NEW study guide ch. 18

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NEW study guide ch. 18
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  1. READ
    • It is helpful to subdivide
    • schizophrenic symptoms into three categories:
    • positive symptoms, characterological traits, and negative symptoms.



    • Schizophrenic
    • Symptoms



    • 1.
    • Positive Symptoms
    • (Targets for medication treatment)

    • a.
    • Delusions and
    • impaired thinking

    • b.
    • Hallucinations

    • c.
    • Confusion and
    • impaired judgment

    • d.
    • Severe anxiety,
    • agitation, and emotional dyscontrol



    • 2.
    • Characterological
    • Traits

    • a.
    • Social isolation
    • and sense of alienation

    • b.
    • Low self-esteem

    • c.
    • Social skills
    • deficits



    • 3.
    • Negative Symptoms

    • a.
    • Flat or blunted
    • affect

    • b.
    • Poverty of
    • thoughts (few or no thoughts and concrete thinking)

    • c.
    • Emptiness and
    • anhedonia (no joy)

    • d.
    • Psychomotor
    • retardation/activity

    • e.
    • Blunting of
    • perception (e.g., insensitivity to pain)



    • Although many general
    • practitioners treat anxiety and depressive disorders, most patients presenting
    • with psychotic symptoms should be referred to a psychiatrist. These patients are often hard to treat. Many psychotic patients can be treated on an
    • outpatient basis; however, hospitalization is often necessary.



    • Antipsychotic meds (also
    • referred to as neuroleptics or major tranquilizers) should be started when the
    • early signs of psychosis appear, since many times a more florid psychotic episode
    • can be averted with appropriate early intervention.



    • Positive symptoms are the
    • primary target symptoms for treatment by antipsychotic meds. Such drugs do little to affect
    • characterological traits or negative symptoms (some possible exceptions are clozapine
    • (Clozaril) and risperidone (Risperdal).





    • MECHANISM OF ACTION OF
    • ANTIPSYCHOTICS

    • 1.
    • The primary model
    • is the dopamine model, which holds that schizophrenia is caused by abnormal
    • dopaminergic activity in the brain.
    • Dopamine neurons, in the basal ganglia, regulate motor functioning. Dopamine neurons, in the limbic and reticular
    • systems, help to control emotions and screen stimuli. In schizophrenia and
    • psychoses, dopamine neurons are overactive or hyper-reactive. Excessive dopamine activity may lead to the
    • inability to screen stimuli, disorganized perception and thought, and
    • behavioral agitation. Antipsychotic
    • drugs bind to and block postsynaptic dopamine (D2) receptors in the mesolimbic
    • system. (Note that drugs that increase dopamine activity, like amphetamines,
    • may produce a psychosis similar to paranoid schizophrenia. Also, drugs like amphetamines, if given to
    • schizophrenics, may exacerbate psychotic symptoms.

    • 2.
    • A modified model
    • of the dopamine model suggests that in schizophrenia, hyperdopaminergic
    • activity in the mesolimbic tracts is associated with positive symptoms, and
    • decreased activity in the prefrontal cortex is associated with negative
    • symptoms.

    • 3.
    • The neurodevelopmental/neurodegenerative
    • model suggests that a genetically determined defect or a defect from an event,
    • such as a viral infection, during fetal or early infantile development, leads
    • to abnormal development later in life, especially during the synaptic “pruning”
    • during adolescence. Treatment is
    • directed not just at the final psychotic symptoms, but toward correcting the
    • abnormal development.



    • Have a familiarity with the
    • high potency dopamine blockers and with the weak (low potency) dopamine
    • blockers, the latter causing minimal neurological side effects. In general, which group causes more sedation
    • and anticholinergic side effects? Which
    • group causes more extrapyramidal side effects?



    • Know the five groups of side
    • effects of all neuroleptics and know the side effects calling for medication
    • reassessment.



    • How are sedation, extrapyramidal
    • side effects, and akathisia managed/treated?




    ATYPICAL ANTIPSYCHOTICS

    • 1.
    • Strong serotonin
    • blockers, but varying degrees of dopamine (D2) blockade.

    • 2.
    • reduction of
    • negative symptoms

    • 3.
    • improved
    • cognition and reduced neuro-anatomical changes (enlargement of lateral
    • ventricles)

    • 4.
    • significantly
    • reduced risk of tardive dyskinesia

    • 5.
    • overall better
    • tolerability by patients

    • 6.
    • Because the
    • atypicals tend to produce weight gain, alter carbohydrate metabolism similar to
    • diabetes, and alter lipid metabolism, all patients on these meds should have
    • their weight, blood sugar, and lipid levels monitored.

    • 7.
    • Clozapine—treats
    • both positive and negative symptoms; up to 40% of those who have failed to
    • respond to haloperidol and chlorpromazine respond to clozapine.

    • a.
    • very sedating

    • b.
    • low incidence of
    • extrapyramidal side effects/very few cases of tardive dyskinesia

    • c.
    • lowers seizure
    • threshold

    • d.
    • can cause
    • hepatitis

    • e.
    • agranulocytosis—has
    • caused several deaths

    • 8.
    • Risperidone
    • (Risperdal)

    • a.
    • potent dopamine
    • blocker

    • b.
    • increased risk of
    • extrapyramidal side effects

    • c.
    • minimal sedation

    • 9.
    • Olanzapine
    • (Zyprexa)

    • a.
    • low incidence of
    • extrapyramidal side effects

    • b.
    • sedating

    • c.
    • increased weight
    • gain and problems in carbohydrate metabolism

    • 10.Quetiapine
    • (Seroquel)

    • a.
    • low incidence of
    • extrapyramidal side effects

    • b.
    • sedating

    • c.
    • dry mouth

    • 11.
    • Ziprasidone (Geodon)

    • a.
    • less sedating

    • b.
    • less weight gain

    • c.
    • causes
    • extrapyramidal side effects

    • d.
    • should be avoided
    • in patients with cardiovascular disease because of its affect on cardiac
    • conduction





    • 12.
    • Aripiprazole (Abilify)

    • a.
    • less sedating

    • b.
    • less weight gain

    • c.
    • nausea and anxiety
    • 13
    • Paliperidone
    • (Invega)—metabolite of risperidone that may be better
    • Tolerated
    • because of extended-release formulation.
    • The choice of antipsychotic medication is
    • based on patient history, motor state, and the side effect profile of the
    • meds. Understand the choice of
    • medication considerations on page 209.



    • Review the patient education
    • and psychotherapeutic issues on page 211.
  2. anxiety/benzo stuff
    • 1.
    • Our wiring
    • (nervous system)—complex network of nerve pathways, brain structures, and
    • glands responsible for eliciting the fight or flight response. This response
    • mobilizes the body and mind during times of potential danger. Nonessential physiological processes (such as
    • digestion and reproduction) shut down, and energy is channeled into a host of
    • bodily functions preparing the organism for rapid action. The nervous system shifts into a state of
    • hyperarousal and vigilance.

    • 2.
    • As stressful
    • events are perceived at the level of the cortex and also processed in a crude
    • way on the subcortical level (the amygdale), lower brain areas become
    • activated. In a sense, the limbic system
    • is put on alert. If you should perceive
    • that there is imminent danger, a burst of excitation emanates from a cluster of
    • nerve cell bodies in the brain stem called the locus coeruleus (LC). The LC nerve cells, which project to the
    • limbic system, are mediated by the neurotransmitter NE.

    • 3.
    • The limbic system
    • and adjacent hypothalamus shift into high gear, and by way of the pituitary
    • gland (and other downstream endocrine glands) and the sympathetic nervous
    • system, many stress hormones are released into the system. The brain and body are ready for action.









































    • 4.
    • There is another
    • feature of the nervous system that plays a role in anxiety. On the surface of most nerve cells in the
    • brain (including cells in the LC) are tiny gateways called chloride ion
    • channels. Chloride ions, which have a
    • slight negative charge, are in abundance in the fluid surrounding the nerve
    • cells. The ion channel can be activated
    • (opened) when stimulated by the naturally occurring neurochemical GABA.

    • 5.
    • As the gate
    • opens, the chloride ions are drawn in.
    • When the nerve cell is infused with negative ions, its electrical
    • characteristics are changed, resulting in decreased excitability (it is
    • hyperpolarized). This operates as a type
    • of biological braking mechanism, serving to damped “limbic alert” and calm
    • overall brain excitation.

    • 6.
    • Benzodiazepine
    • molecules (antianxiety agents) also bind to the chloride ion channels, further
    • facilitating the inflow of negative ions and thus producing a widespread
    • calming in many areas of the brain
  3. adhd stuff
    • KNOW “ISSUES IN DIAGNOSING
    • AND INITIATING PHARMACOLOGIC TREATMENT OF CHILDREN AND ADOLESCENTS,” PAGES
    • 225-228 (EXCLUDING DRUG RESEARCH AND OUTCOME STUDIES).



    ADHD

    • 1.
    • KNOW DIAGNOSTIC
    • ISSUES AND NEUROBIOLOGY

    • 2.
    • PSYCOPHARMACOLOGY

    • A.
    • STIMULANTS (BE
    • FAMILIAR WITH DRUGS IN THIS GROUP—SEE CHART PAGE 230; HOWEVER, YOU ARE NOT
    • RESPONSIBLE FOR TYPICAL DAILY DOSES)

    • 1.
    • MECHANISM OF
    • ACTION: INHIBITION OF

    • DOPAMINE
    • REUPTAKE. IN ADDITION, AMPHETAMINES INCREASE RELEASE OF DOPAMINE FROM VESICLES.

    • 2.
    • CATEGORIZED BY
    • ONSET OF ACTION (USUALLY

    • MODERATELY
    • RAPID, USUALLY 30-45 MINUTES AFTER INGESTION), OR BY DURATION OF ACTION
    • (USUALLY 4 TO 12 HOURS).

    • 3.
    • DOSING IS 2-3
    • TIMES A DAY, OR ONCE-DAILY

    • DOSING
    • WITH LONG-ACTING PRODUCTS.

    • 4.
    • IMPORTANT ISSUES
    • REGARDING STIMULANT

    • TREATMENT
    • (BOTTOM OF PAGE 230-231).

    • 5.
    • CONSEQUENCES OF
    • MISDIAGNOSIS AND

    • STIMULANT
    • TREATMENT (SEE FIGURE 21-D).

    • B.
    • ALPHA-2
    • ADRENERGIC AGONISTS

    • 1.
    • CLONIDINE
    • (CATAPRES) AND GUANFACINE

    (TENEX)

    • a.
    • TREAT CORE ADHD
    • SYMPTOMS

    • b.
    • MOST EFFECTIVE IN
    • REDUCING IRRITABILITY, AGGRESSION AND IMPULSIVITY AND IN PROMOTING SEDATION TO
    • TREAT INITIAL INSOMNIA.

    • 2.
    • TREATMENT OF
    • CHOICE FOR COMORBID TICS

    • 3.
    • COMBINED USE OF
    • ALPHA-2 AGONISTS AND

    • STIMULANTS
    • A COMMON PRACTICE FOR TREATING ADHD AND CORMORBID ADHD AND TICS.

    • C.
    • ANTIDEPRESSANTS

    • 1.
    • BUPROPION
    • (WELLBUTRIN SR/LA) AND

    • ATOMOXETINE
    • (STRATTERA) ARE EFFECTIVE IN TREATING CORE ADHD SYMPTOMS

    • 2.
    • ONLY THOSE THAT
    • INCREASE AVAILABILITY OF

    • DA
    • OR NE ARE USEFUL (THUS SSRIs ARE NOT USEFUL IN TREATING CORE ADHD SYMPTOMS)

    • 3.
    • ONCE A DAY DOSING

    • 4.
    • NON ADDICTING

    • 5.
    • CAN TREAT
    • COMORBID DEPRESSION

    • 6.
    • CLINICAL EFFECTS
    • SEEN 5-40 DAYS AFTER INITIATING TREATMENT, AND USUALLY LAST 24 HOURS A DAY.



    DEPRESSION

    • 1.
    • USE OF
    • ANTIDEPRESSANTS MAY BE RISKY IN BIPOLAR

    • PATIENTS
    • BECAUSE A MANIC EPISODE MAY BE EXACERBATED OR ANTIDEPRESSANTS MAY CAUSE CYCLE
    • ACCELERATION. THUS, POTENTIAL BIPOLARITY
    • IN ALL DEPRESSED CHILDREN AND TEENS MUST BE ADDRESSED AND EVALUATED.

    • 2.
    • KNOW THE HISTORY
    • AND CLINICAL FEATURES THAT

    • MAY
    • SUGGEST A HIGHER RISK OF BIPOLAR DISORDER

    • (PAGE
    • 233).

    • 3.
    • KNOW THE DIAGNOSTIC
    • ISSUES OF CHILDHOOD-ONSET

    • MAJOR
    • DEPRESSION, AND THE DIFFERENCES FROM THOSE OF ADULT-ONSET MAJOR DEPRESSION.

    • 4.
    • PSYCHOPHARMACOLOGY

    • A.
    • SSRIs ARE MORE
    • EFFECTIVE AND HAVE

    • LESS
    • SEVERE SIDE EFFECTS THAN TRICYCLICS

    • B.
    • TIME TO ONSET OF
    • POSITIVE MEDICATION

    • EFFECTS
    • IS GREATER FOR CHILDREN THAN ADULTS.

    • C.
    • APATHY/AMOTIVATION
    • OR EMOTIONAL

    • DISINHIBITION,
    • SOMETIMES SEEN IN ADULTS ON CHRONIC SSRI TREATMENT, IS MORE COMMONLY
    • ENCOUNTERED IN CHILDREN.

    BIPOLAR DISORDER

    • 1.
    • UNDERSTAND THE
    • DIAGNOSTIC ISSUES, AND THE

    • NEED
    • TO DIFFERENTIATE CHILDHOOD-ONSET MANIA

    • FROM
    • ADHD (INAPPROPRIATE MEDICAL TREATMENT OF STIMULANTS OR ANTIDEPRESSANTS MAY
    • CAUSE CYCLE ACCELERATION IN BIPOLAR PATIENTS)

    • 2.
    • PSYCHOPHARMACOLOGY
    • OF BIPOLAR DISORDER

    • A.
    • MAJOR DEPRESSION
    • IN SUSPECTED BIPOLAR

    DISORDER

    • 1.
    • FIRST LINE
    • MEDS—MOOD STABILIZERS THAT

    • HAVE
    • SOME ANTIDEPRESSANT ACTION (LITHIUM OR OLANZAPINE-FLUOXETINE COMBINATION). LAMOTRIGINE (LAMICTAL) NOT USUALLY FIRST LINE
    • BECAUSE OF POTENTIALLY SEVERE RASHES (STEVENS-JOHNSON SYNDROME).

    • 2.
    • COMBINATIONS OF
    • MOOD STABILIZERS

    • (LITHIUM
    • AND DIVALPROEX)

    • 3.
    • ANTIDEPRESSANTS
    • AVOIDED AS

    • MONOTHERAPY
    • SINCE THEY MAY CAUSE SWITCHING OR CYCLE ACCELERATION.

    • 4.
    • IF NECESSARY, ADD
    • AN ANTIDEPRESSANT IF

    • PATIENT
    • IS ALREADY BEING TREATED WITH A

    • MOOD
    • STABILIZER, WHICH WILL DECREASE THE RISK OF SWITCHING OR CYCLE ACCELERATION.

    • B.
    • MANIA

    • 1.
    • FOR VERY SEVERE
    • AGITATION, USE

    • BENZODIAZEPINES
    • OR ATYPICAL ANTI-

    • PSYCHOTICS,
    • WHICH MAY BEGIN TO WORK

    • IN
    • SEVERAL HOURS. LITHIUM AND

    • ANTICONVULSANT
    • MOOD STABILIZERS OFTEN TAKE 1 TO 2 WEEKS TO BEGIN REDUCING SYMPTOMS.

    • 2.
    • CHOICE OF MOOD
    • STABILIZER USED

    • DEPENDS
    • ON SIDE-EFFECT PROFILE. THE MAJORITY OF
    • CHILDREN WITH MANIA MUST BE TREATED WITH TWO OR MORE MOOD STABILIZERS IN
    • COMBINATION TO ACHIEVE A GOOD OUTCOME.

    • 3.
    • ATYPICAL
    • ANTIPSYCHOTICS LIKE OLANZAPINE (ZYPREXA)

    MAY BE ADDED TO MOOD STABILIZER.

    • 4.
    • GABAPENTIN
    • (NEURONTIN) MAY BE ADDED

    • ON
    • TO REDUCE ANXIETY, BUT IS INAFFECTIVE MONOTHERAPY FOR MANIA.

    • C.
    • COMORBID ADHD AND
    • BIPOLAR DISORDER

    1. MOOD STABILLIZERS USED AS INITIAL

    TREATMENT.

    2. ONCE STABILITY ACHIEVED, STIMULANTS

    • MAY
    • BE GRADUALLY ADDED.

    • BE FAMILIAR WITH THE SIDE
    • EFFECTS AND DRUG

    • INTERACTIONS OF LITHIUM AND
    • MOOD-STABILIZING

    • ANTICONVULSANTS THAT CAN BE
    • ESPECIALLY

    • PROBLEMATIC FOR CHILDREN AND
    • TEENAGERS (P. 239-240).



    ANXIETY DISORDERS

    • 1.
    • BE FAMILIAR WITH THE DIAGNOSTIC ISSUES

    • 2.
    • PSYCHOPHARMACOLOGY OF ANXIETY DISORDERS

    • A.
    • OBSESSIVE-COMPULSIVE DISORDERS

    • 1.
    • SSRIs—FIRST LINE TREATMENT;
    • ZOLOFT

    • (SERTRALINE), LUVOX (FLUVOXAMINE),
    • AND

    CLOMIPRAMINE (ANAFRANIL) ARE FDA

    APPROVED FOR USE IN CHILDREN.

    2. GRADUAL IMPROVEMENT THAT USUSALLY

    • PLATEAUS AT
    • ABOUT 12 MONTHS.

    • 3.
    • TREATMENT
    • RESISTANT CASES SOMETIMES RESPOND TO SSRIs AUGMENTED WITH LOW DOSES OF CLOMIPRAMINE, LITHIUM, OR ATYPICAL ANTIPSYCHOTICS LIKE
    • RISPERDAL (RISPERIDONE). B.
    • SEPARATION ANXIETY DISORDER, SOCIAL ANXIETY DISORDER, GENERALIZED ANXIETY DISORDER
    • 1. IF SCHOOL REFUSAL IS PART OF
    • THE PRESENTING PROBLEM, A BENZODIAZEPINE MAY BE HELPFUL SINCE IT CAN PROVIDE

    • QUICK RELIEF
    • SO THAT CHILD CAN RE-ENTER SCHOOL QUICKLY. ANTIDEPRESSANTS, WHICH TAKE SEVERAL WEEKS
    • OF TREATMENT BEFORE SYMPTOMS
    • ARE REDUCED, CAN BE
    • COADMINISTERED. ONCE SSRIs PROVIDE BENEFITS, THE BENZODIAZEPINE CAN BE
    • GRADUALLY DISCONTINUED. 2. FLUVOXAMINE (LUVOX) ESPECIALLY

    • EFFECTIVE. C.
    • POST-TRAUMATIC STRESS DISORDER-SSRIs FIRST-LINE AGENTS D. SPECIFIC PHOBIAS 1.
    • MOST PHOBIAS CAN BE TREATED WITH WITH STANDARD EXPOSURE-BASED COGNITIVE BEHAVIORAL
    • TREATMENT. 2.
    • BENZODIAZEPINES CAN BE USED FOR CONDITIONS THAT REQUIRE URGENT ATTENTION (FEAR OR DENTAL PROCEDURES). E. PSYCHOTIC DISORDERS 1.
    • ATYPICAL ANTIPSYCHOTICS USED MUCH MORE THAN TRADITIONAL


    • ANTIPSYCHOTICS DUE TO LESSER SIDE EFFECTS (TARDIVE DYSKINESIA). 2.
    • WEIGHT GAIN AND EXTRAPYRAMIDAL SIDE EFFECTS MORE COMMON IN CHILDREN AND ADOLESCENTS THAN
    • IN ADULTS. F.
    • AUTISM SPECTRUM DISORDERS—NO MEDS HAVE
    • BEEN FOUND THAT TREAT THE CORE SYMPTOMS.

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