week2 lectures Flashcards
1
Q
religions that have higher riskof suicide (2)
A
jewish + protestant
2
Q
pt’s hx, FH, dmeographics, cultureal/regligous beliefs , and personaty traits are eg’s of
A
immutatble risks
3
Q
4 groups of acute predictors for suicidality?
A
- Anxiety,panic attacks, insomnia, agitation, restlessness
- irritability, hostility, aggressiveness, impulsiveity
- hypomania + mani
- hopeless, helplessness
4
Q
3 components of the risk triad
A
ideation, intention, plan
5
Q
depression is assc with __% of suicides and schizophrenia is assc with __%
A
80%; 10%
6
Q
1/3 of patients have sought medical attn within ___ months of death
A
6 month
7
Q
the ss short allele for ____ conveys poor resiliences; ↑MDD; ↑risk for suicide during stress
A
serotonin
hint: LL long allele = protective
8
Q
using others to kill oneslef; occurs as a pact by females or the elderly
A
victim-precipitated homicide; murder-suicide
hint: murder suicide turns out to be homicide/coercion/rampage kill?
9
Q
3 screening tools
A
- Columbia Suicide Severity Scale
- suicide behaviors Questionnaire
- PHQ-9
10
Q
if you cant hospitalize a high risk suicide pt, what cna you do?
A
detain for 1-63 ∞state law
hint: extension is possible with court involvment (CPL)
11
Q
2 drugs that ↓ suicidal ideation per FDA
A
Lithium + cloazpine
12
Q
what does an involuntary commitment require and what are the 3 types?
A
require psychiatrist sign off
emergency hold (2 wks)
director of Community Service (72 h - 2 mo)
2 Physician Certificate (2 mo)
13
Q
difference bwn informa land formal voluntary commitment
A
formal - pt signs in but is held for 3 days
informal - pt can sign in and out at will
14
Q
suicide tx (4 steps)
A
- interview (triad)
- good hs with risk factos
- ask for protective thngs that keep them alive
- least restrictive approach (acute anxiety medication > slow acting antiDs> ↑support + connectivity > send to hospital)
15
Q
explain autonomic and hormonal control of CV fx (baroR’s and vagal outflow)
A
blood loss –> ↓BP –> ↑sympathetic outflow and renin release + ↓PNS (vagal) outflow
16
Q
M3 rcps _____ (relaxes/contracts) GI + GU sphincters and bv endothelium; explain the pathway
A
relaxes;
M3 rcp –> IC signalling –> MLCK activation (inh by SNS β2, which ↑cAMP)
hint: EDRF (endoth derived relaxing factor) = NO which relaxes sm muscle
17
Q
what rcps what block/ activate in asthma pts?
A
bronchiolar muscle: block M3 (contracts); stim β2 (relaxes)
18
Q
what effect does SNS have on SA node action potentials (2)
A
- ↑rate of phase 4 depolz (cAMP channel)
- ↑AP freq
hint: β1 –> Gs –> ↑cAMP
19
Q
what effect does PNS have on SA node action potentials (2)
A
- ↓rate of phase 4 depolz
- hyperpolz max dialstolic potential (Gi K+ channel) –> ↓AP freq
hint: M2 –> Gi+K+ –> ↑ polz; M2’s are inh autoR’s
20
Q
explain the signalling pathway for smooth muscle contraction
A
𝛂1 –> Gq + PLC –> ↑IP3/Ca+/DAG
21
Q
explain the signalling pathway for inh of NT release
A
𝛂2 –> Gi + K and Gi + -AC –> ↓ cAMP + ↑polz
22
Q
explain the signalling pathway for ↑F and rate of heart contraction
A
β1 –> Gs + AC –> ↑cAMP
23
Q
explain the signalling pathway for smooth muscle relaxation
A
β2 –> Gs + AC –> ↑cAMP
24
Q
explain the signalling pathway for lipolysis + sm muscle relaxation
A
β3 –> Gs + AC –> ↑cAMP
25
explain the dopamine signalling pathway for smooth muscle relaxation
D1 --> Gs + AC --> ↑cAMP
26
3 Muscarinic rcps for ↑IP3 + DAG?; which is for sm muscle contraction + which is for neuroregn?
M1, M3, M5
M3 = sm muscle contrctn; m1 = neuroregn
27
2 Muscarinic rcps for ↓cAMP + ↑polz?; which is for ↓Heart beat (SA node) + NT release?
M2 + M4
M2 = ↓HR + ↓NT release
28
ACh binds to ____ subunits on Nm pentamer rcp
two 𝛂1
29
Guanethidine blocks -__ which is uselful for htn; why?
NE synthesis; SNS target but not PNS target
30
amphetamines + tyranie _____ (MOA)
release NE
31
cocainse and TCA antiD's ___ (MOA)
block NE uptake
32
what enz synth's ACh from acetyl Coa + choline?
choline acetultransferase (ChAT)
33
what are the 3 SNS postganglionic fibers that re NOT adrenergic?
sweat glands - muscarinic
renal vasc sm muscle - dopamine
Chromaggin cells - cholinergic
hint: chromaffin cells secrete epi + NE
34
Post pituitary (neurohypophysis) tumor
Pituicytoma
35
ciliated cuboidal epithelium with globlet cells in pituitary
rathke cleft cyst
36
in kids: adamantinomatous, wet keratin, β-cat⊕
| in adults: papillary, BRAF V600⊕
Craniopharyngioma
37
midline (pineal/pituitary) tumor that occurs in young adults, ± mets or 1˚; responsive to chemo
Germinoma (~seminoma/dysgerminoma)
38
Cellular monomorphism and loss of reticulin netwrok in pituitary gland? What are the 8 types?
pituitary Adenoma;
1. Lactotroph (PRL) - 30% most common
2. somatotroph (GH)
3. Mammosomatrotroph (PRL + GH)
4. Corticotroph (ACTH)
5. Thyrotroph (TSH)
6. Gonadotroph (LH/FSH)
7. null cells - 25-30%
8. Pituitary carcinoma - <1%
39
low prolifn/infiltr potential; cured with surgical resection;(Grade I/GII/GIII/GIV)
grade I
40
low prolifn potential; infiltrate and recur with surgical resection;(Grade I/GII/GIII/GIV)
grade II
41
malignant on histo; infiltr; resection + chemo/radiation (Grade I/GII/GIII/GIV)
grade III
42
Malignant, necoriss, prone, infiltrative, rapid evolution (Grade I/GII/GIII/GIV)
Grade IV
43
```
non nehancing tumor on T1 + contrast
commonly in cerebrum
nuclear atypia
ø necrosis/microvasc prolfn
min mitotic activity.
```
astrocytoma Grade II
age: 30-40 yrs
44
AMEN for Adult astrocytoma grading stands for:
Atypia
Mitosis
endoth hyperplasia
Necrosis
45
Grade the following:
| Diffuse astrocytoma with nuclear atypia
Grade II
hint: 1 criteria; 5-10 yr survival avg
46
Anaplastic astrocytoma with nuclear atypia and mitotic activity
Grade III
hint: more hypercellular -> Grade III tw radiation + chemo; 2-3 yr avg survival
47
Glioblastoma with nuclear atypia, mitoses, endoth hyperplasia vel necrosis
Grade IV
48
ring enhacing lesion is grade as _____
Grade IV;
49
ring enhancing; psuedopalisading around necrosis (crawling away from ischemia); endoth/microvasc prolifn (~glomeruli); ± infiltration (neuron nucelus with tumor cell around); butterfly lesion
Dx?
Glioblastoma
hint: usually unilateral; ± bilateral mutifocal; median survival = 5 mo dt mass effect
50
what test predicts better response to chemo?
MGMT promoter methylation (for Temodar);
51
what mutation status predicts survival? why?
IDH mutant status; ∆IDH metabolite is carcinogenic: 2-OH-glutarate, ∆DNA methylation --> ↑neoplasia
hint: ATRX loss with IDH mut; htz gain of fx mut
52
tumor develops faster, w/o malignatn precurosrs; more common; occurs in older pts apx 64 yo (IDH wt/IDH mutant)
IDH wt = 1˚ GB
hint: 2 yr survival
53
develops from lower grade lesions (anaplastic/diffuse astrocytoma; occurs in younger pts apx 44 yo (IDH wt/IDH mutant)
IDH mutant = 2˚ GB
hint: 5+ yr survival
54
pt <20 yo w/ infratentorial tumor in cerebellum with mural nodule (cystic) ; on histo: bipolar piloid cells (small threadlike processes) + rosenthal fibers (corkscrews) + eosino granualar bodies (EGBs)
Common muts:
KIAA1549-BRAF fusion - 70%
BRAG V600E - 5-10%
Dx?
Pilocytic Atrocytoma Grade I
hint: most common glioma in kids; biphasic pattern bc slow growing
55
difficult gliomas that occur in young adults that are difficult to resect; ∆histone (∆ H3K27M
Brainstem glioma
hint: pontine = wrose px (Grade IV)
56
40 yo pt with Perinuclear halos on parrfin (fried egg + chicken wire appearance); calification on radiology + histo; nuclear atypea
Oligodendroglioma requires 1p/19q co-deletion
hint:
grade II - well ddx
grade III - ↑ mitoeses + endoth prolifn ± necrosis
57
MOlecular markers for oligos (3)
- 1p/19q Co deletion
- ∆IDH1 - R132H
- ATRS + p53 help to ddx from astrocytoma
58
grading better with coresponding astrocytoma
BRAF V600E mutation common (~pilocytic)
low grade ugly tumor (near surface)
clinical: ø focal neuro deficits ; nonenhancing well circ mass on imaging
PLeomorphic xanthoastrocytoma
59
70 yo pt with brainstem w/o edema or enhancement
on histo perivasc pseudorossets
commonly around ventricles
shells out intraoperatively, but low infitlr
common drop mets
Ependymoma
hint: myxopapillary sub type in cauda equina (Grade I); anaplastic (↑cells/mitoses) in kids thf worse px
60
subtype glioma w/ cuboidal-elongated cells, radially arrange around vasc stromal cores; located in conus medullar/cauda quin/filum terminale
Myxopapillary Ependymoma (Grade i)
61
ganglion cells in white matter (atypical); obs with pts with long term epilepsy; seizures improve w/ resection; usually Grade I. Dx? and possible mut
Ganglioma (±∆BRAF 20%)
hint: if histo shows mature ganglion AND neoplastic glial cells; if mature ganglion ONLY = gangliocytoma
62
all histo types of the tumor are Grade IV - firable ± rossettes
on histo: small round blues cells piled up
desmopastic/nodular >>> anaplastic/large cell;
radiosensitive
drop mets - CSF spread
Medulloblastoma
63
tumor seen in immunocompromised pts (EBV genome present);
on histo: perivasc cuffing, ugly mitoses, necrosis .
Dx? tx?
Primary CNS lymphoma (PCNSL)
hint: (± secondary occurence = systemic)
64
on imaging, enhancement comes off dura and pushed in on brain; often grade I
on histo: psammoma bodies (round califications) + whorls structures (pseudo inclusions)
chrom22 deletion (NF2 gene)
grow rapidly during pregnancy
dx?
Meningiomas
hint: brain/bone invasion;
atypical = Grade II (clear cell + chordoid)
anaplastic = Grade III (papillary + rhabdoid)
65
ring enhancing brain tumor with non inflitrative border + surrounding reactive tissue
PMH and Hx sgf for inc cancer risk
Mets Carcinoma
hint:
lung most common
meningeal mets = prostate
66
familial tumor syndromes are assc with 4 types
- Tuberous Sclerosis
- VHL
- NF1
- NF2
67
dx assc with mult meningiomas + schwannommas + gliomas
bilaterater 8th N Scwannoma
DX?
what gene?
Neurofibromatosis type 2 (acoustic neuromas)
NF2 (Merlin/Scwannomin gene on chrom 22)
68
```
Cafe-au-lait skin spots
neurofibromas
Optic gliomia (pilocytic astrocytomas)
lisch nodules (iris hamartomas)
1˚ Fam hx
Dx and what gene?
```
Neurofibromatosis type 1
NF1 (Neurofibromin chrom 17)
69
cortical tubers
glioneuronal hamartomas
subependymal giant cells astrocytoma (SEGA) - Grade I
dx? types and chromosomes implicated?
Tuberous Scerosis
```
TSC1 = chrom 9
TSC2 = chrom 16
```
70
rhabdoid cells in post fossa; ∆genes on chrom 22; ø INI1 expression; common in children under 5 (live < 1 yr)
Atypical Teratoid/Rhabdoid tumor (Medulloblastoma)
71
Dexamethasone (which mimics ___) is may not work in stress/MDD; why?
Cortisol; Negative feedback to shut off CRF is not working
hint: Dezmaethason Suppression Test
72
how does PNS change under stress?
↓PNS w/↑inflamm cytokines
73
how does SNS change under stress? What brain structures are affected?
↑SNS w/ offline prefrontal Cortex (↓self reflectin + nuanced thinking)
- ↓ regn of amygdala/limbic sys
- ↓ problems solving + planning
- ↓self awareness
- ↑mood dysregn (impulsive, reactive behav)
74
which is responsible for abstract cognition/logic (lateral PFC/ medial PFC)
lateral PFC - abstract
75
which is responsible for inegrating cognitions with emotion + visceral input [feelings + mentalization, self reflection + awareness] (lateral PFC/ medial PFC)
medial PFC - feels
76
connected to nucleus accumbens, part of motivation circuit
ant cingulate
77
connected to nucleus accumbens, part of reward circuit
ventromedial preforontal cortex
78
reward/motivation: ___ input from ventral tegmental area (brainstem) --> nucleus accumbens, ventral PFC, ant cingulate
dopaminergic input
79
___ is responsible for craving _ ___ is responsible for addiction
nuc accumbens + DA release --> addiction
| amygdala (cnx to nuc accumbens) --> craving
80
how is the hippocampus damaged by ↑ stress + nflamm? (2)
```
neurotoxic cytokines from WBCs dmg hippo --> atrphy
neurotics cortisal (HPA) --> hippo atrophry
```
hint: suppression of PNS --> ↓ cholinergic anti-inflamm pathway (vagal spleen input)
81
neurogenesis occurs in the ___ zone of the hippocampus and the _____; nuerogenesis is promoted by 3 NTs?
subventricular zone; olfactory bulb (anosmia = neurodegn)
1. serotinin
2. dopamine
3. NE
hintL anosmia precedes PD
82
___ promote neurogeniss; but are not nec low in depression
monoamines
hint: precursors = tryptophan (5HT) and tyrosine (dopamine + NE)
83
how does exercise improve depression? (4)
- ↑ 5HT + NE levels
- ∞ HPA axis
- ↑neural growth factors
- ↑hippocampal neurogenesis
84
therapy for what dx inovlvs mindfulness? what are the benefits (4)
bordeline personality; also anxiety + MDD
- improved emotion regn
- improved attn
- improved awareness + body sensations
- less self referential thinking?
85
vulnerable CNS + psychosoal stressors --> depression
| give an eg...
Stress diathesis model
eg: childhood abuse (epigenetics) + BDNF/SERT (∞ neurogenesis)
hint: genetics is largest contributor for schizophrenia + bipolar do
86
neural changes with mindfuless (4)
- ↓alarm ctr acitvation (amygdala [emotion]+ insula [physical distress])
- ↑PFC/Ant cingulate (ACC) activity
87
sx w/i 3 mo of stressor ≠ MDD
- out of ppn to distress
- out of ppn social impairment
- sx leave w/i 6 mo of soln
adjusment do
88
- waves of dsyphoria (pangs)
| - full range of affect (w/transient joy)
grief
hint: BUT if 5/9 crtieria met --> MDD!!!
89
- ø anhedonia
- appropriate guilt (burden to family)
- ø persistent low mood
- suicidal ideation in ppn to qlty of life*
vegetative state dt medical illness
hint: veg sx = ∆sleep, Energy, conc
90
- ± wt gain + hypersomnia
- leaden paralysis, carb cravings, rejection HS
- ∞ childhood trauma, bipolar do; bulimia
atypical dperession
hint: some enjoyment experienced
91
- 100% anhedonia
- diurnal (worse in AM)
- use Rx/ECT
Melancholic depression
92
- delusions, hallucinations, though do
| - Rx: antiD + antiPsy ± ECT
Psychotic
93
- ∞ time of year (fall/winter ↓ light)
seasonal
94
- PHINE w/ mutism helps dx ____; what does it stand for?
catatonia
```
peculiar movement/posture
hyperactivity
immobility
negativism + mutism*
echolalia/echopraxia
```
95
- ddx w/ SIGECAPS, 2 wk duration, thought do, hallucinations etc
- w/i 2-3 days of delivery
- mild and self limtited w/i 2 wks
postpartum onset blues
96
- more common w/bipolar do
| - infanticide risk = peripartum dp + psychosis
puerperal psychosis
97
Primary psychiatic conidtions (3)
- Mood disorders
- PTSD
- General aniety do GAD)
98
mood disorders (4)
- persistnet Depressive do
- premenetural dysphoric do
- bipolar do
- mood dysregn
99
CRIMES helps dx _____ w/ 6 month of chronic worry in mult areas of life ; what does it stand for?
```
General Anxiety disorder;
Conc ↓
Restlessness
Irritabilitu
Muscle tension
Energy ↓
Sleep ↓
```
100
ddx for 2˚ depression from organic causes (4)
- susbtance induced mood do (alcoholism*)
- dementia (apathy, mood swings)
- delirium (CANT dx mood do)
- depression 2˚ medical conidtions
101
3 signs for organic causes?
- new onset ∆cogn out of ppn w/ psych sx ≠ disorientation***
- letahry/somnolence/arousal difficulty
- new psychosis onset after age 35 (esp after age 45)
102
Structural causes for depression 2˚ to medical illness (2)
- infalmm after stroke
- dmg to monoaminergic pathways (∆5HT, NE, DA transmission)
hint: CNS lesion; L frontal lobe***
103
organic dz's unliekly to cause depression (ø low mood, guilt, SI or anhedonia) - 3
- inftn (pneumonia/flu
- diabetes (endocrine)
- renal/pulmonary dz
104
3 personality DOs that have HIGHEST risk for MDD
- avoidant, borderline, dependent
| hint: dt 1) adverse childhood; 2) low SES 3) less social support
105
- identical to MDD
- ± worsen pre-existing MDD
- ± tx resistance without abstinence***
substance induced depression
hint: ask about prior MDD episodes while sober
106
Rx regiment: what should you di if there's ø risk of recurrence; dperession responsed to Rx and was NOT severe
DC meds after 6 mo
107
Rx regiment: what should you do if pt is at risk for recurrenceafter chronic/severe depression?
Rx for 1-3 years (maint)
108
Rx regiment: what should you do if pt has chronic/severe MDD epidosdies; OR comoborbid psychiatric/medical DOs
Rx indefinitely
109
Rx- reistance depression can occur with what eaily missed, medical conditions (3)
- sleep apnea
- hypothyroidism
- autoimmune conidtions (MS [direct CNS], Crohns, RA)
110
metabolic, Non strucutral organic causes for depressions (3)
B12 defc
sleep apnea
substance idnuced depression (that looks like MDD)
111
inflamm/autoimmune nonstrcutral causes for organic dperession? (2)
lupus, MS
112
infectious nonstrcutral causes for organic dperession? (1)
HIV
hint: damages striatum (reward)
113
endocrine nonstrcutral causes for organic dperession? (3)
- hypothryroidsim
- hyperadrenalism (cushings --> madness)
- hypoadrenalism (Addisons --> apathy)
114
degenerative nonstrcutral causes for organic dperession? (3)
AD, vasc dementia. PD/Lewy body
hint: ↓DA + 5HT
115
neoplastic nonstrcutral causes for organic dperession? (1)
Gi Cancer
hint: pancrese + gastric ***
116
where in the brain is dopamine made? (3)
- Ventral tegmental area
- substantia nigra (movement)
- hypothalamus (↓prolactin release)
117
where in the brain is serotonin and NE made?
- Raphe nucleus - 5HT
| - Locus Coereleus - NE
118
SSRis cause p450 inhibitioon; what 3 drugs cause the lease effect
- citlaopram
- escitalopram
- sertraline
119
name the targeted rcp: transient ↑anxieity --> desensitization and mood improvent (thf start at low dose)
eg of drug?
5HT1A rcp
eg: fluvoxidine
120
name the targeted rcp: assc with GI efx (N/V/D)
eg of drug?
5HT3 rcps (prsynap autoR)
eg: ondansetron
121
sexual dysfx is cuased by? (2 pathways)
1. 5HT2a agonism (trazabone for priapism = 2a antag)
| 2. 5HT --> ↓DA --> ↓orgasm (useful for premature ejac)
122
low dose (1-200 mg) for sleep (non addicting)
anti adrenergic --> ortho BP
anti H1 --> drowsiness
5HT2a antag --> priapism*
trazadone
hint: dont use for depression (too sedating)
123
rel new usefule antiD that's also a serotinine modulator (partial 5HT1a antag)
(vorteoxetine/vilazodone/trazadone)?
Vilazodone
124
5HT7 antag for cogn improvment + serotonin modulatur
(vorteoxetine/vilazodone/trazadone)?
Vrotioxetine
125
Serotonin modulators (SSRI+) - 3?
Trazadone
Vilazadone
Vortioxetine
126
SSRI only fx (6); NO antagonism/agonism
```
Fluoxetine
Sertraline
Ccitalopram
Escitalopram
Paroxetine
Fluvoxamine
```
127
use MAOi as a 3rd line agent in Tx-refractory depression bc?
severe SEs
128
atypical antiD's (3)
bupropion
mirtazepinez
SNRIs
129
other neurostimulation tehcniques for refracotry depression (4, besides ECT)
Vagus Nerve Stim (VNS)
Transcranial Magnetics Stim (TMS)
Deep Brain Stim (DBS)
Transcranial Direct Current Stim (TDCS)
130
Psychotherapies most studied (2)?
CBT and IPT (interpesonal tx)
131
```
Name the Drug Class
Venlafaxine
Desvenlafaxine
Duloxteine
Levomilnacaprine
+ TCAs
```
important SE?
SNRI (5HT + NE only);
SE = htn + discontinuation syndrome (must taper)
hint: neuropathy
132
Name the Drug Class
Tricyclics
important SE?
SNRI+ (5HT + NE); SE = salty HAM
133
Name the Drug Class
Bupropion
important SE?
NDRI (NE + DA);
SE = seizure risk*, anxiety , htn, tachyC
hint:
dont cause sex SEs or serotonin syndrome
contra in eating DO (bc ∆electrolyte), seizure DO
134
Name the Drug Class
Mirtazapine
important SE?
unique (inc NE + some 5HT release); SE = wt gain + sedation (watch out for diabetics!!!
135
2 drug classes + 1 drug that cause discontinuation syndrome?
MAOi, paroxetine (SSRI), SNRIs
136
```
blocks 𝛂2 autoR --> ↑NE
blockks 5HT heteroR --> ↑5HT
blocks H1 --> wt gain, sedation anxiolytic
metabolic SEs
tx depression w. anxiety vel insomnia
```
Mirtazipine
