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Week 7 Flashcards

1
Q

Epidemiology of bipolar disorder? Any genetics?

A

Mood Episodes

  • Epidemiology: age of onset is young adulthood, bipolar disorder usually starts with a depressive episode, most bipolar patients have more than one episode of illness
    • Monozygotic concordance is high in bipolar disorder I and II
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2
Q

Define the following:

  • Mood episode
  • Mood disorder
A
  • Mood Episode: distinct periods of time in which some abnormal mood is present
  • Mood Disorder: patterns of mood episodes
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3
Q

For manic episode:

  • What is the criteria (mnemonic)
  • What is one risk factor for manic episodes?
A
  • Manic episodes (psychiatric emergency)
    • Criteria: a distinct period (at least 1 week) of abnormally and persistently elevated, expansive, or irritable mood
      • 3 or more of the following (4 if irritability is mood): DIGFAST
        • Distractibility
        • Insomnia (decreased need for sleep)
        • Grandiosity
        • Flight of ideas
        • Activity/Agitation (increased/goal-directed)
        • Speech (pressured – fast talking)
        • Thoughtlessness (Hedonistic interests)
    • Causes impairment in occupational/social activities OR requires hospitalization OR has psychotic features
    • Not due to substance use or medical condition
    • Risk factor: antidepressant use (i.e. SSRI)
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4
Q

For hypomanic episodes

  • Criteria?
  • Differences between manic and hypomanic (3 main ones!)
  • Duration?
A
  • Hypomanic episodes
    • Same symptoms as manic episode (with elated, expansive, or irritable mood)
    • Differences: no impairment in function, no hospitalizations, no psychotic features
      • Duration: 4 days (compared to 1 week in mania)
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5
Q

For mixed episodes:

  • Criteria?
  • Duration?
A
  • Mixed episodes (both depressive and manic sx) – psychiatric emergency
    • Criteria for both mania and depressive episodes are met for one week
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6
Q

For bipolar I disorder:

  • Criteria?
  • Specifiers (many)
  • Define rapid cycling subtype.
A

Bipolar I Disorder

  • Presence of one or more manic/mixed manic episode
    • Minor or Major Depressive Episodes MAY be present
    • MAY have psychotic symptoms
  • Specifiers: anxious distress, mixed features, melancholic features, atypical features, mood congruence (belief/action consistent with mood), mood incongruence (belief/action inconsistent with mood), catatonia, peripartum onset, seasonal pattern, rapid cycling
    • Rapid cycling (Bipolar I or II): four or mood episodes within a year (must have a period of remission OR a switch to opposite polarity)
      • Manic, hypomanic, mixed (same pole) vs depressive (opposite pole)
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7
Q

For bipolar II:

  • Criteria
A

Bipolar II Disorder

  • Presence of one or more major depressive episode AND one or more hypomanic episode
    • No full manic or mixed manic episodes
  • Specifiers: same as Bipolar I
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8
Q

For cyclothymia:

  • Criteria
  • Duration?
  • Maximum hiatus?
A

Cyclothymia

  • Criteria: numerous periods with hypomanic sx that DO NOT meet criteria for hypomanic and depressive sx or major depression
    • Must be present for at least half the time with no hiatus longer than 2 months
    • Criteria for major depressive, manic, or hypomanic episodes have not been met
  • Duration: 2 years (1 year in children)
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9
Q

What is the goal for bipolar tx?

What is the first line?

A
  • Goal: treat acute sx, prophylaxis (minimize risk of switching via antidepressants)
  • Lithium (gold-standard for bipolar disorder)
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10
Q

For lithium:

  • Use?
  • Proposed MOA
  • Pharmokinetics
A
  • Lithium (gold-standard for bipolar disorder)
    • Use: first-line (if severe, add anti-psychotics)
    • Proposed MOAs:
      • Interactions with cation transport process by substituting for Na+ → direct effect on NTs (i.e. serotonin, dopamine, NE, Ach) OR inhibits PIP3 pathway
    • Pharmacokinetics: eliminated in kidneys (reabsorbed at PCT)
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11
Q

For lithium:

  • Side effects/teratogenicity?
  • Toxicity effects?
  • Drug interactions?
  • What labs must be monitored?
A
  • Lithium (gold-standard for bipolar disorder)
    • Side Effect
      • Teratogenicity (cardio malformations: Ebstein’s anomaly), goiter, hypotonia, CNS depression
      • SE: tremor, hypothyroidism (weight gain, GI distress, fatigue), nephrogenic diabetes insipidus (ADH inhibited → polyuria), metallic taste
    • Monitor: TSH, T4
    • Toxicity (low therapeutic index): excessive dose, dehydration, sodium depletion, meds (thiazide diuretics, ACEis, NSAIDs, calcium channel blockers)
      • Signs/sx (increasing toxicity): N/V/D → confusion, seizures, hyperreflexia → cardiac arrhythmia
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12
Q

For valproate:

  • Use
  • MOA
  • SE
  • Drug interactions
  • Labs monitored?
A
  • Valproate
    • Use: less severe bipolar disorder, rapid cycling
    • MOA: blockage of voltage-sensitive Na+ channel; increases GABA
    • SE: HA, N/V, hepatotoxicity, teratogenicity (neural tube defects), pancreatitis, PCOS, weight gain, low platelets
      • Drug interactions: weak CYP450 inhibitor (inhibits lamotrigine)
    • Monitor: LFTs, coag tests
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13
Q

For carbamazepine:

  • Use
  • MOA
  • SE
  • Drug interactions
  • Labs monitored?
A
  • Carbamazepine
    • Use: rapid cycling
    • MOA: block voltage-sensitive Na+ channel; decreases Glutamate
    • SE: agranulocytosis, hyponatremia, induces CYP enzymes, Steven Johnsons, teratogenicity (neural tube defects), drowsiness, SIADH
    • Monitor: drug concentration
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14
Q

For oxycarbazepine:

  • Use
  • MOA
  • SE
  • Drug interactions
  • Labs monitored?
A
  • Oxcarbazepine:
    • Use: rapid cycling
    • MOA: block voltage-sensitive Na+ channel; decreases Glutamate
    • SE: somnolence, hyponatremia
    • Drug interactions: CYP inhibitor/inducer
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15
Q

For lamotrigine:

  • Use
  • MOA
  • SE
  • Drug interactions
  • Labs monitored?
A
  • Lamotrigine
    • Use: depressed phase (or lithium – antidepressants are not indicated)
    • MOA: block voltage-sensitive Na+ channels; decreases Glutamate
    • SE: Steven-Johnsons
    • Drug interactions: affected by valproate
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16
Q

What is the epidemiology of anxiety?

A
  • Epidemiology: females>male, onset late teens to early adulthood, often have other psych disorders
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17
Q

What are the sx of anxiety by the following systems?

  • Cardiac
  • Pulm
  • Neuro
  • Psych
  • Other
A
  • Symptoms of anxiety (associated with NT imbalance)
    • Cardiac: palpitations, tachycardia, hypertension
    • Pulmonary: SOB, choking sensation
    • Neuro: dizziness, lightheadedness, hyperreflexia, mydriasis (dilation), tremors, tingling in periphery
    • Psych: restlessness, butterflies
    • Other: sweating, GI issues, urinary urgency, “lump in throat”, feeling of MI
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18
Q

What parts of the brain are involved in anxiety?

A
  • Neuroanatomy: amygdala (hyperactivated during anxiety), medial prefrontal cortex (involved), hippocampus (involved)
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19
Q

Etiologies of anxiety (meds or medical?)

A
  • Etiologies of anxiety
    • Medical: hyperthyroidism, B12, hypoxia, neuro diseases, CVD, anemia, pheochromocytoma, hypoglycemia
    • Meds: caffeine, alcohol, amphetamines, mercury, penicillin, antidepressants
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20
Q

For general anxiety disorder:

  • Criteria
  • Duration?
A

Generalized Anxiety Disorder

  • Criteria: excessive worry more days than not for at least 6 months
    • Must be associated with three of the following: restlessness, easily fatigued, difficult concentrating, irritability, muscle tension, sleep disturbance
    • Causes significant distress or impairment
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21
Q

For panic attack:

  • Criteria
  • Duration?
  • Seen with what disorders?
  • Etiology
  • Presentation
A

Panic Attack

  • Description: discrete periods (10-25 minutes) of heightened anxiety and fear
    • Criteria (PANICS) – 4 of any of the following: Palpitations, Abdominal distress, Numbness/Nausea, Intense fear of death, Choking/Chills/CP, Sweating/Shaking/SOB
  • Can be seen in any anxiety disorder (PTSD, phobias, panic disorders, etc)
  • Etiology: strong genetic component, alcohol
  • Presentation: commonly present to other specialties because it presents similar to an MI
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22
Q

What are provocative studies for panic attack?

A
  • Etiology: strong genetic component, alcohol
    • Provocative studies: Na lactate, CO2, Caffeine, MCPP (5-HT agonist), cholecystokinin, Yohimbine (alpha-2 agonist), isoproterenol (beta agonist – similar to epi/norepi)
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23
Q

For panic disorder:

  • Criteria?
  • What are episodes chraxterized by?
A

Panic Disorder

  • Criteria: at least 2 recurrent unexpected panic attacks followed-by one month with:
    • Persistent worry of additional attacks, worry about implications of attacks, change in behavior due to the attacks
    • Episodes must be characterized by: acute onset with no trigger, peaks and subsides within minutes, autonomic symptoms, anticipatory anxiety, and PANICS sx
    • Can be present with or without agoraphobia
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24
Q

What is the general definition of a phobia?

A
  • General (most common anxiety disorders)
    • Definition: irrational fear that leads to avoidance/escape of the feared object or situation
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25
Q

For specific (simple) phobia:

  • Criteria
  • Tx
A
  • Specific (Simple) Phobias
    • Criteria: marked or persistent fear that is excessive cued by presence/anticipation of a specific object or situation
      • Exposure bring about an immediate out of proportion anxiety response
      • Patient recognizes fear is excessive
      • Interferes significantly with persons routine of function
      • Situation is avoided when possible or tolerated with intense anxiety
      • If patient is < 18, the fear must last > 6 months
    • Tx: gradual systemic desensitization to feared object or situation
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26
Q

For scoial phobia (aka social anxiety disorder)

  • Criteria
  • Is the patient aware that their fear is excessive?
A
  • Social Phobia (Social anxiety disorder)
    • Criteria: fear of being focus of attention or behaving in an embarrassing way → leading to avoidance of social situation (i.e. public speaking, public toilets, attending parties
      • Patient acknowledges fear is excessive
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27
Q

For agoraphobia:

  • Criteria
  • Duration
A
  • Agoraphobia
    • Criteria: marked fear or anxiety for more than 6 months about 2 of the following situations:
      • Use of public transportation, being in open spaces, being in enclosed spaces, standing in line/being in crowd, being outside of home alone
    • Fears or avoids these situations because escape will be difficulty
    • Anxiety is out of proportion
    • Situation is avoided or endured with anxiety
    • Interferes with routine of function
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28
Q

For Obssessive compulsive disorder:

  • Types (4 - define each)
  • Criteria
  • Duration
  • Specifiers
  • Co-morbidities
  • Tx
A

Obsessive Compulsive Disorder (OCD)

  • Types: Body Dysmorphic Disorder (not satisfied with appearance of body), hoarding disorder (collecting items for obsessive reason), trichotillomania (pulling body hair), excoriation disorder (picking at skin)
  • Criteria: obsessions AND/OR compulsions cause marked distress, take >1 hour/day OR cause distress/impairment in function
  • Specifiers: good/fair insight (thoughts are not true), poor insight (probably true), absent insight (OCPD – not aware that thoughts/actions are crazy), tic-related
  • Co-morbidities: depression
  • Tx: psychosurgery (cingulatomy)
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29
Q

For Obssessive compulsive disorder:

  • Epidemiology
  • Define obsessive
  • Define compulsion
  • Define the etiologies (genetic, biological, childhood etiology**)
A

Obsessive Compulsive Disorder (OCD)

  • General (F=M; M earlier onset; chronic course)
    • Obsessive: recurrent and intrusive thought, feeling or idea that is ego-dystonic (i.e. germs)
    • Compulsion: repetitive, irresistible, time-consuming ritual that is performed in attempt to neutralize anxiety due to obsession (i.e. washing, hoarding)
  • Etiologies:
    • Genetics: high concordance in twins
    • Biological: serotoninergic dysfunction, abnormalities in cortico-striatal-thalamic-cortical circuit, dysfunction of caudate nucleus, head injury, epilepsy
    • Childhood OCD (often due to PANDAS – streptococcal autoimmune disorder of basal ganglia) – tx with penicillin, plasmapheresis
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30
Q

For PTSD:

  • Criteria (mnemonic)
  • Duration
A

Post-Traumatic Stress Disorder (PTSD)

  • Criteria: exposure to you or a close person of actual or threatened death, serious, or sexual violence in one or more of the following ways (HARD)
    • Hyperarousal (2+ of these): problem sleeping, anger, hypervigilance, increased startle response, concertation issues
    • Avoidance of associated stimuli
    • Re-experience of event (1+ of these): intrusive memories, nightmares, dissociative reactions, distress with cue of event (Tx: prazosin)
    • Detachment (2+ of these): numbness of cognition or mood → diminished interest, detachment, inability to experience positive emotions, etc.
    • Specifiers: dissociative (depersonalization), delayed expression (do not meet criteria until 6 months later)
    • Duration: >1 month
      • Acute Stress Disorder: symptoms last <1 month after trauma
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31
Q

Non-pharm tx for anxiety disorders

A
  • Non-pharmacological: CBT, Desensitization, group therapy, psychotherapy
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32
Q

List tx options for anxiety disorders

A

antidepressants (SSRI, SNRI, TCA, MAOIs), Benzos, Z comounds, beta agonsits, 5-HT1A agonist

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33
Q

What are antidepressants used for in tx of anxiety disorders?

A
  • Antidepressants (SSRI, SNRI, TCA, MAOI): maintenance; not acute anxiety
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34
Q

Benzodiazapine:

  • Use in anxiety disorder
  • MOA
  • Metabolism
  • Examples (short and long half life)
  • SE:
A
  • Benzodiazepines: acute anxiety, preventative if long half-life
    • MOA: enhance the effect of GABA by binding on GABA A receptor → increased rush of chlorine into post-synaptic neuron
    • Metabolism: well absorbed, metabolized by CYP, excreted as glucuronide conjugates in urine
    • Example:
      • Short half-life: alprazolam (Xanax), Triazolam, Lorazepam (Ativan)
      • Long half-life: diazepam (Valium), Chlordiazepoxide (Librium)
    • SE: tolerance (increased dose to produce effect), sedation, ataxia, anterograde amnesia, confusion, muscle weakness, withdrawal (anxiety, insomnia, muscle twitches/tremors, etc)
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35
Q

For “Z” compounds

  • Examples
  • MOA
  • SE
A
  • “Z” Compounds (Zolpidem, Zopiclone) – structurally unrelated to benzos
    • MOA: same as benzodiazepines
    • SE: less than benzos (no tolerance, no physical dependence, no sleep disturbance)
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36
Q

For 5-HT1A agonist

  • Example
  • MOA
  • Disadvantage
  • Advantages
A
  • 5-HT1A agonist (i.e. buspirone)
    • MOA: partial agonist for 5-HT1A receptors in brain
    • Disadvantages: Slow onset of action; short half-life (needed 2-3x per day)
    • Advantages: no physical dependence, no abuse potential, less sedation, less interaction with alcohol
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37
Q

Screening questions for following anxiety disorders:

  • panic attack
  • generalized anxiety disorders
  • PTSD
  • OCD
  • social anxiety disorder
A

Questions to Screen for Anxiety Disorders

  • Have you ever experienced a panic attack? (panic attack)
  • Do you consider yourself a worrier? (General anxiety disorder)
  • Have you ever had anything happen that still haunts you? (PTSD)
  • Do you get thoughts stuck in your head that really bother you or need to do things over and over like washing your hands or checking things? (OCD)
  • When you are in a situation that people can observe you, do you feel nervous and worry that they will judge you? (social anxiety disorder)
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38
Q

Define classic conditioning

A
  • Classical conditioning (Pavlov’s experiment): correlating an involuntary natural response/behavior (salivation) with a conditioned/learned stimulus (bell) via pairing with an unconditioned stimulus (food)
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39
Q

Define operant conditioning:

  • Define reinforcement, punishment, exctinction
A
  • Operant conditioning: voluntary behaviors based on punishment and reward
    • Reinforcement: target behavior is followed by reward (positive reinforcement) or removal of a negative stimulus (negative reinforcement)
    • Punishment: repeated application of negative stimulus (positive punishment) or removal of reward (negative punishment) to extinguish unwanted behavior
    • Extinction: discontinuation of reinforcing/stimulus eventually eliminates behavior
40
Q

Define transference and countertransference.

A
  • Transference: patient projects feelings about formative or other important persons onto physician (i.e. psychiatrist seen as parent)
  • Countertransference: doctor projects feelings about formative or other important persons onto patients (i.e. patient reminds physician of sibling)
41
Q

Fill in the defense mechanisms

A
42
Q

Fill in defense mechanisms

A
43
Q

Fill in defense mechanisms

A
44
Q

Define personality disorders:

Do they have insight?

A
  • Definition: deeply engrained inflexible patterns of relating toNext others that are maladaptive and cause significant impairment in social and occupational functioning
    • Patients lack insight of their problem and sx are viewed as ego-syntonic (behaviors that are acceptable to one’s self-image)
45
Q

What are the big 5 personality traits (mnemonic)

A
  • “Big 5” Personality Traits (OCEAN): Openness to experience, Conscientiousness, Extraversion, Agreeableness, Neuroticism (personality disorders have variations of these)
46
Q

Criteria for personality disorder?

A
  • Criteria for personality disorders:
    • Pattern of behavior that deviates from culture and is manifested in at least two of the following ways:
      • Cognition, affect, personal relations, impulse control
    • Pattern:
      • Pervasive and inflexible in a broad range of situations
      • Is stable and onset during adolescence/early adulthood
      • Leads to significant distress and functioning
      • Not accounted by another medical condition/substance
47
Q

Define cluster a personality disorders and what three disorders are included?

A

CLUSTER A

  • Definition: odd or eccentric inability to develop meaningful relationships; no psychosis; genetic association with schizophrenia

Paranoid (M>F)

Schizoid

Schizotypal

48
Q

For paranoid disorder:

  • Define
  • General sx?
A

Paranoid (M>F)

  • Pervasive distrust (Accusatory) and suspicious of others and profoundly cynical view of the world
  • General sx: hypervigilant, unforgiving, unjustified doubts, unwarranted fear, feels threatened at all times
49
Q

For schizoid disorder:

  • Define
  • General sx?
A
  • Voluntary social withdrawal (Aloof), limited emotional expression, content with social isolation
  • Sx: cannot form relationships, loner, emotionally cold
50
Q

For schizotypal disorder:

  • Define
  • Sx
A

Schizotypal

  • Eccentric appearance, odd beliefs or magical thinking (interpersonal Awkwardness)
  • Sx: illusions, weird looking, weird speech (i.e. Willy Wonka)
51
Q

For cluster B:

  • Define
  • what disorders?
A

CLUSTER B

  • Definition: dramatic, emotional or erratic; genetic association with mood disorders and substance abuse
  • Disorders: antisocial, borderline, histrionic, narcissistic
52
Q

For antiscoial personality disorder

  • Define
  • Hx
  • Sx
A

Antisocial (M>F; Age>18)

  • Disregard for and violation of rights of others with a lack of remorse, criminality, impulsivity; Bad
    • Hx of conduct disorder (aka antisocial PD <18y/o) before age 15
  • Sx: law-breakers, reckless, lack of remorse
53
Q

For borderline:

  • Definition
  • Sx
A

Borderline (F>M)

  • Unstable mood and unstable interpersonal relationships, impulsivity, self-mutilation, suicidality, sense of emptiness (Borderline)
    • Splitting (viewing others as all good or all bad) is a major defense mechanism
  • Sx: aggressive, try to avoid abandonment
54
Q

For histrionic:

  • Define
  • Sx
A

Histrionic

  • Excessive emotionality and excitability, attention-seeking, sexually provocative, overly concerned with appearance (Basic Bitch)
  • Sx: talkative, seductive
55
Q

For narcissistic:

  • Define
A

Narcissistic

  • Grandiosity, sense-of-entitlement, lacks empathy, requires excessive admiration; often demands the best and reacts to criticism with rage (Best)
56
Q

For CLUSTER C:

  • Define
  • Disorders
A

CLUSTER C

  • Definition: anxious or fearful; genetic association with anxiety disorder
  • Disorders: avoidant, dependent, OCPD
57
Q

For avoidant PD:

  • Definition
  • Sx
A

Avoidant

  • Hypersensitive to rejection; socially inhibited; timid; feelings of inadequacy; scared to develop relationships with others out of fear of embarrassment (but internally desired) (Cowardly)
  • Sx: introverted, anxious, low self-esteem, scared of being rejected
58
Q

For dependent PD:

  • Definition
  • Sx
A

Dependent

  • Submissive and Clingy; excessive need to be taken care of; low self-confidence
  • Sx: reliance on others to make decisions, fear of abandonment, overly-reliant
59
Q

For obsessive compulsive

  • Definiton
  • Sx
A

Obsessive-Compulsive

  • Preoccupation with order, perfectionism, and control; ego-syntonic (behavior consistent with one own’s belief/attitudes) (Compulsive)
  • Sx: perfectionist, competitive
60
Q

abuse definiton

and criteria

A
  • Abuse: pattern of substance use → impairment or distress for at least 12 months with one or more of the following manifestations (WILD):
    • Work, school or home role obligation failure
    • Interpersonal or social consequences
    • Legal problems
    • Dangerous use (i.e. while driving)
61
Q

dependence def and criteria

A
  • Dependence: substance use → impairment of distress manifested by 3 of the following within a 12-month period
    • Tolerance (more drug is required to achieve effect)
    • Withdrawal
    • Using the substance more than originally intended
    • Unsuccessful efforts to cut down on use
    • Significant time recovering/using substance
    • ↓ occupational/recreational activity secondary to substance use
    • Continued use despite subsequent physical problems
62
Q

opioids

examples, MOA for euphoria and analgesia

A
  • Examples: morphine/codeine, oxycodone (semi-synthetic opioids), fentanyl (synthetic opioid)
    • Demerol (Meperidine) dilates pupils (exception)
    • Tramadol: can cause serotonin syndrome (careful with SSRI); less addiction potential
  • MOA (euphoria): binds to Mu receptor → ↓ release of GABA → lack of GABA stimulation → dopamine release from neighboring neuron (Opioid = dope)
    • Acts at nucleus accumbens (reward)
  • MOA (analgesia): binds to Mu-GPCR→ hyperpolarization → ↓ NT → analgesia
    • Acts at anterior cingulate cortex, thalamus, periaqueductal gray (pain areas)
63
Q

opioid

toxidrome and withdrawal

tx for each

A
  • Toxidrome (all decreases): ↓ HR/BP, ↓ RR (overdose risk), ↓ temp, ↓ pupil size (constriction), ↓ bowel sounds, ↓ sweating, euphoria
    • Tx: naloxone (opioid antagonist)
  • Withdrawal (opposite of toxidrome): dilated pupils, tachycardia/HTN, V/D, insomnia, sweating, craving for drug, dysphoria, piloerection (goosebumps), myalgia
    • Tx (not life-threatening)
      • Methadone (long-acting opioid full agonist)
      • Buprenorphine (partial opioid receptor agonist)
      • Naltrexone (competitive opioid antagonist)
64
Q

cocaine

MOA, toxidrome, withdrawal

tx and complications

A
  • MOA: dopamine reuptake inhibitor
  • Toxidrome (all increases): ↑HR/BP, ↑RR, ↑Temp, ↑pupil size (dilation), ↑bowel sounds, ↑sweating
    • Complications: arrhythmias, MI, respiratory distress
    • Acute management for agitation: benzodiazepines or anti-psychotics (severe)
  • Withdrawal (opposite of toxidrome): constricted pupils, malaise, fatigue, hypersomnolence, depression, vivid dreams, psychomotor agitation
    • Tx: supportive (not life-threatening)
65
Q

Amphetamines

classic MOA and designer MOA

examples for each

A
  • Classic MOA: blocks reuptake → facilitates release of dopamine and NE from nerve endings → stimulant
    • Examples: methamphetamine (“speed”, “meth”), Ritalin, Dexedrin
    • Use: ADHD, narcolepsy, depression
  • Substituted (designer) MOA: release of dopamine, NE, and serotonin from nerve endings → stimulant, hallucinogen
    • Examples: MDMA (Ecstasy)
66
Q

amphetamines

toxidrome

chronic complications

A
  • Toxidrome (all increases): ↑HR/BP, ↑RR, ↑Temp, ↑pupil size (dilation), ↑bowel sounds, ↑sweating
    • Chronic use can lead to tooth decay (meth mouth)
67
Q

Sedatives

BZDs an barbituates

MOA and examples

A
  • Benzodiazepine (BDZs) MOA – gamma unit: increases Cl- channel opening → more Cl- in post-synaptic cell → GABA potentiator
    • BZDs are not lethal alone
    • Examples: Diazepam (Valium), alprazolam (Xanax), Chlordiazepoxide (Librium), lorazepam (Ativan)
  • Barbiturate MOA - beta unit: increases Cl- channel opening → more Cl- in post-synaptic cell → GABA potentiator
68
Q

Sedatives

toxidrome and withdrawal

tx for each

A
  • Toxidrome (all decreased – except eyes): ↓HR/BP, ↓RR, ↓Temp, ↓Bowel sounds, ↓Sweating, drowsiness, slurred speech, ataxia,
    • Tx:
      • BDZ: Flumazenil (short-acting BDZ antagonist)
      • Barbiturate: Na-HCO3 (promotes renal excretion)
  • Withdrawal (life threatening): HTN/tachycardia (medical emergency), hand tremor, psychomotor agitation, N/V, anxiety, irritability, sweating
    • Complications: tonic-clonic seizure
      • Tx: phenobarbital, clonazepam (anti-epileptics)
69
Q

ETOH

MOA, metabolism and toxidrome

A
  • MOA: activates GABA (alpha) and serotonin receptors in CNS → depressant
  • Metabolism: alcohol → acetaldehyde (via alcohol dehydrogenase) → acetic acid (via aldehyde dehydrogenase)
    • Asian glow: lack aldehyde dehydrogenase (less susceptible to dependence)
  • Toxidrome
    • <50 mg/dL: impairment in skilled tasks, increased talkativeness, relaxation
    • >100 mg/dL: ataxia, hyperreflexia, impaired judgement, lack of coordination, nystagmus, slurred speech
    • >200 mg/dL: amnesia, diplopia, N/V, hypothermia, dysarthria
    • >400 mg/dL: respiratory depression, coma, and death
70
Q

ETOH

withdrawal sx and complications

tx for some

A
  • Delirium Tremens (DT): peaks 2-4 days after last drink; characterized autonomic hyperactivity (tachycardia/HTN, tremors, sweating, anxiety, etc)
    • Tx: BZDs (Chlordiazepoxide – Librium, Lorazepam, Diazepam) → taper
  • Wernicke’s encephalopathy: encephalopathy, oculomotor dysfunction, ataxia
  • Korsakoff’s syndrome (chronic dz from untreated Werkicke’s):
    • Pathophysiology: necrosis of mamillary bodies (often irreversible)

Sx: Retrograde/anterograde amnesia, confabulation, unaware of illness

71
Q
  • Chronic Tx for alcohol dependence

disulfiram, naltrexone, acamprosate, topiramate, gabapentin

MOA and uses

A
  • Disulfiram
    • MOA: blocks aldehyde dehydrogenase (Asian glow – flushing, N/V)
    • Contraindicated in cardiac disease, pregnancy, LFTs must be monitored, adherence is low
  • Naltrexone
    • MOA: opioid receptor antagonist → decreases cravings and high associated with alcohol
  • Acamprosate
    • MOA: GABA-like agonist
    • Use: post-detox; indicated in patients with liver disease
  • Topiramate
    • MOA: GABA potentiator
    • Use: reduces cravings
  • Gabapentin (only if vital signs are stable)
72
Q

Weed

MOA and toxidrome

A
  • MOA: THC → binding to cannabinoid receptors on presynaptic neuron → inhibition of adenyl cyclase → release of inhibitory NT (GABA)
  • Toxidrome: impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgement, conjunctival injection (red eyes), increased appetite, dry mouth, tachycardia
    • These symptoms cannot be explained by another substance or mental disorder
    • Complications: Cyclic vomiting syndrome (daily vomiting relieved by showering)
      • Dx: Stop marijuana use for two weeks to see if causal
73
Q

Anti-cholinergics

examples, MOA, toxidrome, SE

A
  • Examples: antihistamines (Benadryl). TCAs (Amitriptyline)
  • MOA: inhibition of Ach receptor
  • Toxidrome: ↑HR/BP, ↑Temp, ↑pupil dilated, ↓Bowel sounds, ↓Sweating, confusion, agitation
  • SE: Hot, dry, blind, red, mad
74
Q

hallucinogens

LSD PCP MOAs

other examples

A
  • LSD MOA: believed to act on serotoninergic receptors
    • Toxidrome: VS stable, perceptual distortion, depersonalization, anxiety, paranoia
  • PCP MOA: NMDA glutamate receptor antagonist → activates dopamine release
    • Toxidrome: anesthetic, dissociative, violence, impulsivity, tachycardia/HTN. Seizures
    • Tx: BZDs, rapid-acting anti-psyhotics
  • Other example: K2/synthetic marijuana, magic mushrooms, ketamine (anti-depressant effects), MDMA
75
Q

caffeine

MOA, toxidrome, withdrawal

split toxidrome by amount

A
  • MOA: adenosine antagonist → increase in cAMP → stimulant effect via dopaminergic system
  • Toxidrome
    • 250 mg (2 cups): anxiety, insomnia, muscle twitching, GI problems, tachycardia
    • > 1 g: tinnitus, agitation, cardiac arrhythmias
    • >10 g: death secondary to seizures/respiratory failure
  • Withdrawal: headache, nausea, vomiting, depression, irritability
76
Q

nicotine

epidemiology, MOA. toxidrome, withdrawal

A
  • Epidemiology: smoking common in patients with mental illness
    • Known to increase chronic pain
  • MOA: stimulates nicotinic receptors and autonomic ganglia of the SNS/PNS
    • Highly addictive via the dopaminergic system
  • Toxidrome: restlessness, insomnia, anxiety, increased GI motility
  • Withdrawal: cravings, dysphoria, anxiety, decreased HR, increased appetite, insomnia
77
Q

nicotine tx

(4) if applicable provide MOA

A
  • Nicotine replacement therapy (patches, gums, sprays)
  • Bupropion: antidepressant (partial agonist of nAChR & inhibits dopamine reuptake → reduces withdrawal sx)
  • Varenicline: antidepressant (partial agonist of nAChR → mimics nicotine → reduces withdrawal sx)
  • Nortriptyline: antidepressant
78
Q

GENERAL SOMATIC/SOMATOFORM DISORDERS

defintion, epidemiology

A
  • Category of disorder characterized by physical symptoms which cause significant distress and impairment; motivation of these physical sx are unconsciously produced; symptoms are not intentionally feigned
  • More common in women
79
Q

Somatic Symptoms Disorder

criteria, duration, specifers

A
  • Criteria: Excessive thoughts, feelings, or behaviors related to the somatic complaints (variety of body sx – pain, fatigue lasting for many years) that may occur with an actual medical illness manifested by at least ONE of the following:
    • Disproportionate/persistent thoughts about seriousness of sx
    • Persistent high levels of anxiety about health/sx
    • Excessive time and energy devoted to sx/health concerns
  • Must cause distress or disrupt daily life
  • Patient must be persistently symptomatic (>6 months)
  • Specifiers: pain disorder, persistent, somatization, hypochondriasis
80
Q

Illness Anxiety Disorder (aka hypochondriasis)

description, duration and specifiers

A
  • Description: preoccupation with having/acquiring a serious illness despite medical evaluation and reassurance; often excessively performs health-related behaviors
    • Minimal somatic sx exist
    • Must be present for at least 6 months
  • Specifiers: care-seeking, care-avoidant
81
Q

Conversion Disorder

description, criteria, examples

A
  • Description: patients who have a neurological symptom that cannot be explained by a medical disorder following a psychological stressor
  • Criteria
    • At least one neurological symptom
    • Psychological factors associated with initiation or exacerbation of sx
    • Not intentional feigned or produced
    • Causes significant distress; not explained by another conditions
  • Common examples: paralysis, blindness, mutism, seizures, paresthesias
82
Q

Physiological Factors Affecting Other Medical Conditions

example and criteria

A
  • Examples: anxiety aggravating asthma, ignoring heart attack sx
  • Criteria
    • A medical sx or condition (other than mental disorder) is present
    • Psychological/behavioral factors adversely affect the condition in the following manner:
      • Delays recovery, interferes with treatment, increases health risks, or exacerbates pathophysiology/sx
83
Q

Other Specified Somatic Symptom and Related Disorders

criteria

A
  • Criteria:
    • Brief somatic symptom disorders (sx last < 6 months)
    • Brief illness anxiety disorder (sx last < 6 months) OR illness anxiety disorder without health-related behaviors
    • Pseudocyesis: a false belief of being pregnant due to objective signs/sx of pregnancy
84
Q

Unspecified Somatic Symptom and Related Disorders

description

A
  • Not meeting full criteria
  • Unusual situations where there is insufficient info to make another dx
85
Q

GENERAL FACTITIOUS DISORDERS

factitious and malingering

define each

A
  • Both of the following do not exclude the presentation of a true medical diagnosis
  • Factitious (primary gain): Patient consciously creates physical or psychological sx in order to assume “sick role” and to get medical attention and sympathy
    • Peregrination (wandering from treatment setting to treatment setting)
    • Pseudological Fantastica: fantastic liar
  • Malingering (secondary gain): patient consciously fakes or exaggerates having a disorder to attain a secondary gain (i.e. avoiding work) à poor compliance with healthcare/ceases feigning after gain
86
Q

Factitious Disorder Imposed on Self

criteria

whats another name

A
  • Criteria: – aka Munchausen syndrome: disorder with physical signs and sx characterized by a history of multiple hospital admissions and willingness to receive treatment
    • Deceptive behavior is evident even in the absence of obvious external rewards
87
Q

Factitious Disorder Imposed on Another

criteria

A
  • Criteria: falsification of physical/psychological sx or a disease in another person via deception
    • Deceptive behavior is evident even in absence of obvious external rewards
88
Q

Diagnostic Criteria of Delirium

A
  • Disturbance in attention and awareness
    • Develops over a short period of time (hours to days) and tend to fluctuate in severity over the period of a day
  • An additional disturbance in cognition (memory, disorientation, language, perception)
    • Hallucinations, illusion, misperceptions, disturbances in sleep
  • Not explained by another neurocognitive disorder
  • Consequence of another medical condition, substance intoxication, or withdrawal
    • Hepatic encephalopathy, alcohol withdrawals, overdose of antidepressant, secondary to UTI
89
Q

Delirium

sutypes, risk factors, etiologies,

A
  • Subtypes: hyperactive (hyperaroused, hyperalert, agitated), hypoactive (hypoaroused, hypoalert, lethargic), mixed
  • Risk Factors: age, dementia, alcohol abuse, male, sensory impairment
  • Etiologies: drugs, withdrawal states, electrolyte disturbances, endocrine disturbances (glucose), nutritional issues, organ failure (liver, renal, cardiac, pulmonary), CNS infections, seizures, head injury, sepsis
90
Q

delirium

pathophys, dx

A
  • Pathophysiology: deficiency of Ach, elevation of dopamine/Glutamate/GABA/histamine/ serotonin/cortisol/inflammatory markers
  • Dx: EEG shows diffuse slowing
91
Q

Treatment of Delirium

A
  • Environmental: changing light, correcting visual/auditory impairments, reorient to person, place, and time
  • Pharmacological
    • First line: haloperidol (typical psychotic)
    • Benzos for withdrawal from alcohol/benzos/barbiturates or seizures
    • Cholinergic meds are only indicated in cases caused by anticholinergics or antihistamines (may have secondary anticholinergic effects)
    • Avoid anticholinergic drugs in treatment
92
Q

Work-up for Dementia

A
  • Screen for the following: depression (pseudodementia), sleep apnea, cognitive testing, MMSE, Alzheimer Disease Assessment Scoring, check for other causes:
    • MRI (stroke, MS), EEG, Metabolic (CBC, B12, glucose), Hormone levels (cortisol, testosterone), Autoimmune (ESR, ANA, thyroid), infection (HIV, Lyme, meningitis, CJD, neurosyphilis)
    • Rule out pseudodementia (dementia secondary to depression/hypothyroidism)
      • Pseudodementia: acute-onset dementia in which the patient is aware of their disease à treat with antidepressants
93
Q

Dementia

define, reversible and irreversible etiologies

A
  • Definition: a decrease in intellectual function without affecting level of consciousness
  • Etiology:
    • Irreversible (true dementia): Alzheimer’s, Lewy Body dementia, Huntington’s, Pick disease, cerebral infract, Wilson Disease, Creutzfeldt-Jakob Disease, substance abuse, HIV, vascular dementia, progressive supra-nuclear palsy
    • Reversible (presents like dementia): hypothyroidism, depression, Vit deficiency (B1/B3/B12), normal pressure hydrocephalus, neurosyphilis
94
Q

dementia

risk factors, sx, dx, complications

A
  • Risk Factors: older age, FHx, risks associated with stroke, alcohol, head trauma, Trisomy 21 (via Alzheimers early onset)
  • Sx: memory deficits, apraxia, aphasia, agnosia, loss of abstract thought, behavior/personality changes, impaired judgement
  • Dx: EEG is normal, Fluorodeoxy glucose PET, atrophy on MRI/CT
  • Complications: delirium
95
Q

Treatment

for Alzheimers related dementia

name 3

know general MOA

A

Cholinesterase inhibitors (Donepizil, galantamine, rivastigmine)

Memantine

Anti-amyloid

NBS (8 decks)

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