatives have high risk dependency
>Antidepressants SSRI or TCA

> Cognitive Behavioural Therapy

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14
Q

Mgmt with Antidepressants

A
  • selection based on response hx, sfx, coexisting conditions
  • 2-4w delay before improvement

indications: uni/bipolar, organic, anxiety: OCD, social, PTSD

Medication
(1) SSRI

(2) SNRI

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15
Q

SSRIs

A

tx for anxiety and depressive symptoms
serotinergic

sfx: GI upset, sexual dysf., anxiety, restlessness, nervousness, insomnia, fatigue/sedation, dizziness

little cardiotox in overdose

  • discontinuation syndrome = agitation, GI uspset, disequilibrium, dysphoria

> FLUOXETINE

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16
Q

Activation syndrome and deactivation syndrome

A

activation = ⇧serotonin = GI, anxiety, panic and agitation
2-10d; warn pt.!

discontinuation = agitation, GI uspset, disequilibrium, dysphoria
* more common w/ shorter half life drugs

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17
Q

Fluoxetine

A

*SSRI

  • long half-life thus ⇩discontinuation syndrome; but can build up
  • initially activating thus good for energy levels
  • good for pt with noncompliance issues
  • inapp for hepatic pt.
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18
Q

Sertaline

A

*SSRI

  • weak P450 = good inpolypharmacy
  • short half life = low build up risk
  • less sedating
  • full stomach req for max absorption
  • GI adverse reaction risk
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19
Q

TCAs

A
  • effective family but significant sfx profile

antihistaminic, cholinergic, adrenergic
lethal overdose
Long QT syndrome

  • secondary TCA metabolites, sfx less severe as 3º TCA
  • tertiary TCAs cross-react w/ other receptors = more sfx

> Amitriptyline
Desipramine

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20
Q

MAOIs

A
  • irreversibe binding and increase of NE, dop, serotonin
  • indicated in resistant depresseion

*SFX: ortho hypoT, wt gain, dry mouth, sedation, sexual dysf., sleep disturbance

!cheese reaction = tyramine-rich foods precipitate hypertensive crisis
- cheese
-cured meats
- pickled fermented foods
- high salt sauces
- alcoholic beverages

!serotonin syndrome: ⇧serotonin = GI, tachy, hyperpyrexia
- 2w break before switching to MAOI from SSRI except for fluoxetine = 5w break dt long half life

> Selegiline
Isocarboxazid
Phenelzine

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21
Q

SNRIs

A
  • inhibit serotonin and NA uptake like TCA but without poor sfx profile
  • depression, anxiety, NEUROPATHIC PAIN

> Venlafexine
Duloxetine

22
Q

Venlafexine

A

*SNRI

*minimal drug interactions
*short half-life = fast renal clearance thus good for renal pt and geris

  • increase in diastolic BP
  • GI sfx
  • bad discontinuation syndrome thus TAPER
    *QT
  • sexual dysf.
23
Q

Duloxetine

A
  • SNRI
  • beneficial for physical symptoms for depression
  • less BP sfx than venlafexine
  • drug-interactions
  • bad LT compliance
24
Q

Vortioxetine

A
  • SNRI
  • less GI sfx, BP sfx

*expensive!!!

25
Q

Mirtazapine

A
  • novel antidepress.
  • serotinergic, may augment SSRI
    + hypnotic at lower doses 2º to antihistaminic effects
  • !increases cholesterol, wt gain
  • very sedating
26
Q

Tx-Resistant Depression

A

> SSRI / SNRI + Mirtazepine
+Lithium
+ or antipsychotic

> ECT

27
Q

Prophylactic Tx of Depression

A

1st episode = requires 6mos post remission

2nd episode = requires 1yr post remission

3rd epiisode = lifelong

*risks of relapse

28
Q

Indications of mood stabilisers

A

bipolar, cyclothymia, schizoaffective

*lithium
* anticonvulsants
* antipsych.

29
Q

Lithium

A
  • reduces suicide rate
  • LT prophylaxis in mana and depressive episodes
  • +ve outcome = +ve FH response, pure mania (Bip. I), mania followed by depp.

! UE & TSH monitoring = steady state after 5d. then 3mos check, and then 6mos
= goal between 0.6-1.2

30
Q

Lithium Sfx

A

GI, diarrhea

  • thyroid abn = polyuria/dypsia
  • leukocytosis
  • hair loss, acne
  • reduced seizure threshold, cognitive slowing

!lithium toxicity!

31
Q

Valproic acid

A
  • effective in mania, not as. much in deppr; better tolerated than lithium
  • pt +ve. predictors
  • rapid cycliing
  • comorbd substance issues
  • comorbid anxiety disorders
  • baseline liver function tests, prego, FBC
    !folic acid reduction = neral tube defect
32
Q

valproic acid sfx

A

platelet dysfunction
GI sfx
wt gain
sedation, tremor
hair loss

*LFT increase, but not of concern unless triples+

33
Q

Why avoid valproic acid in child bearing women

A

Risk of neural tube defect secondary to folic acid reduction

34
Q

Acute mania mgmt

A

> olanzapine
quetiapine
risperidone.

If you’re taking an antidepressant when the mania or hypomania starts, your doctor or nurse may advise you to stop taking the antidepressant.

!agranulocytosis;

+mood stab: lithium
+ or mood stab: Na valporate (CI in young child bearing)

Carbamezepine = acute mania and mania prophylaxis
- basline liver function tests, FBC, ECG
- follow up and adjust at 1mos
* for rapid cyclers and mixed patients

35
Q

Carbamezepine sfx

A

Rash most common

GI sfx
sedation, dizzy
AV conduction delays
D-D interactions

36
Q

Lamotrigine

A
  • anticonvulsants and neuropathic pain with baselines
  • if stopped for 5d must restart initiation dose pattern
37
Q

Lamotrigine sfx

A

GI sfx
sedation, dizzy

*toxic epidermal necrolysis
* SJS

*blood dyscrasias

*d-d= and valproic acid, sertaline can increase lamotrigine levels

38
Q

Antipsychotics

A

for: schizophrenia, schizoaffective, bipolar, or when augementing agent in resistant disorders

  • dopamine receptor antagonists
    (1) high risk to extrapyramidal sfx= high binding
    (2) high cardiotox. and ACh sfx = low binding dt receptor cross-interaction
    (3) atypical serotonin-dop. antag. =

1
> Fluphenazine
> Haloperidol
> Pimozide
2
> risperidone
> chlorpromazine
> Thioridazine
3

39
Q

What is the most significant projections in the brain concerned in psychoticsymptoms and patients

A

mesocortical

40
Q

What is the most significant projections in the brain concerned in positive symptoms (hallucinations and dleusions etc.) in patients

A

mesolimbic

41
Q

Risperidone

A
  • atypical but acts like a typical at higher doses
  • increased extrapyramidal sfx
  • most. likely to induce hyperprolactinemia
  • best profile for existing hyperlipidemia
  • wt gain and sedation
  • ci: hypotension, extrapyramidal akathisia
42
Q

Olanzapine

A
  • atypical antipsychotic
  • hypercholesterolemia + etc., +wt gain
  • hyperprolactinemia risk
  • abn LFTs
43
Q

Quetiapine

A
  • atypical antipsych
  • most likely to cause orthostatic hypotension
  • abn LFT
  • wt gain, but lesser risk
  • hypercholesterolemia etc
44
Q

Aripiprazole

A
  • atypical antipsyc
    *1st line?

*partial D2 agonist
* nil wt gain, QT prolong, low sedation
* but significant D-D interactions thus dosing required in polypharm.

45
Q

Clozapine

A
  • reserved for treatment resistant but very effective despite sfx profile
  • agranulocytosis = thus persistent monitoring
  • increased risk of seizures
  • !sedation, wt gain, abn LFTs, hypercholesterolemia etc
46
Q

Significance of insight and link to relapse

A

Commonest psychotic symptom is lack of insight = greatest reason for non-compliance = relapse

  • third episode = reduced functionning, lower IQ, negative symptoms
47
Q

Most significant antipsychotic adverse effects

A

tarditive dyskinesia = involuntary muscle movements, may not resolve with cessation

*neuroleptic malignant syndrome = PSYCHIATRIC EMERGENCY, muscle. rigidity, fever,mental status, autonomic instability, deragend bloods

*extrapyramidal side effects:acute dystonia, parkinson syndrome, akathisia

48
Q

mgmt of extrapyramidal syndrome

A

> anticholinergics: benztropine etc.

> dopamine facilitators: amantadine

> betablockers (akathisia)

> benzodiazepines (akathisia)

!ACh d-d interactions

49
Q

Significance of akathisia

A

increased risk for suicide!

> BB
benzodiazepines

50
Q

Anxiolytics

A
  • used in tandem with SSRIs/SNRIs in GAD

> Buspirone - serotonin agonist, nil sedation, 2w acting
benzodiazapines - insomnia in anxiety disorders, used in withdrawal but significant sfx profile

A3 ME3034 SPECIALTIES (27 decks)

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