Psychiatry 2

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Psychiatry 2
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DPAP2012 Psychiatry
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  1. Selective serotonin reuptake inhibitor
    Have little blocking activity at muscarinic, alpha-adrenergic, and histaminic h1 receptors
  2. The SSRI with the lowest risk of causing an SSRI discontinuation syndrome
    Fluoxetine
  3. Sometimes effective in relieving neuropathic pain such as diabetic peripheral neuropathy
    SNRI's and tricyclics
  4. Not recommended in patients with end stage renal disease
    Duloxetine
  5. Should not be administered in patients with hepatic insufficiency
    Duloxetine
  6. Is unique in that it assists in decreasing the craving and attenuating the withdrawal symptoms for nicotine
    Bupropion
  7. Is markedly sedating due to its antihistaminic activity, can also cause increased appetite and weight gain
    Mirtazapine
  8. Has been associated with causing priapism
    Trazodone
  9. Uncommon side effects for SSRI's
    Orthostatic hypotension, sedation, dry mouth, and blurred vision
  10. The TCA imipramine has been used to control
    Bed wetting in children
  11. The TCA amitriptyline has been used to treat
    Migraines
  12. Blockade of muscarinic receptors leads to
    Blurred vision, xerostomia, urinary retention, constipation, and aggravation of narrow angel glaucoma
  13. Blockade of alpha-adrenergic receptors leads to
    Orthostatic hypotension, dizziness, and reflex tachycardia
  14. Common AE of TCA
    Weight gain
  15. Occurs in a significant minority of patients on TCA's as compared to SSRI's
    Sexual disfunction
  16. TCA's should be used with caution in known manic depressives because they may
    Cause manic behavior
  17. Depressed patients should only be given limited quantities of TCA's because
    Of their narrow therapeutic window
  18. MAOI's have a ____ effect
    Amphetamine like stimulant
  19. MAOI's are indicated for
    Patients allergic/unresponsive to TCA's
  20. TCA's are an important alternative to
    SSRI's
  21. This limits the widespread use of MAOI's
    Unpredictable side effects due to food and drug interactions
  22. Considered a mood stabilizer, it is not a sedative, euphoriant, or depressant
    Lithium salts
  23. Patients with personality disorders tend to show ___ when pathological coping mechanisms fail
    Anxiety and depression
  24. The more severe cases of personality disorder can decompensate into __ under stress
    Psychosis
  25. The best predictor of death by suicide
    Previous attempt
  26. Paranoia is a warning sign for
    Violence
  27. Acute psychosis, suicidality, violence, and mania are all considered
    Types of psychiatric crises
  28. No improvement (despite treatment), psychiatric co-morbidities, suicidal or homicidal (serious or continuing), questions about drug therapies, time and expertise (more needed to resolve problems than you can provide)
    When to make a mental health referral
  29. Anxiety
    a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create an unpleasant feeling that is typically associated with uneasiness, fear, or worry
  30. Generalized anxiety disorder
    Characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry. This excessive worry often interferes with daily functioning
  31. Cognitive behavioral therapy
    Is a psychological method of treatment for GAD, which involves a therapist working with the patient to understand how thoughts and feelings influence behavior. The goal of the therapy is to change negative thought patterns, replacing them with positive ones
  32. Panic disorder
    Characterized by recurring severe attacks. It may also include significant behavioral change lasting at least a month, and of ongoing worry about the implications or concern about having other attacks
  33. Obsessive compulsive disorder
    Characterized by intrusive, repetitive thoughts resulting in compulsive behaviors and mental acts that the person feels driven to perform, according to rules that must be applied rigidly, aimed at preventing some imagined dreaded event
  34. Obsession
    Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and that cause marked anxiety or distress. The thoughts, impulses, or images are not simply excessive worries about real-life problems
  35. Compulsion
    Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing disaster
  36. Anxiety disorder that can develop after exposure to one or more terrifying events that threatened or caused grave physical harm. It is a severe and ongoing emotional reaction to an extreme psychological trauma
    Post traumatic stress disorder
  37. Excessive social anxiety (anxiety in social situations) causing abnormally considerable distress and impaired ability to function in at least some areas of daily life
    Social phobia
  38. Irrational, intense, persistent fear of certain situations, activities, things, or people. The main symptom of this disorder is the excessive, unreasonable desire to avoid the feared subject.
    Phobia
  39. External signs of __ may include pale skin, sweating, trembling, and pupillary dilation
    Anxiety
  40. Can be accompanied by physical effects such as heart palpitations, fatigue, nausea, chest pain, shortness of breath, stomach aches, or headaches
    Anxiety
  41. Neural circuitry involving the amygdala and hippocampus is thought to underlie
    Anxiety
  42. Choices of treatment for __ include psychotherapy (such as cognitive behavioral therapy); lifestyle changes; or pharmaceutical therapy (medications).
    Anxiety
  43. Meta-analysis indicates that psychotherapeutic interventions have superior long-term efficacy when compared to pharmacotherapy for treatment of
    Anxiety
  44. Is a mental disorder characterized by a pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities
    Major depression
  45. Mood disturbance of at least 2 weeks' duration, with between two and five symptoms of depression
    Minor depression
  46. Is a mood disorder that falls within the depression spectrum. It is considered a chronic depression, but with less severity than major depressive disorder.
    Dysthymia
  47. A mild, reactive, depression which last only a few months. The disorder occurs in response to some specific stressful situation or circumstance.
    Adjustment disorder with depressed mood
  48. A brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function
    Bipolar disorder
  49. A severe medical condition characterized by extremely elevated mood, energy, unusual thought patterns and sometimes psychosis.
    Mania
  50. __ is characterized by persistent and pervasive elevated or irritable mood. People experiencing __ symptoms typically have a flood of ideas, and sometimes mildly grandiose thoughts and visions
    Hypomania
  51. Is a mood disorder; a very mild form of bipolar disorder
    Cyclothymic disorder
  52. Markedly diminished interest or pleasure in almost all activities, reported or observed
    Anhedonia
  53. Major depressive episode mnemonic: Sig e caps(s)
    Sadness, interest, guilt, energy, concentration, appetite, psychomotor activity, sleep, suicide
  54. Symptoms of a major depressive episode must last at least __ weeks
    2
  55. DIGFAST (mania mnemonic)
    Distractibility, insomnia, grandiosity, flight of ideas, activities, speech, thoughtlessness
  56. Obstructive sleep apnea may cause __
    Executive dysfunction, impaired vigilance, and depression
  57. __ is more predominant in depressed men than depressed women
    Substance abuse
  58. Insomnia increases the risk of depression __ times
    4
  59. Involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration
    Vaginismus
  60. Inflammation at the entrance of the vagina characterized by a burning sensation
    Vestibulitis
  61. Vaginismus, vestibulitis
    Dyspareunia
  62. Compulsive masturbation, fetish, transvestism
    Paraphilia
  63. Characterized by shame, and secretiveness, not interactive, not transferable to partner sex
    Variant arousal patterns
  64. Implies that the belief is pathological (the result of an illness). As a pathology it is distinct from a belief based on false or incomplete information or certain effects of perception which would more properly be termed an apperception or illusion.
    Delusion
  65. Paranoid, grandiose, religious, nihilistic, somatic
    Types of delusions
  66. Thought insertion, thought withdrawal, thought broadcasting, ability to read, others’ thoughts, ideas of reference
    Delusions: Schneider’s “first rank symptoms”
  67. Do you feel that others can read your thoughts?
    Thought broadcasting
  68. Is the person on TV/radio sending you special messages or talking directly about you. Do things out in the public relate to you in a unique way?
    Ideas of reference
  69. Behaviors that have no explanation, the patient doesn't know why they are doing it. Present in psychosis
    Automatisms
  70. Blunted or flat, bizarre, incongruent with content
    Abnormalities of affect associated with psychosis
  71. Substance induced and due to general medical condition
    2 most common causes of psychosis
  72. Schizophrenia affects __% of the population worldwide
    1
  73. Typical onset of schizophrenia is __
    Late teens to early 20's
  74. Hallucinations, delusions, disorganized speech and behavior, agitation, respond fairly well to conventional antipsychotic medications.
    Positive symptoms of schizophrenia
  75. Avolition, withdrawal/autism, anhedonia, blunted affect, poverty of speech, may respond somewhat better to ‘atypical’ antipsychotic medications.
    Negative symptoms of schizophrenia
  76. Choreoathetoid movements (irregular, writhing), may involve tongue, cheeks, lips, trunk, extremities, develops after months to years of antipsychotic med use in up 25% in patients on chronic therapy. May be irreversible.
    Tardive dyskinesia
  77. Akathisia, acute dystonias, parkinsonism
    Acute extrapyramidal effects of antipsychotics
  78. Subjective inner restlessness
    Akathisia
  79. Bradykinesia, shuffling gait, regular resting tremor
    Parkinsonism
  80. A psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking
    Schizophrenia
  81. Negative symptoms of __ are so-named because they are considered to be the loss or absence of normal traits or abilities
    Schizophrenia
  82. In the united states, __ million females and 1 million males are struggling with an eating disorder such as anorexia or bulimia
    10
  83. __ has the highest mortality rate of all psychiatric illnesses
    Anorexia nervosa
  84. Refusal to maintain body weight at or above minimum (85% of expected given age, height, intense fear of gaining weight, disturbance in the way body weight, size, or shape is experienced
    Anorexia nervosa
  85. __ can cause amenorrhea >= 3 months
    Anorexia nervosa
  86. Life time prevalence of anorexia nervosa is as high as __%
    3.7
  87. Approximately __% of those with anorexia nervosa are female
    90-95%
  88. Recurrent episodes of binge eating, eating large quantities of food in discrete period, sense of lack of control
    Bulimia nervosa
  89. In bulimia nervosa behaviors occur at least __ times per week for 3 months
    2
  90. These patients tend to maintain a normal weight
    Bulimia nervosa
  91. The two types of bulimia nervosa are
    Purging and non-purging
  92. When anorexia nervosa is suspected you need to specify between
    Restricting behaviors and binge-eating/purging
  93. Cardiac arrhythmias, esophageal, inflammation, tear, tooth decay and staining, vagus nerve irritation, loss of bowel elasticity, motility, gastric rupture possible, and are health consequences of
    Bulimia nervosa
  94. __% of those with bulimia nervosa are female
    80
  95. Frequent episodes of eating large quantities of food in short periods of time, feeling out of control over eating behavior, feeling ashamed or disgusted by the behavior. Eating when not hungry and eating in secret.
    Binge eating disorder
  96. High blood pressure, high cholesterol levels, heart disease, diabetes mellitus, gallbladder disease
    Binge eating disorder
  97. __% of those with binge eating disorder are female
    60
  98. __ has the greatest stability over time and considerably worse long-term outcome
    Anorexia nervosa
  99. Anxiety (OCD, social phobia, GAD), depression, AXIS II (anxious-fearful cluster) emotional-dramatic cluster
    Common comorbidities of eating disorders
  100. Individual’s mood has been depressed for two or more weeks or person has had anhedonia for over two weeks.
    Major depression:
  101. Individual has had chronically depressed mood for at least 2 years. Two other associated depression symptoms when person has the depressed mood.
    Dysthymic disorder
  102. Individual has at least one week of mania. Manic episode is a persistently elevated, expansive, or irritable mood with 3 or more: inflated self-esteem or grandiosity, decreased need for sleep, more talkative, agitated, goal-directed, thoughts racing
    Bipolar disorder type I
  103. A distinct period during which there is an abnormally and persistently elevated, expansive or irritable mood that lasts at least 4 days.
    Hypomanic episode
  104. Bipolar disorder type II (recurrent major depressive episodes with hypomanic episodes)
    Bipolar disorder type II
  105. During the period of pts mood disturbance, 3+ of these sx present: inflated self-esteem or grandiosity, decreased need for sleep, more talkative, agitated, goal-directed, thoughts racing, distractible, excessive danger-pleasure involvement
    Bipolar disorder type II
  106. Is a chronic mood disturbance with episodes of depression and hypomania.
    Cyclothymia
  107. Symptoms must have at least a 2-year duration and are milder than those that occur in depressive or manic episodes.
    Cyclothymia
  108. Manifestations include depressed mood, tearfulness, or feelings of hopelessness. Disorder occurs within 3 months of the stressor and causes impairment in functioning.
    Adjustment disorder with depressed mood
  109. Is a psychological response to an identifiable stressor that result in clinically significant symptoms.
    Adjustment disorder
  110. Respondent with lifetime MDD also met the criteria for >1 other DSM-IV disorders: with anxiety disorder; with substance use disorder; with impulse control disorder
    Major depression: psychiatric co-morbidities
  111. Increased risk of hypertension; CVA; CAD; risk of death after mi; mechanisms: increase HPA activation, sympatho-medullary activity, platelet aggregation; coagulation; decrease fibrinolysis, heart rate variability
    Major depression: in CAD
  112. After a mi, patients with depression have a 3.5-fold increase in cardiovascular mortality relative to patients without depression
    Major depression: in CAD
  113. Increase non-adherence, hba1c, retinopathy; neuropathy; nephropathy macrovascular complications
    Major depression: in diabetes
  114. Nine item brief self-report developed for primary care. Items from DSM-IV-TR signs/sx of MDD. Use for provisional dx and tx monitor
    PHQ-9
  115. Restricting type or binge-eating/purging type
    Anorexia nervosa
  116. Purging type or non-purging type
    Bulimia nervosa
  117. Has a mortality rate of 5-20%.
    Anorexia nervosa
  118. Secrecy about and preoccupation with food and eating behaviors. Concerns about body weight and image. Self-esteem issues. Denial
    Common characteristics of eating disorders
  119. Influenced by chemical imbalances. Serotonin. SSRIs have been shown to be helpful. A biologically mediated affective disorder.
    Bulimia
  120. Distorted body image. Intense fear of becoming overweight. Weight loss to 15% below ideal body weight. Amenorrhea. Absence of at least 3 consecutive periods.
    Anorexia nervosa
  121. Engages in binge eating or purging behaviors. Laxatives. Vomiting. Diuretics. Enemas
    Binge eating type: anorexia nervosa
  122. Self-starvation
    Restrictive type: anorexia nervosa
  123. Preoccupied with food. Rituals. Cooks for others only. Social withdrawal. Exercises obsessively. Weighs frequently. Fatigue. Loss of hair. Stops menstruating. Sensitivity to cold.
    Signs and symptoms of anorexia nervosa
  124. Death. Starvation/arrhythmia. Dehydration. Renal symptoms. Electrolyte abnormalities. Malnutrition. Amenorrhea. Hypotension. Bradycardia. Reduced bone density. Fractures. Hypothermia. Fainting and chronic fatigue. Lanugo – fine hair growth on body.
    Complications of anorexia nervosa
  125. Recurrent episodes of binge eating. Lack of control. Constant body image dissatisfaction. Inappropriate compensatory behavior in order to prevent weight gain. Min. 2/wk for 3 months.
    Bulimia
  126. Purging: laxatives, vomiting, diuretics, enemas. Non-purging: fasting, excessive exercise, prevent weight gain.
    Bulimia
  127. Engages in binge eating and cannot. Voluntarily stop. Followed by purging and sense of relief. Reacts to emotional stress by overeating. Experiences frequent. Fluctuations in weight. Feels guilty or ashamed about eating. Has depressive moods.
    Symptoms bulimia nervosa
  128. Death, dehydration and malnutrition, electrolyte abnormalities, hypotension and bradycardia, heart failure, parotiditis, chipmunk cheeks. Tooth decay. Irregular bowel motility due to loss of bowel elasticity. Esophageal inflammation and rupture risk.
    Complications of bulimia nervosa
  129. Must have at least 3: eating more rapidly than normal. Eating till uncomfortably full. Eating food when not hungry. Eating alone b/c of embarrassment. Feeling disgusted, depressed, or guilty after overeating. 2 or more days/week for 6 month period.
    Binge eating disorder
  130. Unlike bulimia: binge eating happens in episodes and is not constant. No purging behaviors.
    Binge eating disorder
  131. Unlike anorexia: ashamed of behavior. Like anorexia: eating in secret.
    Binge eating disorder
  132. Obesity, high blood pressure, high cholesterol, heart disease, diabetes mellitus, gall bladder disease
    Complications of binge eating disorder
  133. Most common diagnosis among eating disorders. Issues around food and body weight. Food diaries. Do not fit criteria for other disorders. Secrecy. Difficult to establish trust. Loss to follow up. Denial
    Eating disorder nos
  134. Treatment of choice for anorexia nervosa:
    Maudsley family therapy
  135. Treatment of choice for bulimia nervosa
    Cognitive behavioral therapy or interpersonal therapy.
  136. Acceptance and mindfulness along with commitment and behavior change strategies.
    Acceptance and commitment therapy (act)
  137. Biggest challenge in an treatment:
    Ego-syntonic nature of the symptoms.
  138. Biggest challenge in BN and BED treatment
    Shame and embarrassment.
  139. Bulimia is
    Ego-dystonic.
  140. Potentially fatal condition. Rapid changes in fluids and electrolytes. Malnourished patients that are given oral, enteral or parenteral feedings.
    Re-feeding syndrome
  141. At risk patients: severe anorexia nervosa, <75%ile of ideal body weight. Lost a large amount of weight rapidly. Prolonged weight loss.
    Re-feeding syndrome
  142. Defined primarily by manifestations of severe hypophosphatemia: cardiovascular collapse, rhabdomyolysis, seizures, delirium, malnourished patients can have depleted intracellular phosphate stores.
    Re-feeding syndrome
  143. With re-feeding there is a shift from fat to carbohydrate metabolism. Hypokalemia results from insulin secretion in response to caloric load. Shifts potassium into cells. Hypokalemia can lead to arrhythmias. Risk of
    • Wernicke’s encephalopathy.
    • Re-feeding syndrome
  144. Can result in impaired energy stores due to depletion of intracellular ATP and tissue hypoxia
    Hypophosphatemia
  145. Dramatic increase in food preoccupations and odd eating behaviors/rituals. Strong emotional reactions around food. Binge eating followed by regret and self-disgust. Emotional changes: irritability, anxiety, apathy, depression or suicidality, psychosis
    Effect of starvation
  146. Disordered eating, menstrual dysfunction, osteoporosis
    Female athletic triad
  147. The prevailing, underlying emotional tone; it is also what the patient feels
    Mood
  148. The objective, observed component of emotion. It is also the variability of emotion as thoughts change.
    Affect
  149. Allow the patient to give spontaneous responses. Give control to the patient. Not time-efficient. Combine open and closed questions.
    Open-ended questions
  150. Naming the emotion you see and reflecting it back to the patient
    Reflective listening
  151. Gestures or words that encourage communication, but don’t lead the patient.
    Facilitation
  152. Implies an understanding of the patient’s feelings (doesn’t necessarily imply agreement). Gives patient feeling of being supported.
    Legitimization
  153. The process of moving as the other person moves as a means of acknowledging the other’s behavior and reflecting their emotional state.
    Matching: non-verbal communication
  154. Facial expressions, gestures, touch, position, body tension
    Kinesics: non-verbal communication
  155. Spatial relationships and barriers
    Proxemics: non-verbal communication
  156. Voice tone, rhythm and rate, volume, emphasis
    Paralanguage: non-verbal communication
  157. Flushing, sweating, changes in breathing and pupil size, dry mouth
    Autonomics: non-verbal communication
  158. A change in a patient’s condition attributable to the symbolic import or therapeutic intent of a treatment.
    The placebo effect
  159. Clinical disorders” (most psychiatric disorders, and other psychiatric conditions that are a focus of clinical attention) including schizophrenia.
    AXIS I
  160. Personality disorders and R
    AXIS II
  161. General medical conditions.
    AXIS III
  162. Psychosocial and environmental problems.
    AXIS IV
  163. Global assessment of functioning.
    AXIS V
  164. Cluster A
    Schizotypal, schizoid, paranoid
  165. Cluster B
    Antisocial, histrionic, borderline, narcissistic
  166. Cluster C
    Anxious-fearful: avoidant, dependent, obsessive-compulsive
  167. An event is experienced as overwhelming. Psychological symptoms are triggered. Physical symptoms are triggered
    Psychiatric crises
  168. Feelings patient has for you
    Transference
  169. Feelings for your patients
    Countertransference
  170. Sense of self as a male or a female. Established by about 18 mo of age
    Gender identity
  171. Concept that boys become men and girls become women. Established between 18 mo and 30 mo
    Gender stability
  172. Immutability of one's gender. Is firmly established and resistant to change by 30 mo
    Gender constancy
  173. Public behaviors commonly thought to be associated with maleness or femaleness (within a culture)
    Gender role
  174. A strong, persistent discomfort (dysphoria) with one's anatomic gender coupled with persistent cross-gender identification.
    Gender identity disorder
  175. Reassure that questions are a routine part of clinical practice and preventive care
    Inclusion
  176. Communicate to the patient that these experiences are quite prevalent and that she or he is not alone.
    Normalization
  177. Phrase questions as if everyone has done everything, which makes answering in the affirmative easier for potentially sensitive questions.
    Universalization
  178. Refers to recurrent or persistently deficient sexual fantasies or desire for sexual activity that causes personal distress or interpersonal difficulty
    Hypoactive sexual desire disorder
  179. Usually refers to the avoidance of, or aversion to, all or nearly all genital (or other, e.g., breast) sexual contact with a partner. Must also cause distress or difficulty to be considered a disorder.
    Sexual aversion disorder
  180. The inability for a male to achieve an erect penis as part of the overall multifaceted process of male sexual function
    Erectile dysfunction
  181. Refers to pain experienced immediately before, during, or after intercourse by women or men.
    Dyspareunia
  182. Is usually caused by insufficient lubrication or spasm of the anal musculature
    Anal dyspareunia
  183. Defined in the DSM-IV as the inability to attain or maintain a genital lubrication-swelling response during sexual activity divided into subjective, genital, and combined subtypes .
    Female sexual arousal disorder
  184. Orgasmic dysfunction refers to the inability to reach orgasm when desired.
    Female orgasmic disorder
  185. In which the patient has never experienced orgasm
    Primary inhibited orgasm
  186. In which the dysfunction manifests after previous satisfactory orgasmic functioning
    Secondary inhibited orgasm
  187. Involuntary, usually painful, spastic contraction of the pelvic musculature surrounding the outer third of the vagina.
    Vaginismus
  188. Severe pain on vestibular touch or attempted vaginal entry. Tenderness to pressure localized within the vulvar vestibule. Physical findings confined to vestibular erythema, etiology currently unknown
    Vulvar vestibulitis
  189. Refers to pain experienced immediately before, during, or after intercourse by women or men
    Dyspareunia
  190. Severe breakdown of mental functioning with impaired contact with reality
    Psychosis
  191. Loosening of associations, poverty of thought, thought blocking, mutism
    Thought disorder
  192. New invented idea speech
    Neologisms
  193. Word salad
    Verbigeration
  194. Sensory stimuli that is misinterpreted
    Illusions
  195. No external stimulation, visual is most common
    Hallucinations
  196. Fixed, bizarre, unrealistic beliefs. Not subject to rational argument. Not accounted for by accepted cultural or religious beliefs. Patient may conceal.
    Delusions
  197. General mistrust or suspiciousness. Plausible but false beliefs. Bizarre delusions. Elaborate delusional systems
    Paranoid delusions
  198. Paranoid. Grandiose. Religious. Nihilistic. Somatic. Referential
    Types of delusions
  199. Hallucinations. Delusions. Disorganized speech and behavior. Agitation. Respond fairly well to conventional antipsychotic medications.
    Positive symptoms of schizophrenia
  200. Avolition. Withdrawal/autism. Anhedonia. Blunted affect. Poverty of speech. May respond somewhat better to ‘atypical’ antipsychotic medications.
    Negative symptoms of schizophrenia
  201. On AXIS, clinician rates the person's level of functioning both at the present time and the highest level within the previous year. This helps clinician understand how the other axes are affecting the person and what type of changes could be expected.
    AXIS v: highest level of functioning
  202. Events in a persons life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in AXIS I and II. These events are both listed and rated for this AXIS.
    AXIS Iv: severity of psychosocial stressors
  203. Which play a role in the development, continuance, or exacerbation of AXIS I and II disorders, physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here.
    AXIS III: physical conditions
  204. Developmental disorders include autism and mental retardation, disorders which are typically first evident in childhood personality disorders are clinical syndromes. They include paranoid, antisocial, and borderline personality disorders.
    AXIS II: developmental disorders and personality disorders
  205. This is what we typically think of as the diagnosis (e.g., depression, schizophrenia, social phobia)
    AXIS I: clinical syndromes
  206. A feeling of nervousness or worry”. “a complex set of psychobiological responses to perceived danger or threat”
    Anxiety
  207. In response to threat, heightened alertness, concentration, readiness for muscle action, reduced GI function, “fight-or-flight”
    An adaptive response to anxiety
  208. Benign stimuli perceived as threat. Response is exaggerated, self-perpetuating, impairs ability to function
    A maladaptive response to anxiety
  209. The most prevalent psychiatric disorders in the us
    Anxiety disorders
  210. A reaction to stress: causes of stress are different at different ages. Reactions include anxiety and depression, avoidant behavior. Maladaptive behavior is called adjustment disorder. Does not meet criteria for other “major” types of anxiety disorders
    Adjustment disorder with anxious mood
  211. Treatment: psychological, stress reduction techniques, daily log, relaxation exercises, CBT. Pharmacological: sedatives (benzodiazepines), danger of addiction
    Adjustment disorder with anxious mood
  212. Disabling condition commonly seen in primary care. Patients suffer from attacks with rapid onset of symptoms and persistent concern about having an attack. Can occur one to several times per week, usually unpredictably. Frequency of attacks wax and wane.
    Panic disorder
  213. Fear of open spaces or of being in crowded, public places or leaving a safe place
    Agoraphobia
  214. Fear of situations that may involve scrutiny or judgment by others
    Social phobia
  215. A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes
    DSM-IV criteria for panic attack
  216. Felt to be due to phobia of internal sensations. Drives avoidance behavior. Cognitive model suggests patents misinterpret thoughts and emotions as physical symptoms. Alternate theory that benign body sensations spiral into panic attacks
    Panic disorder
  217. Antidepressants plus CBT. Antidepressants SSRIs and TCAs are equally effective in reducing severity and number of attacks
    Panic disorder
  218. Classified as a disorder without panic attacks or symptoms of depression
    Generalized anxiety disorder
  219. Excessive physiologic arousal, distorted cognitive processes, poor coping strategies
    Generalized anxiety disorder
  220. Highest prevalence of all anxiety disorders
    Generalized anxiety disorder
  221. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry
    DSM diagnostic criteria: GAD
  222. Relaxation and biofeedback to decrease arousal. Cognitive therapy to limit distortions and make better plans to manage anxiety. Benzodiazepines. Serax (oxazepam) Klonopin (clonazepam)
    GAD treatment
  223. For those with chronic anxiety and those who relapse after benzodiazepine therapy
    BuSpar
  224. Arises following exposure to perceived life-threatening trauma. Symptoms can mimic that of anxiety or depressive disorders. Symptoms may be transient, may take longer than 6 months to appear, and may last a lifetime
    Post-traumatic stress disorder (PTSD)
  225. Has exposed to traumatic event which: experienced, witnessed, or confronted with event that involved actual/threatened serious injury, or a threat to the physical integrity of self or others. Person’s response involved intense fear, helplessness or horror
    DSM diagnostic criteria: PTSD
  226. Similar to PTSD in that it occurs after exposure to a traumatic event. Appears within 4 weeks of trauma. Fewer symptoms required to make diagnosis. More dissociative symptoms (“in a daze,” temporary amnesia).
    Acute stress disorder (ASD)
  227. PTSD treatment
    SSRI. Goal is to break pattern of self-defeat by reexamining the traumatic event and the response to it. Education and recognition of cues are key
  228. Social anxiety disorder
    • An intense, irrational and persistent fear of being scrutinized or negatively evaluated by others
    • Feared situations are avoided or else are endured with intense anxiety or distress
    • The avoidance, anxious anticipation, or distress in the feared performance situation(s) interferes significantly with the person’s normal routine, occupational functioning, or social activities or relationships, or there is marked distress
    • Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
    • Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack
  229. Treatment social anxiety disorder
    SSRIs (Paxil, Luvox, Zoloft, and Celexa) and MAOIs are effective. Benzodiazepines can also be effective but may relapse after discontinuation. And CBT.
  230. Characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety. Feelings of shame and secrecy
    Obsessive-compulsive disorder (OCD)
  231. Involvement of the dorsolateral prefrontal cortex, basal ganglia, and thalamus. Thought that serotonin system is heavily involved
    OCD
  232. Obsessions and compulsions are severe enough to be time consuming (more than 1 hour daily) or to cause marked distress or significant impairment
    OCD
  233. Treatment OCD
    CBT & SSRIs are first line
  234. Short-term goals: reduce severity and duration of symptoms; improve functioning
    Generalized anxiety disorders (GAD)
  235. Long-term goals: achieve symptom remission facilitate patient’s return to pre-morbid level of functioning. Reduce length of episodes. Reduce severity of episodes & prevent recurrence
    Generalized anxiety disorders (GAD)
  236. Benzodiazepines
    First-line treatment GAD
  237. Selective serotonin reuptake inhibitors (SSRIs)
    First-line treatment GAD
  238. Selective norepinephrine reuptake inhibitors (SNRIs)
    First-line treatment GAD
  239. Buspirone (BuSpar)
    GAD treatment
  240. Hydroxyzine, imipramine, and propranolol
    GAD treatment
  241. Located in every region of the brain. Consists of GABAA and GABAB receptors
    ⋎- aminobutyric acid (GABA)
  242. Receptors produce inhibitory effect on CNS
    GABA-a receptors
  243. Receptors produce inhibitory effect on GABA release
    GABA-b receptors
  244. Chloride ion channel open and influx of chloride ions. Hyper-polarization and reduced firing of the neuron
    GABA-a receptors
  245. Expression of receptors may fluctuate over time and in response to stress
    GABA receptors
  246. Potentiates inhibitory effect of GABA. Bz-GABA receptor complex. Binds of benzodiazepines coupled with GABA binding. Increases the opening of the chloride ion channel
    Benzodiazepines
  247. Varying degrees of lipophilicity. Affects ability to cross the blood-brain barrier. May produce rapid onset of action. Experience rush of euphoria. Unpleasant feeling/loss of control
    Side effects of benzodiazepines
  248. CNS depression; impairment of memory or recall; abuse (unlikely in general population), dependence
    Side effects of benzodiazepines
  249. Patients with liver dysfunction. Slower onset of effect
    Lorazepam and oxazepam
  250. Non-compliance, avoidance of withdrawal symptoms
    Diazepam
  251. Treatment of choice for acute anxiety relief. Produce effects within days to one week. Produce additional benefit on sleep and muscle relaxation
    Benzodiazepines
  252. Immediate return of original symptoms, sometimes with higher intensity. Usually seen with bz
    Rebound symptoms
  253. Common symptoms: anxiety, restlessness, insomnia, agitation, muscle tension, irritability
    Withdrawal symptoms in bz
  254. Partial agonist at 5-ht1a pre- and post-synaptic receptors. Stimulation of pre-synaptic somatodendritic 5-ht1a autoreceptor allows 5-ht repletion. Stimulation of post-synaptic 5-ht1a produces anxiolytic effect
    Mechanism of action of buspirone
  255. Lack of sedation and anxiolytic properties are major advantages. Dizziness, nausea, and headache. Minimal drug interactions
    Buspirone side effects
  256. Metabolized by cyp3a4
    Buspirone
  257. Use in GAD. Current/history of substance abuse. Intolerant to by therapy. Refractory GAD. Less sedation and functional impairment than by
    Buspirone
  258. Vistaril, Atarax
    Hydroxyzine
  259. Potent antihistanergic, anticholinergic, and antispasmodic effects
    Mechanism of action: hydroxyzine (Vistaril, Atarax)
  260. GI, headache, sedation, and minimal drug interactions
    Side effects: hydroxyzine (Vistaril, Atarax)
  261. Blocks reuptake of 5-ht and ne
    Mechanism of action: imipramine (Tofranil)
  262. Anticholinergic, sedative, cardiovascular, and CNS
    Side effects: imipramine (Tofranil)
  263. Imipramine
    Tofranil
  264. Moa (anxiolytic): blockade of postsynaptic beta receptors results in decrease of autonomic symptoms
    Beta blockers in GAD
  265. Use in GAD. Good for patients with prominent CV symptoms (palpitations, tremors). Adjunctive therapy for refractory GAD
    Beta blockers in GAD
  266. Antidepressants: SSRI’s; venlafaxine (Effexor); mirtazapine (Remeron), TCAMAOI, benzodiazepines (2nd line), alprazolam, clonazepam
    Panic disorder
  267. Venlafaxine, mirtazapine, trazodone
    SSRI’s
  268. Imipramine
    TCA
  269. Clomipramine, nortriptyline, desipramine
    TCA
  270. Phenelzine
    MAOI
  271. Second line therapy due to drug-drug and drug-food interactions. Reserved for refractory cases
    MAOI
  272. Only by with FDA approval for panic disorder
    Alprazolam
  273. CBT
    Cognitive behavioral therapy
  274. CBT first-line for mild cases. CBT + SSRI for severe cases (may try SSRI alone in adults). Clomipramine for 2-3 failed SSRI trials. If concomitant depression, psychosis or mania present, treat those first.
    OCD
  275. Affects both ne and 5ht, potent 5ht effects treat OCD. Lots of se
    TCA
  276. H1 - sedation, weight gain. M1 - dry mouth, blurred vision, tachycardia, constipation, urinary retention, confusion. Alpha1 - oh, dizziness. CV - conduction disturbances, seizures. Sexual dysfunction
    Side effects of clomipramine
  277. H/o liver disease: LFTs. Fever and sore throat. CBC to check for agranulocytosis cg - clomipramine in patients > 40yoelicit side effects via questioning at each outpatient appointment (usually once a week to every 3 months)
    Clomipramine
  278. Incorrect diagnosis, inadequate treatment, wrong drug, dose too low, length of therapy too short, no behavioral therapy, poor compliance
    Reasons for therapy failure
  279. Substantia nigra innervating the caudate nucleus, putamen. Controls voluntary movement
    Nigrostriatal pathway (a9)
  280. D2 receptor blockade causes extrapyramidal symptoms (eps). Increased activity may be associated with positive symptoms.
    Nigrostriatal pathway (a9)
  281. D2 receptor blockade causes
    Extrapyramidal symptoms (eps)
  282. Increased activity of nigrostriatal pathway may be associated with
    Positive symptoms
  283. Midbrain ventral tegmentum innervating limbic area structures. Integrates emotions with sensorimotor functions. Arousal, memory, stimulus processing, motivation
    Mesolimbic pathway
  284. Hyper da activity produces positive symptoms. Blockage of da receptors relieves psychosis
    Mesolimbic pathway
  285. Hyper da activity produces
    Positive symptoms in schizophrenia
  286. Blockage of da receptors relieves
    Psychosis schizophrenia
  287. Midbrain ventral tegmentum innervating frontal/prefrontal cortex
    Mesocortical da pathway
  288. Integrates executive functioning, thinking, and memory, cognition, communication, social functioning, stress
    Mesocortical da pathway
  289. Hypo da activity leads to negative symptoms. Blockade of da receptors relief of psychosis. May increase negative symptoms
    Mesocortical da pathway
  290. Hypo da activity leads to
    Negative symptoms in schizophrenia
  291. Hypothalamus innervating anterior pituitary gland. Integrates release of prolactin
    Tuberoinfundibular da pathway
  292. Blockade of d2 receptors increases in prolactin levels
    Tuberoinfundibular da pathway
  293. Receptors found in all 4 da tracts
    D1 and d2 receptors
  294. Blocking d2 in mesolimbic pathway produces
    Antipsychotic effect
  295. Cognition and emotion. D3 and d4 receptors found in the
    Mesolimbic pathway
  296. Found in hippocampus, hypothalamus, and thalamus. Affective, neuroendocrine, and pain symptoms.
    D5 receptors
  297. Hypofunction/expression of NMDA receptors. Symptoms similar to da hyperactivity
    Role of glutamate
  298. Antipsychotics may increase
    Glutamatergic transmission
  299. Dysfunction produces changes in mood, appetite, sleep, thermoregulation, attention, and motor behavior
    Role of 5-ht
  300. Lessen eps in nigrostriatal pathway. Lessen negative symptoms in prefrontal cortex
    Antagonism of 5-ht2 receptors blocks inhibition on da
  301. First episode psychosis
    Atypicals
  302. Noncompliance
    Long-acting medications
  303. Aggression
    Clozapine. High potency typical. Olanzapine and quetiapine
  304. Insomnia
    Olanzapine, quetiapine. Low potency typicals
  305. Dysphoria
    Atypicals
  306. Suicidal behavior
    Atypicals
  307. Substance abuse
    Atypicals
  308. Cognitive problems
    Atypicals
  309. Compulsive water drinking
    Clozapine
  310. Predictors of good treatment response
    Previous response to treatment. Acute onset. Short duration of illness. Presence of acute stressors. Later age of onset. Family history of affective illness. Good pre-morbid levels of social functioning.
  311. Predictors of poor treatment response
    Extreme negative or cognitive symptoms. Poor initial treatment response. Even if conditions optimized pts. Still negative towards therapy.
  312. Blockade highest with low potency typicals
    Cholinergic receptors & histaminergic receptors
  313. Low potency typicals. High affinity for 5-ht2 receptors. Clinical doses produce saturation of these receptors
    Chlorpromazine
  314. Main feature of atypicals is
    Diminished eps and prolactin levels
  315. Attach at the same rate to the d2 receptor as typicals. Quick rate of dissociation from the d2 receptor. Fast dissociation increases response to phasic bursts of da. Modulation of the da signal without disruption.
    • Da receptors
    • Increased ratio of 5-ht to da blockade. Low doses produce significant blockade
  316. 5-ht receptors
    Only true atypical antipsychotic
  317. Clozapine
    Diminished eps due to high anticholinergic properties. D2 blockade increased eps, akathisia
  318. Olanzapine
    Blocks alpha-1, h1
  319. Risperidone
    Lowest d2 binding of all antipsychotics. Diminishes with time from last dose, undetectable at 12hrs
  320. Quetiapine
    Inhibits reuptake of ne and 5-ht
  321. Ziprasidone
    Partial agonist activity at d2 and 5-ht1a receptors. Antagonist activity at 5-ht2a
  322. Aripiprazole
    Muscle spasms. Jaw, tongue, neck. Increases in da release. Hypersensitivity of da receptors.
  323. Dystonia
    Treatment: acute: stop offending medication; start anticholinergics or benzodiazepines at lower dose: start prophylactic therapy. Switch to atypical
  324. Dystonia
    Subjective restlessness. Objective inability to be still. Da blockade. Increase in motor activity. Dysfunction of ne
  325. Akathisia
    Treatment: start at low dose or decrease dose. Switch to an atypical agent. Clozapine. Anticholinergics are ineffective. Benzodiazepines/beta-blockers. Propranolol
  326. Akathisia
    Impulsive/violent behavior. High risk for suicide.
  327. Akathisia
    Four cardinal symptoms: akinesia, bradykinesia. Pill rolling tremor. Cogwheel rigidity. Shuffling gait. Masked facies. Imbalance of da/ach
  328. Pseudoparkinsonism
    Treatment: anticholinergics. Benztropine. Trihexyphenidyl. Diphenhydramine
  329. Pseudoparkinsonism
    BLM: first detectable sign fly catchers tongue, puckering, facial movements, grimacing, chewing. Truncal movements: rocking, gyrating. Upper and lower extremities: fast/slow, irregular, purposeless, spontaneous movements. Foot tapping
  330. Tardive dyskinesia
    Hypersensitivity of da receptors in nigrostriatal pathway. Imbalance of da/ach. Decreased da decreases GABA inhibition. GABA-enhancing drugs ineffective. Role of free-radicals, ne, and 5-ht
  331. Tardive dyskinesia
    Risk factors: high doses, long length of therapy, cumulative therapy, increased age, organic mental disorder, diabetes mellitus, mood disorder, female gender
  332. Tardive dyskinesia
    Treatment: switch to atypical. Risperidone, olanzapine/quetiapine; clozapine; vitamin e
  333. Tardive dyskinesia
    Autonomic instability: tachycardia, labile blood pressure, sweating, tachypnea, incontinence. Muscle rigidity. Altered consciousness
  334. Neuroleptic malignant syndrome (NMS)
    Abnormal labs: temperature > 38°c; creatine kinase; myoglobinuria; AST/ALT; WBC with/out left shift
  335. Neuroleptic malignant syndrome (NMS)
    Da blockade: hypothalamus: disruption of thermoregulatory process; increase heat production due to increased muscle contraction. Nigrostriatal pathway: increased rigidity and eps
  336. Disruption of thermoregulatory process. Increase heat production due to increased muscle contraction.
    Hypothalamus
  337. Increased rigidity and eps
    Nigrostriatal pathway
  338. Clozapine, quetiapine, risperidone
    Cardiovascular side effects of antipsychotics
  339. Low-potency typicals; quetiapine, risperidone, clozapine
    Tachycardia: combination of anticholinergic effects, orthostatic hypotension, and elevated norepinephrine levels
  340. ECG changes: antiarrhythmic or arrhythmogenic. Bind to ikr (k+ rectifier). Involved in repolarization. Torsades de pointes
    Haloperidol iv, thioridazine, mesoridazine, ziprasidone
  341. Clozapine and olanzapine; risperidone; quetiapine
    Weight gain side effects antipsychotics
  342. Clozapine, olanzapine, quetiapine
    Diabetes side effects of antipsychotics
  343. Clozapine, olanzapine
    Hyperlipidemia side effects of antipsychotics
  344. Dry mouth, constipation, tachycardia, blurred vision, urinary retention
    Anticholinergic
  345. GABA depletion, changes in CNS permeability, disruption of da/ach, activation of latent seizure focus
    Seizure side effects of antipsychotics
  346. Anticholinergic, alpha-1 blockade, hyperprolactinemia, decreased testosterone
    Genitourinary system: side effects of antipsychotics
  347. Urinary retention/hesitancy. Erectile dysfunction. Decreased libido. Ejaculation dysfunction. Priapism
    Genitourinary system: side effects of antipsychotics
  348. Da blockade; anticholinergic blockade; inhibits sweating; concern with agents with greater anticholinergic properties, low potency typicals. Clozapine, olanzapine recommended. Mid potency typicals. Other atypicals
    Thermoregulation: side effects of antipsychotics
  349. Cataracts, retinopathy; photosensitivity, blue grey skin; phenothiazines; quetiapine
    Ocular/dermatological: side effects antipsychotics
  350. Typicals, risperidone. Most common with high potency typicals.
    Hyperprolactinemia
  351. Chlorpromazine, thioridazine
    Hematological
  352. Symptoms: amenorrhea, galactorrhea, gynecomastia
    Hyperprolactinemia
  353. Clozapine – reduces impulsive aggression. Self-harm/mutilation
    Chronic aggression
  354. Blockade of d2 receptors >> 5ht2a receptors
    Typical antipsychotics
  355. Blockade of d2 receptors >> 5ht2a receptors
    Butyrophenone: haloperidol
  356. Blockade of 5ht2a receptors > blockade of d2 receptors
    Atypical antipsychotics
  357. Mechanism of action uncertain. Suppresses inositol signaling and inhibits glycogen synthase kinase-3 (gsk-3), a multifunctional protein kinase
    Lithium
  358. Mechanism of action in bipolar disorder unclear
    Anticonvulsants
  359. Bind to specific GABAA receptors subunits at CNS neuronal synapses facilitating GABA –mediated chloride ion channel opening, enhance membrane hyperpolarization
    Benzodiazepines
  360. Mechanism uncertain: partial agonist at 5-ht receptors but affinity for d2 receptors also possible
    5-ht-receptor agonist
  361. Highly selective blockade of serotonin transporter (sert). Little effect on norepinephrine transporter (net)
    Selective serotonin reuptake inhibitors (SSRIs)
  362. Moderately selective blockade of net and sert
    Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  363. Mixed and variable blockade of net and sert
    Tricyclic antidepressants (TCAs)
  364. Inhibition of 5-ht2a receptor. Nefazodone also blocks sert weakly
    5-ht2 antagonists
  365. Increased norepinephrine and dopamine activity (bupropion). Net>sert inhibition (amoxapine, maprotiline). Increased release of norepi, 5-ht (mirtazapine)
    Tetracyclic, unicyclic
  366. Blockade of mao-a and mao-b (phenelzine, nonselective). Mao-b irreversible selective mao-b inhibition (lose dose selegiline).
    Monoamine oxidase inhibitors (MAOIs)
  367. The anticholinergic adverse effects of antidepressants are related to their interaction with
    Muscarinic receptors
  368. Blocking muscarinic receptors causes the classic anticholinergic symptoms
    Constipation, dry mouth, blurred vision, drowsiness, urinary retention, etc.
  369. A common adverse effect of atypical antipsychotics such as risperidone (Risperdal) and olanzapine (Zyprexa) is:
    Weight gain
  370. Chlorpromazine (Thorazine)
    Tardive dyskinesia
  371. It is important to monitor patients initiating therapy with clozapine (Clozaril) before treatment & weekly for the first 6 months because of the risk of:
    Agranulocytosis
  372. Enhances effects of gamma-aminobutyric acid
    Alprazolam (Xanax)
  373. Inhibits the reuptake of both serotonin (5-ht) and norepinephrine (ne)
    Amitriptyline
  374. Blocks use-dependent sodium channels and blocks the influx of calcium through the NMDA-glutamate receptor
    Carbamazepine (Tegretol)
  375. Potentiates the pharmacological effects of serotonin (5-ht) in the CNS
    Escitalopram (Lexapro)
  376. Potent serotonin 5-ht2-receptor and dopamine (d2)-receptor antagonist
    Ziprasidone (Geodon)
  377. Ad: bupropion (Budeprion xl)
    Seizures
  378. Ad: lamotrigine (Lamictal)
    Rash
  379. Ad: lithium
    Nephrogenic diabetes insipidus
  380. Ad: risperidone (Risperdal)
    Pseudoparkinsonism
  381. Ad: venlafaxine (Effexor)
    Hypertension
  382. Which receptor when stimulated produces antidepressant effects?
    Atypical antipsychotics
  383. Which SSRI causes the most anticholinergic adverse effects?
    Paroxetine (Paxil)
  384. Tardive dyskinesis
    Typical antipsychotics
  385. Psychiatric: schizophrenia (alleviate positive symptoms, bipolar disorder (manic phase)
    Typical antipsychotics
  386. Nonpsychiatric: antiemesis, preoperative sedation (promethazine), pruritus
    Typical antipsychotics
  387. Schizophrenia (alleviates (+) symptoms), bi-polar disorder (manic phase), Huntington’s chorea, Tourette’s syndrome
    Butyrophenone: haloperidol
  388. Schizophrenia – improve both (+) and (-). Bipolar disorder (olanzapine or risperidone adjunctive w/ lithium)
    Atypical antipsychotics
  389. Agitation ion Alzheimer’s and Parkinson’s (low doses)
    Atypical antipsychotics
  390. Major depression (aripiprazole)
    Atypical antipsychotics
  391. Bipolar affective disorder – prophylactic use can prevent mood swings b/w mania and depression
    Lithium
  392. Are also used both in acute mania and for prophylAXIS In depressive phase
    Carbamazepine and lamotrigine
  393. Is increasingly used as first choice in acute illness
    Valproic acid
  394. Acute anxiety states: panic attacks, generalized anxiety disorder, insomnia and other sleep disorders, relaxation of skeletal muscle, anesthesia (adjunctive) seizure disorders,
    Benzodiazepines
  395. Generalized anxiety states
    5-ht-receptor agonist (buspirone)
  396. Major depression, anxiety disorders, panic disorder, obsessive-compulsive disorder, PTSD, perimenopausal vasomotor symptoms, eating disorder (bulimia)
    Selective serotonin reuptake inhibitors (SSRIs)
  397. Major depression, chronic pain disorders, fibromyalgia, perimenopausal symptoms
    Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  398. Major depression, sedation and hypnosis (trazodone)
    5-ht2 antagonists
  399. Major depression not responsive to other drugs. Chronic pain disorders, incontinence, obsessive-compulsive disorder (clomipramine)
    Tricyclic antidepressants (TCAs)
  400. Major depression, smoking cessation (bupropion), sedation (mirtazapine), amoxapine and maprotiline rarely used
    Tetracyclic, unicyclic
  401. Major depression unresponsive to other drugs
    Monoamine oxidase inhibitors (MAOIs)
  402. Blockade of dopamine receptors may result in akathisia, dystonia, ¬parkinsonian symptoms, tardive dyskinesia, and hyperprolactinemia
    Typical antipsychotics
  403. Extrapyramidal dysfunction is major adverse effect
    Butyrophenone: haloperidol
  404. Agranulocytosis
    Clozapine
  405. Diabetes, hypercholesterolemia, wt. Gain
    Clozapine, olanzapine
  406. Hyper prolactinemia
    Risperidone
  407. Qt elongation
    Ziprasidone
  408. Renal elimination;
    Lithium
  409. Interactions: clearance decreased by thiazides and some NSAIDs
    Lithium
  410. Toxicity: tremor, edema, hypothyroidism, renal dysfunction, dysrhythmias, pregnancy, category d
    Lithium
  411. Hematotoxicity and induction of p450 drug metabolism (carbamazepine). Rash (lamotrigine). Tremor. Liver dysfunction. Wt gain. Inhibition of drug metabolism (valproic acid)
    Anticonvulsants
  412. Toxicity: extensions of CNS depressant effects. Dependence liability. Interactions: additive CNS depression with ethanol and many other drugs.
    Benzodiazepines
  413. Tachycardia, paresthesias, GI distress. Interactions: cyp3a4 inducers and inhibitors
    5-ht-receptor agonist
  414. Well tolerated but cause sexual dysfunction. Interactions: some CYP inhibition
    Selective serotonin reuptake inhibitors (SSRIs)
  415. Anticholinergic, sedation, hypertension (venlafaxine), interactions: some cyp2d6 inhibition
    Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  416. Anticholinergic, α-blocking effects, sedation, weight gain, arrhythmias, seizure in overdose
    Tricyclic antidepressants (TCAs)
  417. Hypotension, insomnia
    Monoamine oxidase inhibitors (MAOIs)
  418. Interactions: hypertensive crisis with tyramine, other indirect sympathomimetics/serotonin syndrome with serotonergic agents, meperidine
    Monoamine oxidase inhibitors (MAOIs)
  419. SSRI moa
    Selectively inhibit 5-ht reuptake by blocking 5-ht transporter
  420. SSRI: most potent SSRIs re: blocking 5-ht transporter
    Paroxetine & citalopram
  421. SSRIs that produce effect on ne:
    Fluoxetine and paroxetine (doses > 40mg)
  422. SSRIs: advantages
    Low affinity for histamine- 1, alpha-1, muscarinic (m) rec; so low sedation, no orthostasis, dry mouth or CV issues
  423. SSRI w/longest half life
    Fluoxetine
  424. Most common AE reason for SSRI early dc
    GI problems (titrate slowly, take w/meals)
  425. Most common SSRI AE when starting drug
    Akathisia (esp. w/fluoxetine)
  426. Tx for SSRI akathisia
    Start low, early am, benzo, trazo, and propranolol
  427. Sexual dysfunction greatest/least with:
    Greatest: paroxetine; least: citalopram
  428. SSRI AE: sedation greatest with:
    Paroxetine (d/t anticholinergic properties)
  429. Serotonin syndrome s/s
    Hyperreflexia, tremor, GI complaints, CV problems, seizures, respiratory depression, coma, death; concern re: SSRI combo w/other drugs
  430. SSRI withdrawal s/s
    Nightmares, flu-like symptoms, GI, shock-like sensations, & insomnia (seen usually in 2 to 7 days after abrupt d/c)
  431. SSRI withdrawal worst with:
    Paroxetine & sertraline (switch to fluoxetine?)
  432. SSRI benefit seen in:
    Atypical, psychotic, and dysthymia
  433. Fluoxetine effective dose range
    20-40 mg/day
  434. Wt gain: SSRIs with greatest/least
    Least: fluoxetine; greatest: paroxetine
  435. Paroxetine effective dose range
    30-50 mg/day
  436. Citalopram/escitalopram effective dose range
    20-60 mg/day
  437. Lexapro effective dose range
    10-20mg/day
  438. Classes: equal in depression tx
    SSRI, SNRI, atypicals
  439. SNRI moa
    Block reuptake of 5-ht and ne (& da)
  440. SNRI moa: venlafaxine only produces effects on ne at:
    A higher dose (so push dose pretty high)
  441. SNRI moa: duloxetine has a high level of effect on:
    Both 5-ht and ne
  442. SNRI good to tx:
    Refractory depression, melancholy; more physical pain sx of dependence; comorbid pain (duloxetine: dm peripheral neuropathy)
  443. SNRI AE profile (which worse?)
    Venlafaxine > duloxetine
  444. SNRI side fx
    GI (1st 3 wks); HTN (dose-dept (dbp) venlafaxine); withdrawal sim to SSRI
  445. Use Venlafaxine IR cautiously in pts with:
    HTN & cardiac dysfunction (use dulox or venla xr)
  446. Mirtazapine (atypical) moa
    Unique: blocks central alpha-2 recs increasing ne & 5-ht; antag 5-ht2, 5-ht3 post-synaptic recs
  447. Mirtazapine AE
    Somnolence, wt gain/inc appetite (used in cachectic pts), ortho hypotn
  448. Bupropion moa
    Weak reuptake inhibitor of ne and da
  449. Bupropion active metabolite:
    Hydroxy bupropion; has amphetamine properties (potent reuptake inhibitor of both ne and da)
  450. Bupropion AE
    Lower seizure threshold; vivid nightmares, delusions, psychosis
  451. Do not give bupropion to pts with:
    Eating disorders (low electrolytes): seizure risk
  452. Bupropion dosing
    Highest dose s/b usu 300; dose at early am and noon (d/t insomnia, etc)
  453. Atypical: good option for pts with sedation / fatigue / sexual dysfunction
    Bupropion
  454. TCA moa
    Block the reuptake of 5-ht and n; 1stgen: greater effect on 5-ht reuptake (doxepin); 2ndgen: greater effect on ne reuptake (esp. desipramine; clomipramine)
  455. TCAs with best blockade of alpha- 1 & histamine- 1 recs:
    Amitriptyline & doxepin
  456. TCA AE
    Anticholinergic (dry mouth, urine hesitancy, GERD; cardiovascular (ortho hypotn, tachy, conduction, HTN); CNS (tremor, sedation, myoclonic twitch); wt gain; sexual dysfunction
  457. TCA dosing
    Start at low dose, titrate slowly, switch to less offensive agent; bethanechol for anticholinergic AE; lethal in overdose
  458. MAOI moa
    Block destruction of monoamines by presynaptic neuronal mao; effect both central & peripheral; mao-a = on ne & 5-ht; mao-b = on phenylethylamine & da
  459. Irreversible MAOI =
    Phenelzine & tranylcypromine
  460. MAOI AE
    Wt gain; rash (selegiline); diet restriction (liver, cheese, wine, yeast)
  461. Star-d general findings
    6 wks necessary for pts achieve response; pts unable to tolerate med preferred switch; pts able to tolerate med preferred augmentation
  462. Star-d: Buproprion XR:
    Better results than buspirone
  463. Star-d level 1
    Start citalopram
  464. Star-d level 2
    Switch to: bupropion sr, CBT, sert, venlafaxine XR; or augment w/bupropion sr, BuSpar, CBT
  465. Star-d level 2a
    (if CBT in level 2): switch to: bupropion sr or venlafaxine XR
  466. Star-d level 3
    Switch to mirtazapine or nortriptyline; or augment w/lithium (poss t3 if bupropion, sertraline, venlafaxine)
  467. Star-d level 4
    Switch to tranylcypromine or mirtazapine combo w/venlafaxine xr
  468. Bipolar: theories
    Monoamine, dysregulation, anticholinergic, kindling, neuroendocrine, membrane & cation hypothesis, secondary messenger system, biologic rhythms, switch phenomenon
  469. Lithium moa
    Not well known; block da rec sensitivity; inc ne release in depn; dec ne release in mania; reduces beta-adrenergic stim of adenylate cyclase; inc 5-ht synth
  470. Lithium indicated for
    Acute mania; maintenance
  471. Lithium advantages
    Antidep & antimanic fx (no switching nec); prevent relapse; better than valproate at prevent suicide
  472. Lithium: best results in pts:
    Fewer prior episodes; hx euthymia; periods of good functioning; pos fh w/lithium
  473. Lithium: reduced fx:
    Severe mania w/psychotic; mixed episodes; rapid / continuous cycling; ETOH/ drug abuse
  474. Lithium dosing
    Start at 600-900; inc by 300 q 2-3d (target 900-2400)
  475. Lithium monitoring
    Draw trough 12h post last dose (tx day 5); then 1-2 wks for 1st months; 5 days post dose change
  476. Lithium tx serum level
    0.8 to 1.2 mEq/l (acute manic: poss 1.2 – 1.5); sr has no ref range
  477. Lithium half life
    Usu 24 h (8 – 20 h in mania)
  478. Lithium AE (early)
    Blocks ADH fx on its receptors (polydipsia / polyuria); mx weakness; fine hand (intentional) tremor
  479. Lithium AE (late)
    Ndi; increased lytes (na, k, h2o), cr; cardiac; persistent neuro probs (memory loss; mg, eps); thyroid; GI; inc WBC & wt
  480. Leading cause of lithium noncompliance
    Loss of creativity / memory
  481. Lithium toxicity factors
    Na restriction; dehydration; drug interactions
  482. Lithium: mild toxicity =
    1.5 – 2.0; prob memory/conc; GI; tremor
  483. Lithium: moderate toxicity =
    2.0-2.5; confusion, ataxia, nystagmus, inc DTR
  484. Lithium: severe toxicity =
    Over 3.0; choreoathetosis, seizure, coma, death
  485. Tx lithium tox (>2.5)
    • D/c lithium; gastric lavage; monitor levels
    • Tx lithium tox (>3.5)
    • D/c lithium; hemodialysis; monitor levels
    • Lithium contraindications
    • Renal disease; severe CV disease; hx leukemia; first tri of pg; hypersensitivity; breastfeeding?
  486. Drugs that have anti-kindling properties
    Anticonvulsants (valpro, carbamazepine, lamotrigine)
  487. Bipolar drugs: category d (avoid in pg, dc in first trimester):
    Lithium, valpro, carba
  488. Valpro moa
    Unk; prob inhib GABA metab &stim GABA synth
  489. Valpro good for:
    FDA: acute mania, rapid cycling (> lithium at mixed, secondary bipolar, subst induced)
  490. Valpro less good for:
    Depression
  491. Valpro absorption delayed:
    With food
  492. Valpro AE
    GI, sedation, ataxia/tremor, low PLT, liver probs
  493. Carbamazepine moa
    Unk; prob block voltage-sensitive Na+ channels; block ca+ influx thru NMDA-glutamate receptor
  494. Carbamazepine efficacy
    Xr same as lithium; also acute mania, prophylaxis, bipolar depn
  495. Carbamazepine better than lithium:
    Severe mania; rapid cycling; mixed episodes
  496. Carbamazepine dosing
    Start 200-400 mg/d; target 400-2400; max 15mg/kg/d
  497. Carbamazepine monitoring
    No est tx level; anticonvulsant = 6-12 mcg/ml; carba levels 12h postdose & day 6
  498. Carbamazepine pk
    Well absorbed (not affected by food); peak levels in 1-5 hr; 80% pro bound
  499. Carbamazepine AE
    CNS tox; GI (divide doses); leukopenia, hepatotox, low PLT; SIADH, osteomalacia, derm
  500. Carbamazepine potentially lethal:
    >15 mcg/ml
  501. Carbamazepine contraindications
    Bone marrow depn; hypersensitivity
  502. Lamotrigine moa
    Blocks voltage-sensitive Na+ and ca+ channels
  503. Lamotrigine efficacy
    Maintenance (esp. bipolar depn); not for acute mania
  504. Lamotrigine pk
    Well absorbed (not affected by food); peak levels 1-4 hr; half life 25 hr (so x1/d dose) (inc to 60 hr w/valpro)
  505. Lamotrigine AE
    Usu well tolerated; Stevens Johnson’s syndrome; rash
  506. Antipsychotics dosing
    Risperidone, olanzapine, quetiapine: mono or combo w/valp or lithium; aripiprazole, ziprasidone: monotx
  507. Antipsychotics good for:
    Acute mania; mixed (quetiapine: bipolar depn)
  508. SSRIs in bipolar depn
    Monotx inappropriate; high uncertainty in risk to manic switch
  509. Benzo: benefit in bipolar
    Reduce insomnia and agitation in acute mania
  510. CCBs: benefit in bipolar
    In lithium pts unable to tolerate AE
  511. Typical antipsychotics
    Haloperidol (Haldol); fluphenazine (Prolixin); perphenazine (Trilafon); thioridazine (Mellaril); chlorpromazine (Thorazine
  512. Atypical antipsychotics
    Clozapine (Clozaril); olanzapine (Zyprexa); risperidone (Risperdal); quetiapine (Seroquel); ziprasidone (Geodon); aripiprazole (Abilify)
  513. Choice of antipsychotic for: first episode
    Atypicals
  514. Choice of antipsychotic for: noncompliance
    Long-acting medications
  515. Choice of antipsychotic for: aggression
    Clozapine; high potency typical; olanzapine and quetiapine
  516. Choice of antipsychotic for: insomnia
    Olanzapine, quetiapine; low potency typicals
  517. Choice of antipsychotic for: dysphoria
    Atypicals
  518. Choice of antipsychotic for: suicidal behavior
    Atypicals
  519. Choice of antipsychotic for: substance abuse
    Atypicals
  520. Choice of antipsychotic for: cognitive problems
    Atypicals
  521. Choice of antipsychotic for: compulsive water drinking
    Clozapine
  522. Sufficient trial w/typical / atypical antipsychotics =
    4-6 weeks
  523. Antipsychotics: tx length: first episode
    12 months following sx remission
  524. Antipsychotics: tx length: multiple episodes
    5 yrs following sx remission
  525. Antipsychotics: relapse prevention
    Slow taper (3-9 mo); 20% relapse rate after 1 yr of tx; 50% rate within 6 mo post-d/c of tx
  526. Antipsychotic tx resistance =
    3 different antipsychotic meds from 2 different classes; hx of poor social functioning
  527. Only antipsychotic to show improvement in well defined treatment resistance:
    Clozapine
  528. Monitoring for clozapine
    Due to risk of low WBCs; monitor qwk for 6 mo, q2wks for 6 mo, q4wk for life; greatest risk first 6 mo
  529. Only true atypical antipsychotic:
    Clozapine
  530. Akathisia is an AE of all antipsychotics except:
    Clozapine
  531. Cardinal sx of pseudoparkinsonism
    Akinesia, bradykinesia; pill rolling tremor; cogwheel rigidity; shuffling gait; masked facies
  532. Dystonia risk factors
    Young males; high potency agents; high doses; previous dystonia
  533. Definition of dystonia
    Mx spasms (jaw, tongue, neck)
  534. Definition of neuroleptic malignant syndrome (NMS)
    Autonomic instability; mx rigidity; altered consciousness; high temp; myoglobinuria
  535. Definition of akathisia
    Subjective restlessness; objective inability to be still
  536. Definition of tardive dyskinesia
    Buccolingual movements (fly catchers tongue; puckering); facial movements (grimacing, chewing); truncal movements (rocking, gyrating); upper / lower extremities (irregular purposeless movements, foot tapping)
  537. Tx for tardive dyskinesia
    Switch to atypical
  538. Treatment for akathisia
    Start at low dose; decrease dose; switch to an atypical; anticholinergics are ineffective
  539. Main feature of atypicals is:
    Diminished eps and prolactin levels
  540. Treatment for pseudoparkinsonism
    Anticholinergics
  541. Risk factors for tardive dyskinesia
    High doses; long length of tx; cumulative tx; increased age; organic mental disorder; dm; mood disorder; female
  542. NMS mortality =
    10-20%
  543. Antipsychotic tx algorithm
    Trial of SGA; trial of other SGA; [trial of single agent (FGA or new SGA) or clozapine]; clozapine plus (FGA, SGA, or ECT); trial of single agent (FGA or new SGA); combo tx
  544. Antipsychotic AE
    #dystonia; akathisia; pseudoparkinsonism; tardive dyskinesia; NMS; CV (ortho hypotension, tachycardia, EKG: prolonged qt / torsades); wt gain; diabetes; hyperlipidemia; anticholinergic; sedation; seizure; gu; thermoregulation / fever; agranulocytosis
  545. Anti-anxiety med: adequate trial =
    6-8 weeks
  546. Classes of anti-anxiety drugs
    Benzodiazepines; SSRIs; SNRIs; buspirone; other (hydroxyzine, imipramine, and propranolol)
  547. Which drugs are first-line for anxiety?
    Benzodiazepines; SSRIs; SNRIs
  548. Tx of choice for acute anxiety relief
    Benzodiazepines
  549. Anxiety tx of choice for noncompliance / avoidance of withdrawal sx
    Diazepam
  550. Advantage of buspirone
    Lack of sedation AE; good if pt h/o substance abuse
  551. Advantage of beta blockers in anxiety tx
    Good for pt w/ hx of CV sx; adjunct for refractory
  552. Moa: benzodiazepines
    Potentiates inhibitory effect of GABA
  553. Moa: SSRIs
    Selectively inhibit the reuptake of 5-ht by blocking the 5-ht transporter
  554. Moa: SNRIs
    Block the reuptake of 5-ht and ne (and da)
  555. Moa: buspirone
    SSRI
  556. Moa: hydroxyzine
    Potent antihistaminergic, anticholinergic, and antispasmodic effects
  557. Moa: imipramine (TCA)
    Blocks reuptake of 5-ht and ne
  558. Moa: propranolol
    Beta-blocker
  559. Bz side effects
    CNS depression / sedation; anterograde amnesia; dependence / abuse
  560. Shorter acting benzodiazepines
    Alprazolam; lorazepam; oxazepam
  561. Longer acting benzodiazepines
    Chlordiazepoxide; clonazepam; diazepam
  562. Benzodiazepines: increased toxicity / mortality if:
    Taken with other CNS depressants
  563. Benzodiazepine od mild sx
    Drowsy, confusion, somnolence, impaired coordination, diminished reflexes, lethargy
  564. Benzodiazepine od serious sx
    Ataxia, hypotonia, hypotension, hypnosis, coma, death
  565. Benzodiazepine od: tx:
    Gastric lavage, supportive measures, flumazenil
  566. Benzodiazepine withdrawal sx
    Anxiety, restlessness, insomnia, agitation, muscle tension, irritability
  567. Bz withdrawal sx more likely in:
    Users of high doses for long periods of time
  568. Tx: by withdrawal
    Taper over several weeks when discontinuing
  569. Antidepressants for anxiety dz:
    SSRIs; venlafaxine; mirtazapine; TCA; MAOI
  570. SSRI dosing for anxiety
    Delayed tx response; initiate w/smaller dose than ad dose
  571. Anxiety: MAOI reserved for:
    Refractory cases
  572. FDA approved for panic disorder
    Paroxetine, fluoxetine, sertraline, venlafaxine xr, alprazolam, clonazepam
  573. Tx for OCD
    CBT first-line for mild; CBT and SSRI for severe (clomipramine if 2-3 failed SSRIs); tx mania, depression, or psychosis first

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