Term
| Which gender is more likely to develop major depressive disorder? |
|
Definition
|
|
Term
| How many adults experience depression within their lifetime? |
|
Definition
|
|
Term
| What is the likelihood of someone with depression actually being treated? |
|
Definition
| Only 1 in 3 are diagnosed and treated |
|
|
Term
| Why is depression often overlooked? |
|
Definition
Many present with somatic complaints
Difficult to separate depression from normal emotional ups and downs
Stigma: leads to fear, criticism or ignoring mental illness |
|
|
Term
| How does age increase the likelihood of suicide following major depression? |
|
Definition
Up to 15% if individuals die by suicide
Individuals over 55 have fourfold mortality |
|
|
Term
| What criteria are required for a clinical diagnosis of major depression? |
|
Definition
One or more Major Depressive Episodes
No manic, mixed or hypomanic episodes
Symptoms not exclusively caused by a substance or another medical condition
The episodes must not be better accounted for by a psychotic illness |
|
|
Term
| What are the DSM-IV diagnostic criteria for major depression in adults (5 of the following symptoms during the same 2 week period that is a change from previous functioning)? |
|
Definition
Depressed mood*
Loss of interest or pleasure*
Change in appetite and/or weight
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Poor concentration or indecisiveness
Suicidal ideation |
|
|
Term
| What are the DSM-IV diagnostic criteria for major depression in children (5 of the following symptoms during the same 2 week period that is a change from previous functioning)? |
|
Definition
Depressed or irritable mood*
Loss of interest or pleasure*
Change in appetite and/or weight or failure to make expected weight gains
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Poor concentration or indecisiveness
Suicidal ideation |
|
|
Term
| What symptoms must be present for the diagnosis of depression in children? |
|
Definition
| Either depressed mood or loss of interest or pleasure |
|
|
Term
|
Definition
How positively a person feels about themselves - an evaluation of self
The system that helps us monitor our social worlds for indications that we might be rejected and motivates us to make ourselves acceptable to other people |
|
|
Term
| What are potential complications of low self-esteem? |
|
Definition
Often leads to negative emotions, may precipitate rejection
People function best when they have a realistic view of their strengths and weaknesses |
|
|
Term
| When is an episode of major depressive disorder considered to be over? |
|
Definition
| When the full criteria for a Major Depressive episode have not been met for at least two months |
|
|
Term
| What are the different rating scales for depression? |
|
Definition
Hamilton Depression Rating Scale (HAM-D)
Montgomery-Asberg Depression Rating Scale (MADRS)
Zung Self-Rating Scale (ZSRDS)
Geriatric Depression Scale (GD) |
|
|
Term
| What is the key mediator gene that is most likely involve in the genetic basis for depression? |
|
Definition
Serotonin transporter gene
50% population has one short allele (likely vulnerable) |
|
|
Term
| How does the length of the serotonin transporter gene allele and stress correlate with a risk of major depression? |
|
Definition
1 short allele : increased risk
2 short alleles : greatly increased risk
2 long alleles : hardiness |
|
|
Term
| What physical symptoms potentially indicate depression? |
|
Definition
Fatigue
Disturbed sleep
Menstrual problems
Dizziness
GI complaints
Headache
Joint or limb pain
Back pain
Abdominal pain
Chest pain
Sexual dysfunction, lack of interest in sex |
|
|
Term
| What is the likelihood of remission of depression? |
|
Definition
| Longer earlier in course, becomes progressively more likely with subsequent episodes |
|
|
Term
| Patients with depression are at twice the risk of what painful conditions? |
|
Definition
Chronic daily headache
Atypical chest pain/non-cardiac chest pain
Musculoskeletal pain/fibromyalgia
Low back pain/chronic radiculopathy |
|
|
Term
| How does depression affect cardiovascular function? |
|
Definition
| Increased risk for IHD and CHF, worsens prognosis possibly due to increased platelet activation and reactivity |
|
|
Term
| What is Dysthymic Disorder? |
|
Definition
| Depressed mood most of the day, more days than not, for at least two years |
|
|
Term
| What is required for a diagnosis of dysthymic disorder? |
|
Definition
Presence, when depressed, of at least two of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
Not without symptoms more than two months of the two years
No Major Depressive Episode occurs during the two years |
|
|
Term
| What characterizes dysthymic disoders in children? |
|
Definition
| Depressed OR irritable mood most of the day, more days than not, for at least ONE year |
|
|
Term
| What is Premenstrual dysphoric disorder? |
|
Definition
Occurs in most menstrual cycles last week of luteal phase and remits within few days of onset of menses
Symptoms: markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities |
|
|
Term
| What is Minor depressive disorder? |
|
Definition
| Episodes of at least two weeks of symptoms but with fewer than five items required for major depressive disorder |
|
|
Term
| What is Recurrent brief depressive disorder? |
|
Definition
| Depressive episodes lasting from 2 to 14 days at least once a month for twelve months |
|
|
Term
| What is Postpsychotic depressive disorder of schizophrenia? |
|
Definition
| A major depressive episode that occurs during the residual phase of schizophrenia |
|
|
Term
| What guidelines are suggested for the management of depression? |
|
Definition
Establish optimistic tone in initial interview
Assess severity of symptoms
Avoid extensive psychological “probing” when the patient is deeply depressed
Assess and reassess risk of suicide |
|
|
Term
| What is the goal in the acute phase of treatment for depression? |
|
Definition
Achieve remission
Restore baseline level of symtomatology and functioning
Takes 1-2 months |
|
|
Term
| What is the goal in the continuation phase of treatment for depression? |
|
Definition
Prevent relapse of episode
Medication dose that achieved remission should generally be used in this phase
Lasts 2-6+ months |
|
|
Term
| What is the goal in the maintenance phase of treatment for depression? |
|
Definition
Prevent recurrence of new episode
Decision to employ maintenance treatment based on clinical condition of patient (eg, number and severity of prior episodes)
Beyond 6 months |
|
|
Term
| What is Interpersonal Therapy? |
|
Definition
Focuses on helping patients understand his/her interpersonal problems
Help patients cope with stressors |
|
|
Term
| What is Cognitive Behavioral Therapy? |
|
Definition
Focuses on changing negative thinking and behavior patterns
Assist patients in abandoning negative or self-deprecating attitudes toward his or her depression |
|
|
Term
| How does guilt affect a depressed patient's relationship with their physician? |
|
Definition
Expectation of being criticized or punished
Try to please physician by underreporting symptoms so as not to appear to be a complainer |
|
|
Term
| How does anger affect a depressed patient's relationship with their physician? |
|
Definition
May feel rejected
May be prone to struggle against perceived mistreatment
May verbalized disappointment at prior clinicians inability to treat symptoms
May elicit helpless feeling in physician |
|
|
Term
| How do feelings of dependency affect a depressed patient's relationship with their physician? |
|
Definition
Hoping for rescue, but believing physician powerless
May elicit “rescue” fantasy in physician |
|
|
Term
| What is the most commonly prescribed psychiatric medication? |
|
Definition
|
|
Term
| What class of antidepressants are the most widely used? |
|
Definition
| Selective Serotonin Reuptake Inhibitors: (SSRI’s) |
|
|
Term
| What are characteristics of SSRI's? |
|
Definition
Little or no effect on norepinephrine or dopamine
Fewer side effects than cyclic antidepressants and MAOI’s
Relative absence of anticholinergic, antihistaminic, anti-alpha1-adrenergic, and cardiotoxic effects
Relative safety in overdose
Less need for titration |
|
|
Term
| What demographic has the highest risk for suicide while taking antidepressants? |
|
Definition
<18yo
Increases again after 65yo |
|
|
Term
| What are the side effects of SSRI's? |
|
Definition
Sexual dysfunction
Decreased appetite/weight loss
Sedation
Headache
Sleep disturbances/vivid dreaming
Hyponatremia (rare)
Decreased blood coagulation |
|
|
Term
| Which SSRI's are least likely to cause sedation? |
|
Definition
|
|
Term
| Which SSRI's are most likely to cause sedation? |
|
Definition
|
|
Term
| What are the symptoms of serotonin syndrome? |
|
Definition
| generalized restlessness, sweating, insomnia, nausea, diarrhea, cramps, delirium |
|
|
Term
| How is serotonin syndrome treated? |
|
Definition
| Remove offending agent, stop or reduce dose of SSRI, give cyproheptadine |
|
|
Term
| Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) may have what additional benefits over SSRI's? |
|
Definition
| May benefit pain syndromes |
|
|
Term
| How do the side effects of SNRI's differ from SSRI's? |
|
Definition
Mostly similar
Constipation, sweating, hypertension and tachycardia more common with SNRI’s |
|
|
Term
| What is Discontinuation Syndrome? |
|
Definition
May occur on dose reduction or discontinuation of SSRI or SNRI; gradual weaning is recommended
Shorter acting agents more vulnerable: paroxetine and venlafaxine |
|
|
Term
| What are the symptoms of discontinuation syndrome? |
|
Definition
Dizziness, shock-like sensations, sweating, nausea, tremor, nightmares
Typically resolve spontaneously in a week
Replacement of short-acting med with longer acting med (fluoxetine) may resolve symptoms |
|
|
Term
| What are the characteristics of Cyclic Antidepressants? |
|
Definition
May be more effective than SSRI’s in most ill (often hospitalized) patients
Block reuptake of serotonin and norepinephrine, as well as alpha-1 adrenergic and muscarinic receptors
Require titration to reach antidepressant dosages
Serum levels may help with achieving therapeutic dose |
|
|
Term
| What are the anticholinergic side effects of cyclic antidepressants? |
|
Definition
Dry mouth
Blurry vision
Constipation
Urinary retention |
|
|
Term
| What are the CNS side effects of cyclic antidepressants? |
|
Definition
Drowsiness
Insomnia and agitation
Disorientation and confusion
Headache
Fine tremor |
|
|
Term
| What are the characteristics of Monoamine Oxidase Inhibitors (MAOI’s)? |
|
Definition
Inhibit monoamine oxidase, an enzyme that metabolizes serotonin, epinephrine, and norepinephrine
Need to eat low tyramine diet or risk a hypertensive crisis |
|
|
Term
| What foods are high in tyramine and discouraged during the use of MAOI's? |
|
Definition
| Aged cheese, dried fish, sauerkraut, sausage, chocolate, avacados |
|
|
Term
| Which antidepressant has the fewest side effects? |
|
Definition
Bupropion
Minimal weight gain, sexual dysfunction
Helpful for smoking cessation |
|
|
Term
| What are the characteristics of Mirtazapine? |
|
Definition
5 HT 2A and 5 HT 2C antagonist, alpha 2 adrenergic antagonist; thus increases serotonin and norepinephrine neurotransmission without inhibiting serontonin or norepinephrine reuptake
Not associated with cardiac side effects and safe in overdose
Tends cause sedation and weight gain |
|
|
Term
| How long must antidepressants be taken to elicit a noticeable affect? |
|
Definition
|
|
Term
| How long should antidepressants be taken to prevent relapse? |
|
Definition
| At least 16-20 weeks following remission |
|
|
Term
| What is Electroconvulsive Therapy? |
|
Definition
Electric current is passed through the scalp and selected parts of the brain to produce a grand mal seizure
Causes multiple effects on the CNS, including neurotransmitter changes, neuroendocrine effects and alterations in intracellular signaling pathways |
|
|
Term
| When is electroconvulsive therapy indicated? |
|
Definition
Medication-refractory depression
Suicidal depression
Depression accompanied by refusal to drink or take fluids
Depression during pregnancy
History of positive response to ECT
Catatonic syndromes
Acute forms of schizophrenia
Mania unresponsive to medication |
|
|
Term
| When is electroconvulsive therapy contraindicated? |
|
Definition
Chronic depression or personality disorders
Benzodiazepines and anticonvulsants must be stopped ahead of time |
|
|
Term
| How often is electroconvulsive therapy successful? |
|
Definition
Tends to work quicker than medication
80% patients report favorable response; 80% say they would have procedure again if needed |
|
|
Term
| How is electroconvulsive therapy dosed? |
|
Definition
| The amount of electricity should be the minimum required to induce a seizure and be therapeutic |
|
|
Term
| What are the adverse effects of electroconvulsive therapy? |
|
Definition
Hypotension or hypertension
Bradyarrhythmias and tachyarrhythmias
Fractures (more common in past)
Prolonged seizures, laryngospasm, prolonged apnea
Postictal confusion
Headache, nausea and muscle pain
Memory impairment: retrograde and anterograde |
|
|
Term
| What is Transcranial Magnetic Stimulation? |
|
Definition
TMS uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field
A noninvasive method to cause depolarization in neurons |
|
|
Term
| What are the indications for Transcranial Magnetic Stimulation? |
|
Definition
| Major Depressive Disorder, Migraines, Parkinson’s disease, dystonia, stroke rehabilitation |
|
|
Term
| How is vagal nerve stimulation used to treat depression? |
|
Definition
| Afferent vagal fibers connect to the nucleus of the solitary tract which in turn projects connections to other locations in the CNS |
|
|
Term
| What are the side effects of vagal nerve stimulation therapy? |
|
Definition
| Voice alteration, cough, dyspnea, sleep apnea, neck pain, dysphagia, laryngismus, paresthesias |
|
|
Term
| What is the purpose of Deep Brain Stimulation? |
|
Definition
Investigational for refractory depression and OCD
Approved for essential tremor, Parkinson’s disease, and dystonia
Also used for chronic pain, Tourette’s |
|
|
Term
| What is deep brain stimulation? |
|
Definition
Impulse generator is implanted near the clavicle
One or two leads are tunneled under the scalp along the skull
An electrode is inserted through a burr hole in the skull over the desired area |
|
|
Term
| What defines a suicide attempt? |
|
Definition
| An intentional action to kill oneself that does not result in death |
|
|
Term
| What defines suicide ideation? |
|
Definition
| Wish to kill oneself without action |
|
|
Term
| What is passive suicide ideation? |
|
Definition
| Suicidal ideation without intent |
|
|
Term
|
Definition
| Intensity of the wish to die |
|
|
Term
| What is deliberate self-harm? |
|
Definition
| Willful infliction of injury without intent to die |
|
|
Term
| How is suicide associated with contact with physicians? |
|
Definition
50% have had contact with physician in past 6 months
Those who commit suicide generally have less contact with the mental health system
Among those discharged from psychiatric hospital, highest rate is in first month |
|
|
Term
| Patients undergoing what type of treatment have a 400x greater risk of suicide? |
|
Definition
|
|
Term
| How is lithium treatment associated with suicide? |
|
Definition
Lithium reduces risk in bipolar 7x
Lithium discontinuation increases risk 13x
Rapid discontinuation doubles risk |
|
|
Term
| What are common risk factors for suicide? |
|
Definition
Severe psychic anxiety
Global insomnia
Alcohol use
Severe anhedonia
Agitation
Hopelessness
Delusions
Quality of plan |
|
|
Term
| What are common postmortem findings in suicide? |
|
Definition
Serotonin deficiency in CSF
Decreased levels of platelet MAO
Abnormal EEG’s
Potential link to Toxoplasma gondii |
|
|
Term
| What are potential protective factors that discourage suicide? |
|
Definition
Children in the home
Sense of responsibility to family
Pregnancy
Life satisfaction
Good support system
Cultural beliefs
Religiosity
Fear of the act
Fear of the unknown |
|
|
Term
| When should a suicide risk assessment be done? |
|
Definition
Initial evaluation
Within two weeks of initiation of anti-depressant
No improvement with treatment
Clinical worsening
Recent discharge from hospital (1st week is greatest risk)
Times of real or anticipated loss
Shame situations |
|
|
Term
| How should questions progress when assessing for suicide? |
|
Definition
How bad do you feel?
Wish you were dead?
Thoughts of suicide?
Plan for suicide?
How close have you come? |
|
|
Term
| What factors should be met before discharging a patient that was previously at high risk for suicide? |
|
Definition
Medically stable
Believable commitment to not killing self
Absence of intoxication, delirium, dementia, psychosis
Firearms secured
Acute precipitants addressed and resolved
Follow-up treatment arranged
Social supports agree with discharge plan |
|
|
Term
| How does age of first exposure to alcohol influence the likelihood of dependence abuse? |
|
Definition
14 or younger, 13.8% classified with dependence or abuse
1.8% if age at first use age 21 or older |
|
|
Term
| What BAL is considered legal intoxication? |
|
Definition
| Greater than 0.08 g/dl (80 mg/dl) in most jurisdictions |
|
|
Term
| What are the general tiers of BAL? |
|
Definition
Initially feel tranquil, sedated BAL 0-100
BAL 100-150 uncoordinated, irritable
BAL 150-250 slurred speech, ataxic
BAL > 250 pass out, unconscious
BAL > 350 comatose, death |
|
|
Term
| What are the CAGE questions? |
|
Definition
felt you should Cut down on your drinking?
felt Annoyed by criticism of your drinking?
felt bad or Guilty about your drinking?
taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
One positive answer = 90% chance of alcohol disorder |
|
|
Term
| Alcohol abuse is defined as a maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as shown by what consequences? |
|
Definition
Failure to fulfill major role obligations at work, school or home
Recurrent use in situations where it is physically hazardous
Recurrent substance-related legal problems
Continued use despite persistent or recurrent social or interpersonal problems |
|
|
Term
| Alcohol dependence is defined as having 3 or more of what characteristics? |
|
Definition
Tolerance which is need for more for desired effect or diminished effect of same amount
Withdrawal which is a characteristic syndrome of symptoms or the same or a closely related substance is taken to avoid/relieve withdrawal symptoms
Taken in larger amounts and longer than intended
Persistent desire or unsuccessful efforts to cut down
Great deal of time obtaining and using or recovering
Important social, occupational or recreational activities given up
Continued use in spite of persistent physical or psychological problem caused or exacerbated by alcohol |
|
|
Term
| How is dopamine associated with substance abuse? |
|
Definition
| Alcohol stimulates the mesolimbic dopamine system as do many of the other drugs of abuse such as cocaine, morphine and nicotine |
|
|
Term
| How does GABA influence withdrawal symptoms of alcohol? |
|
Definition
Chronic use of alcohol may lead to reduced potentiation of GABA-mediated chloride flux through the GABA-a receptor channel complex = tolerance
GABA-mediated neurotransmission is decreased in withdrawal, leading to the hyperactivity symptoms |
|
|
Term
| Which drug class is effective against some withdrawal symptoms? Why? |
|
Definition
Benzodiazepines
Also potentiate GABA |
|
|
Term
| How is glutamate associated with alcohol withdrawal |
|
Definition
Alcohol inhibits glutamate at the N-methyl-D-aspartate (NMDA) receptor
Chronic alcohol use leads to upregulation of the NMDA receptor complex and an increase influx of calcium into neurons
Withdrawal leads to neuronal hyperexcitability and some signs and symptoms of withdrawal, particularly seizures, anxiety and sleep disturbances |
|
|
Term
| What are the symptoms of alcohol withdrawal? |
|
Definition
Autonomic hyperactivity (sweating or HR > 100)
Increased hand tremor
Insomnia
Nausea or vomiting
Transient visual, tactile or auditory hallucinations or illusions
Psychomotor agitation
Anxiety
Grand mal seizures |
|
|
Term
| What are Alcohol Withdrawal Deliriums (DT’s)? |
|
Definition
Disturbance of consciousness with reduced ability to focus, sustain or shift attention
Change in cognition (such as memory deficits, disorientation, or language) or perceptual disturbance
Develops over a short period of time and tends to fluctuate during the course of the day
Symptoms develop during or shortly after a withdrawal syndrome |
|
|
Term
| How long does it take for withdrawal to manifest? |
|
Definition
| Begins within 12 to 18 hours after cessation or significant decrease in use |
|
|
Term
| How long does it take for withdrawal symptoms to subside? |
|
Definition
| Usually accomplished in 5 days |
|
|
Term
| How are withdrawal symptoms treated? |
|
Definition
Benzodiazepines (BZD’s) such as chlordiazepoxide
Replace fluids and give thiamine and folic acid |
|
|
Term
| How do you decide which BZD to give for the treatment of withdrawal? |
|
Definition
Longer acting BZD’s such as chlordiazepoxide or diazepam in those without severe liver disease or brain damage
Shorter acting drugs such as oxazepam or lorazepam with more frequent dosing for those with liver disease or brain damage |
|
|
Term
| What drugs help prevent seizures, preserve cognition and may aid in relapse prevention in withdrawal patients? |
|
Definition
| Anticonvulsants such as valproic acid, carbamazepine or gabapentin |
|
|
Term
| What are the five stages of change? |
|
Definition
Precontemplation = not interested in change
Contemplation = aware of and thinking of change but not yet committed
Preparation = has decided to change
Action = has started modifying behavior
Maintenance = changed behavior and working on preventing relapse |
|
|
Term
| What is Motivational Interviewing? |
|
Definition
Therapist adopts a non-judgmental and supportive stance
Explores ambivalence about changing addictive behaviors
Method avoids confrontational questions
Circumvents defensiveness and creates an open environment
Useful in contemplative stage |
|
|
Term
| How is Disulfiram (Antabuse) used to prevent relapse in alcoholics? |
|
Definition
Alters alcohol’s metabolism, increasing the concentration of acetaldehyde in the body by inhibiting aldehyde dehydrogenase
Produces sensations of feeling hot, facial flushing, pounding headaches, nausea, copious vomiting |
|
|
Term
| How is Naltrexone used to prevent relapse in alcoholics? |
|
Definition
Decreases the pleasurable effects of alcohol
May work best in those whose disease is characterized by craving
Nausea, headache, anxiety or sedation are side effects
Cannot be prescribed in patients with severe liver disease |
|
|
Term
| How are NMDA antagonists such as Acamprosate used to prevent relapse in alcoholics? |
|
Definition
| Reduces the intensity of post-cessation alcohol craving on exposure to high-risk drinking situations |
|
|
Term
| Which opioid receptor is most involved with clinical effects of opioids? |
|
Definition
|
|
Term
| What are potential medical complications of opioid misuse? |
|
Definition
Infections, primarily from injecting
Decreased sperm motility
Menstrual abnormalities and amenorrhea
Constipation
Pseudo-obstruction of the bowel
Respiratory depression
Trauma from accidents, violence, sexual abuse
Depression and suicide |
|
|
Term
| What are the signs and symptoms of opioid withdrawal? |
|
Definition
Severe bone pain, chills, piloerection, sweating, extreme restlessness, nervousness, yawning, rhinorrhea, nausea, vomiting and diarrhea
Most signs and symptoms abate in 48-96 hours but some persist for months |
|
|
Term
| How is opioid withdrawal treated? |
|
Definition
Methadone
Cross tolerant, orally effective, long-acting and cheap
Short-term detox is less than 30 days and long-term detox is not more than 180 days |
|
|
Term
| Methadone should not be used for detox of less addictive drugs such as propoxyphene or pentazocine. What should be used instead? |
|
Definition
|
|
Term
| How is methadone metabolized? |
|
Definition
Primarily in the liver
Increased by those that induce CYP enzymes
Addition of these meds may precipitate withdrawal
Decreased by drugs that inhibit CYP enzymes |
|
|
Term
| What are the adverse affects of chronic methadone use? |
|
Definition
No long term damage to organ systems
Constipation common - treat actively
May cause orgasmic dysfunction in men
Widening of QT Interval (on EKG) reported at high doses |
|
|
Term
|
Definition
A mixed μ receptor agonist / antagonist
Used in sublingual tablet and rapidly dissolving film for detox and maintenance
long-acting and safe |
|
|
Term
| How does pregnancy affect detox treatment? |
|
Definition
Methadone is usually used
Infant will be born physically dependent and may need to be withdrawn with tincture of opium or alternative
No known birth defects associated with methadone exposure |
|
|
Term
| What are the features of Benzodiazepine abuse? |
|
Definition
While relatively safe in overdose alone, can be deadly when combined with other depressant drugs
Heavy use can lead to lethargy, cognitive dysfunction, blackouts, accidents, disinhibition and self-neglect
Highly intoxicated individuals are ataxic, slur speech and are poorly coordinated |
|
|
Term
| What is the mechanism of action of cocaine? |
|
Definition
Increases dopamine in the synapse by blocking reuptake
Leads to a rapid sense of intense pleasure |
|
|
Term
| Heavy users of Methamphetamine often develop what characteristic feature? |
|
Definition
| Suffer from self-neglect and can often develop serious dental problems, “meth-mouth” |
|
|
Term
| What are medical complications of meth addiction? |
|
Definition
Psychotic symptoms
Myocardial infarctions
Strokes
Anoxic brain damage from seizures
Infections such as HIV and Hepatitis B & C from injecting |
|
|
Term
| What are the effects of hallucinogens? |
|
Definition
Bad “trips” can lead to severe anxiety and paranoia
Flashbacks or re-experiencing of the drug’s effects
Some have developed a chronic psychosis
Designer drugs such as Ecstasy can cause intense feelings of attachment and energy during high but cognitive and memory deficits in chronic use |
|
|
Term
| What can be used to calm patients suffering from a hallucinogen overdose? |
|
Definition
Benzodiazepine
Can be a medical emergency |
|
|
Term
|
Definition
PCP
Affects several neurotransmitters but known antagonist of NMDA receptors and activates dopamine neurons
Induces euphoria, derealization, tingling, warmth |
|
|
Term
| What are the effects of phencyclidine? |
|
Definition
Moderate doses may cause bizarre behavior, myoclonic jerks, confusion
Can produce delirium, psychosis, mood disorders, flashbacks, agitation and violence
Higher doses can lead to coma, seizures and death from respiratory depression |
|
|
Term
| What are the effects of abusing inhalants? |
|
Definition
Induce feelings of excitation, disinhibition and euphoria
Adverse effects such as dizziness, slurred speech, ataxia
Hallucinations and delusions reported
Can cause permanent brain damage, presumably due to presence of heavy metals and the hydrocarbons
Can also be toxic to liver and kidneys |
|
|
Term
| How quickly does nicotine withdrawal present? |
|
Definition
| Withdrawal begins in an hour, peaks at 24 hours and lasts for months in some |
|
|
Term
| How is nicotine withdrawal treated? |
|
Definition
Treatments mostly nicotine replacement:
Transdermal patches
Gum, lozenges and inhalers
Bupropion (Zyban, Welbutrin) an antidepressant
Varenicline (Chantix) a nicotine partial agonist |
|
|
Term
| How do you treat Co-Occurring Psychiatric Disorders alongside alcohol abuse? |
|
Definition
Cognitive Behavioral Therapies most useful for anxiety disorders and substance abuse
SRI’s very helpful in depression and may require higher doses as alcohol may have induced hepatic microsomal activity |
|
|
Term
| What is intermittent explosive disorder? |
|
Definition
Person has several discrete episodes of losing control over his or her aggressive impulses that are out of proportion to any stressor
Loss of control is out of character and not simple overreacting |
|
|
Term
| What demographics are more likely to suffer from intermittent explosive disorder? |
|
Definition
More common among young men with low frustration tolerance
Comorbid mood and anxiety disorders are common |
|
|
Term
| How is cognitive behavior therapy used to treat intermittent explosive disorder? |
|
Definition
| Patients learn to recognize signs they are angry and to identify and diffuse triggers |
|
|
Term
|
Definition
Resistant failure to resist impulses to steal objects not for personal use or monetary value
Increased sense of tension immediately before committing theft followed by pleasure/relief
Most shoplifters do not have kleptomania |
|
|
Term
| When does Kleptomania usually present? |
|
Definition
| In early adulthood, tends to be chronic and comorbid with mood and anxiety disorders, substance abuse, and eating disorders |
|
|
Term
| How is Kleptomania managed? |
|
Definition
| Aversive therapy, covert sensitization, self-imposed ban on shopping, psychodynamic therapy, Naltrexone to reduce stealing urges and antidepressants/mood stabilizers |
|
|
Term
|
Definition
Deliberate and purposeful fire setting on more than one occasion, tension or affective arousal before the act, fascination, curiosity, and attraction to fire
Pleasure/relief when setting fires or witnessing aftermath
Arsonists who set fire for gain do not have pyromania |
|
|
Term
| Pyromania is more common among what demographic? |
|
Definition
Likely equal distribution, onset in late teens or early twenties, mood and substance abuse is commonly comorbid
Poor prognostic sign in children with conduct disorders, correlates with aggression in adults |
|
|
Term
| How is pyromania managed? |
|
Definition
Treat comorbid conditions, medications have no role for core symptoms
Education, family therapy, psychotherapy, etc. |
|
|
Term
| What is Trichotillomania? |
|
Definition
Recurrent pulling out of one's hair that results in noticeable hair loss
Increased tension before pulling hair followed by pleasure/relief |
|
|
Term
| How does Trichotillomania progress? |
|
Definition
Generally chronic, begins in childhood and can affect any area where hair grows
Predominantly females |
|
|
Term
| How is Trichotillomania treated? |
|
Definition
Behavior therapy
Medication has mixed results, Clomipramine is most promising
Cognitive therapy to correct faulty beliefs about self
Hypnosis |
|
|
Term
|
Definition
Perceptions experienced without an external stimulus to the sense organs and have a quality similar to a true perception
Auditory is most common, may be visual, etc.
Formication: sensation that insects are crawling under the skin |
|
|
Term
|
Definition
Disturbance in thought rather than perception
Firmly held beliefs that are untrue and contrary to background
May be somatic, grandiose, religious, etc.
Persecutory is most common |
|
|
Term
| What is disorganization of language and communication (a possible dimension of psychosis)? |
|
Definition
Derailment, poverty of speech and content, perseveration
Clanging: conceptual connections between words and thoughts replaced by sound associations
Neoligisms: made up words with meaning known only to a patient
Echolalia and thought blocking |
|
|
Term
| What is catatonic stupor (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Immobile, mute, and unresponsive yet fully conscious |
|
|
Term
| What is catatonic excitement (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Uncontrolled and aimless motor activity, sometimes bizarre and uncomfortable posture maintained for long periods |
|
|
Term
| What is stereotypy (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Repeated but non-goal directed movement such as rocking |
|
|
Term
| What is a mannerism (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Goal-directed activites that are either odd in appearance or out of context such as grimacing |
|
|
Term
| What is echopraxia (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Imitates movements or gestures of another person |
|
|
Term
| What is automatic obedience (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Carries out simple commands in robot-like fashion |
|
|
Term
| What is negativism (a possible abnormal motor behavior in psychosis)? |
|
Definition
| Refuses to cooperate with simple requests for no apparent reason |
|
|
Term
| What medical conditions are associated with psychosis? |
|
Definition
Temporal Lobe Epilepsy
Tumor, CVA, Brain Trauma
Endocrine/Metabolic Disorders
Vitamin Deficiencies (B12, thiamine, niacin)
Infectious Disease
Autoimmune Disorder
Toxic Illness (heavy metal poisoning) |
|
|
Term
| What kind of drugs are associated with psychosis? |
|
Definition
Stimulants
Hallucinogens
Anticholinergics
L-dopa and dopamine agonists
Isoniazid
Digitalis toxicity
Alcohol withdrawal
Barbituate withdrawal |
|
|
Term
| What demographics are affected by schizophrenia? |
|
Definition
Early 20s in men, slightly later in women
High risk for suicide
Accounts for 1.5-3% health care costs |
|
|
Term
| What kind of genetics associations are there with schizophrenia? |
|
Definition
| Higher concordance with twins, some genetic link exists and multiple genes are implicated for vulnerability |
|
|
Term
| How does schizophrenia progress? |
|
Definition
After first psychotic break there is a course of accruing morbidity during the first 10 yrs
With each additional break, patients fail to return to previous level of functioning
Cortical grey matter loss and enlargement of 3rd and lateral ventricles
Very high incidence of noncompliance with treatment |
|
|
Term
| How often do schizophrenia patients relapse? |
|
Definition
| Monthly relapse 3.5% per month when on maintenance medication, 4x higher if not |
|
|
Term
| What are risk factors for schizophrenia? |
|
Definition
Smoking is greatest risk factor
Obesity, hypertension, elevated cholesterol, sedentary lifestyle |
|
|
Term
| What are the diagnostic criteria for schizophrenia? |
|
Definition
At least 2 of the following for at least a month:
Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (flattening, alogia, avolition) |
|
|
Term
| What kind of social/occupational dysfunction are seen in schizophrenia? |
|
Definition
Since the onset of the disturbance, one or more ares of functioning are disturbed:
Occupational functioning, interpsonal skills, self-care, academic achievement |
|
|
Term
| What is characteristic of the paranoid type of schizophrenia? |
|
Definition
Preoccupation with one or more delusions or frequent hallucinations
However, no disorganized speech, catatonic behavior, or flattening |
|
|
Term
| What characterizes the disorganized type of schizophrenia? |
|
Definition
All of the following:
Disorganized speech, disorganized behavior, flattening |
|
|
Term
| What characterizes the catatonic type of schizophrenia? |
|
Definition
At least 2 of the following:
Motor immobility (catalepsy or stupor)
Excessive motor activity
Extreme negativism/mutism
Posturing, stereotyped movements, mannerisms or grimacing
Echolalia or echopraxia |
|
|
Term
| What characterizes the undifferentiated type of schizophrenia? |
|
Definition
| Core symptoms present, does not meet criteria for paranoid, disorganized, or catatonic types |
|
|
Term
| What characterizes the residual type of schizophrenia? |
|
Definition
Absence of prominent hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior
However, there is continuing evidence of the disturbance such as negative symptoms and attenuated core symptoms (odd beliefs) |
|
|
Term
| What is included in the positive PANSS scale for schizophrenia? |
|
Definition
| Delusions, conceptual disorganization, hallucinations, hyperactivity, grandiosity, suspiciousness/persecution, hostility |
|
|
Term
| What is included in the negative PANSS scale for schizophrenia? |
|
Definition
| Blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotyped thinking |
|
|
Term
| What is included in the general psychopathology scale for schizophrenia? |
|
Definition
| Somatic concern, anxiety, guilty feelings, tension, mannerisms and posturing, depression, motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, poor impulse control, preoccupation, active social avoidance |
|
|
Term
| What are some examples of positive symptoms for schizophrenia? |
|
Definition
Delusions
Hallucinations
Disorganized speech
Catatonia |
|
|
Term
|
Definition
Negative symptom of schizophrenia
A reduction in the amount of spontaneous speech or a lack of speech altogether |
|
|
Term
| What is affective flattening/blunting? |
|
Definition
Reduced intensity of emotional expression and response
Unchanging facial expression, decreased spontaneous movements, lack of expressive gestures, poor eye contact, slow speech, etc. |
|
|
Term
|
Definition
A negative symptom of schizophrenia
Loss of the ability to initiate goal-directed behavior
Inability to carry goals through to completion |
|
|
Term
|
Definition
A negative symptom of schizophrenia
Inability to experience pleasure |
|
|
Term
| What neurologic pathway most likely explains negative symptoms in schizophrenia? |
|
Definition
| Decreased stimulation in the mesocortical dopamine tract in the brain |
|
|
Term
| What is the progression of stages in schizophrenia? |
|
Definition
Prodromal phase
Active phase
Residual phase |
|
|
Term
| What characterizes the prodromal phase of schizophrenia? |
|
Definition
Onset is from months to years
Subtle behavioral changes: social withdrawal, work impairment, blunting emotions, avolition, odd ideas/behavior |
|
|
Term
| What characterizes the active phase of schizophrenia? |
|
Definition
| Actual development of psychotic symptoms |
|
|
Term
| What characterizes the residual phase of schizophrenia? |
|
Definition
Active symptoms are absent or no longer prominent
Role impairment, negative symptoms, attenuated positive symptoms |
|
|
Term
| What are some factors that predict a better long term outcome in schizophrenia? |
|
Definition
Acute or late onset
Female gender, married, good premorbid functioning
Good psychosexual functioning and high intelligence
Normal neurological function, no structural brain abnormalities, no family history |
|
|
Term
| What are the interview guidelines when managing schizophrenia? |
|
Definition
Listen attentively and respectfully
Provide structure to conversation
Keep interactions brief if severely delusional
Avoid arguing about delusionas (but don't condone them)
Help contextalize the delusions as a reaction to stress
Do not remain in a situation that feels dangerous |
|
|
Term
| What is first line in the treatment of acute psychosis? |
|
Definition
| Antipsychotic medication (1st or 2nd gen) |
|
|
Term
| What are secondary options in the treatment of psychosis? |
|
Definition
Clozapine if you want to avoid agranulocytosis
Benzodiazepines for anxiety or to prevent EPS |
|
|
Term
| The effectiveness of anti-psychotics are improved in the treatment of schizophrenia under what conditions? |
|
Definition
Treatment of acute episodes is initiated rapidly
Treating after 1st episode may be more responsive and require lower doses than patients with multiple episodes
Antipsychotic is determined by efficacy, safety, and tolerability |
|
|
Term
| How long should a patient continue to undergo treatment for schizophrenia following successful treatment of their first psychotic episode? |
|
Definition
| At least a year after full remission of symptoms |
|
|
Term
| When should patients begin maintenance management for schizophrenia? |
|
Definition
| If they have had two psychotic episodes in 5 years or multiple episodes |
|
|
Term
| What is prescribed if schizophrenia patients are noncompliant with oral medication? |
|
Definition
| A long acting depot medication may be indicated |
|
|
Term
| What do you monitor when a patient is on antipsychotics? |
|
Definition
| Glucose, lipids, BMI, weight, abnormal movements |
|
|
Term
| What should the patient and family be educated about concerning complications and side effects of antipsychotic use? |
|
Definition
| Metabolic syndrome, diabetes, weight gain and obesity, dyslipidemia, extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome |
|
|
Term
| What acute extra-pyramidal symptoms (EPS) are common with antipsychotic use |
|
Definition
Dystonia: can occur within the first hours of treatment, most commonly within 3 days
Akathisia: usually about 5 days for onset |
|
|
Term
| What are the long term extra-pyramidal symptoms (EPS) associated with antipsychotic use? |
|
Definition
Tardive dyskinesia
Takes months-years |
|
|
Term
| What are other side effects of antipsychotics other than EPS? |
|
Definition
Neuroleptic malignant syndrome
QTc prolongation
Hyperprolactinemia
Postural hypotension
Sedation
Hyperglycemia/diabetes
Dyslipidemia
Neutropenia |
|
|
Term
| When should you hospitalize a schizophrenic patient? |
|
Definition
Following new onset to clarify diagnosis/stabilize meds
Special procedures
Aggressive/assaultive behavior
If patient is unable to care for self
If meds become disabling or life threatening
If patient is suicidal |
|
|
Term
| What is schizophreniform disorder? |
|
Definition
| Same diagnostic criteria as schizophrenia but an episode lasts at least one month but less than six |
|
|
Term
| What are good prognostic factors for schizophreniform disorder? |
|
Definition
Onset of psychotic symptoms within 4wks of noticeable change in behavior
Confusion or perplexity at the height of the episode
Good premorbid social and occupational functioning
Absence of blunted or flat affect |
|
|
Term
| What is schizoaffective disorder? |
|
Definition
During period with core symptoms of schizophrenia, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode
2wks without prominent mood symptoms during illness course
Mood episode symptoms are present for a substantial portion of the total duration of the active and residual periods of the illness
Not due to a medical problem or effects of substances |
|
|
Term
| What characterizes the bipolar type of schizoaffective disorder? |
|
Definition
| The additional disturbance alongside the core symptoms is a manic or mixed episode |
|
|
Term
| What characterizes the depressive type of schizoaffective disorder? |
|
Definition
| The additional disturbance alongside the core symptoms is a major depressive episode |
|
|
Term
| What are the different possible disease states of delusional disorder? |
|
Definition
| Course can be remission without relapse, remission alternating with relapse, or chronic waxing and waning |
|
|
Term
| What are the characteristics of delusional disorder? |
|
Definition
Nonbizarre delusions (situations that occur in real life) of at least one month’s duration
Lacks at least 2 of the core schizophrenia symptoms
Functioning and behavior are not markedly impaired
Mood episodes are absent or brief
Not caused by a medical condition or substance |
|
|
Term
| What are the characteristics of the persecutory type of delusional disorder? |
|
Definition
| Delusions that the person (or someone to whom the person is close) is being malevolently treated in some way |
|
|
Term
| What characterizes the somatic type of delusional disorder? |
|
Definition
| Delusions that the person has some physical defect or general medical condition |
|
|
Term
| What characterizes the mixed type of delusional disorder? |
|
Definition
| Delusions characteristic of both persecutory and delusional types but without one theme predominating |
|
|
Term
| What characterizes the erotomanic type of delusional disorder? |
|
Definition
| Delusions that another person, usually of higher status, is in love with the individual |
|
|
Term
| What characterizes the grandiose type of delusional disorder? |
|
Definition
| Delusions of inflated, worth, power, knowledge, identity, or special relationship to a deity or famous person |
|
|
Term
| What characterizes the jealous type of delusional disorder? |
|
Definition
| Delusions that the individual’s sexual partner is unfaithful |
|
|
Term
| How is delusional disorder managed? |
|
Definition
Attempt to build a trusting relationship with the patient
Help patient understand how symptoms interfere with functioning
Antipsychotics should be tried but are often ineffective, SSRI's occasionally help, Pimozide works for somatic delusions |
|
|
Term
| When do brief psychotic disorders usually arise? What is unique about them? |
|
Definition
Typically late 20s, early 30s
Can resolve within days |
|
|
Term
| What characterizes brief psychotic disorder? |
|
Definition
Presence of one (or more) of the following symptoms:
Episode duration is at least 1 day but less than a month
Eventually returns to premorbid levels of functioning
Disturbance isn't caused by a condition or substance |
|
|
Term
| What are the different subtypes of brief psychotic disorders? |
|
Definition
With or without marked stressors
Postpartum onset |
|
|
Term
| How are brief psychotic disorders managed? |
|
Definition
Supportive therapy in hospital milieu
Antipsychotic if very agitated or in emotional distress |
|
|
Term
| What characterizes a shared psychotic disorder? |
|
Definition
| Delusion develops in the context of a close relationship with another person(s) who has an already established delusion. The delusions are similar in content |
|
|
Term
| What is Charles Bonnet Syndrome? |
|
Definition
Occurs in patients with visual impairment
Complex recurrent visual hallucinations, most commonly faces
Patients know they are not real |
|
|
Term
| What is Caprgras Syndrome? |
|
Definition
Occurs in patients with schizophrenia, brain injury and dementia
Delusion that friend, spouse, parent or close family member has been replaced by an imposter |
|
|
Term
| Potency of an antipsychotic is dependent on what? |
|
Definition
Its relative affinity for blocking the dopamine 2 receptor
Some drugs may bind to the D2 receptor with similar affinities but dissociate at different rates
The more "loosely" the drug binds, the lower likelihood of EPS symptoms than those that bind tightly
D2 occupancy of 65 – 70% correlates with maximal antipsychotic efficacy |
|
|
Term
| Atypical antipsychotics have weaker affinity for the D2 receptor but instead have significant affinity for what? |
|
Definition
Anticholinergic and antihistamine receptors
5-HT 2A antagonism broadens therapeutic effects and reduces EPS |
|
|
Term
| What is the function of 5HT2 receptors in relation to dopamine? |
|
Definition
Activation inhibits release of dopamine
Blockade enhances the release of dopamine |
|
|
Term
| Where does the mesolimbic pathway project? |
|
Definition
| Midbrain tegmentum to the nucleus accumbens |
|
|
Term
| Where does the mesocortical pathway project? |
|
Definition
| Originates in the tegmentum and projects to the limbic cortex |
|
|
Term
| How is the mesocortical pathway associated with schizophrenia? |
|
Definition
| It may have a role in mediating positive and negative symptoms of schizophrenia as well as cognitive side effects of antipsychotics |
|
|
Term
| How is the nigrostriatal pathway associated with schizophrenia? |
|
Definition
| Involved in the control of movements. Blockade of D2-dopaminergic receptors associated with this pathway has been implicated in the induction of EPS |
|
|
Term
| Where does the nigrostriatal pathway project? |
|
Definition
| From the substantia nigra to the basal ganglia |
|
|
Term
| How is the tuberoinfundibular projection associated with schizophrenia? |
|
Definition
| Projects from the hypothalamus to the anterior pituitary where dopamine exerts tonic inhibition of prolactin release. The dopamine-blocking actions of antipsychotics block tonic inhibition of prolactin, resulting in hyperprolactinemia |
|
|
Term
| What drug has the greatest efficacy in treating positive symptoms of schizophrenia? |
|
Definition
|
|
Term
| Why might the 5HT antagonism of atypical antipsychotics be more profound than the D2 receptor blocking activity? |
|
Definition
There may be more 5HT2A receptors than D2 receptors in the mesocortical tract
This may help with negative symptoms |
|
|
Term
| What is a side effect of blockade of the D2 receptors in the nigrostriatal tract by antipsychotics? |
|
Definition
| Hyperkinetic movement such as tardive dyskinesia |
|
|
Term
| Why do atypical antipsychotics have a lesser propensity for extrapyramidal symptoms? |
|
Definition
| Additional blockade of the 5HT2A receptors in the nigrostriatal tract increases dopamine, mediating EPS |
|
|
Term
| What are the characteristics of acute dystonia (an acute EPS induced by antipsychotics) |
|
Definition
More common >40yo, in men, and with first gen antipsychotics
Muscular rigidity and cramping, usually in the musculature of the neck, tongue, face and back
May have tongue thickness and problems swallowing
Oculogyric crisis is possible |
|
|
Term
| How is acute dystonia treated? |
|
Definition
| Anticholinergics such as benztropine or diphenhydramine |
|
|
Term
| What are the symptoms of parkinsonism? What demographic is more at risk when taking antipsychotics? |
|
Definition
Bradykinesia, rigidity, cogwheeling, tremor, masked facies, stooped posture, festinating gait, and drooling
More common in elderly and if on a high dose |
|
|
Term
| How is Parkinsonism reduced in patients taking antipsychotics? |
|
Definition
Can switch to a 2nd gen or lower dose
Benztropine |
|
|
Term
|
Definition
An intensely unpleasant sensation of restlessness and the need to move, especially the legs caused by antipsychotic use
Can cause anxiety or agitation and may lead to noncompliance
May increase risk of suicide |
|
|
Term
| How is akathisia reduced in patients taking antipsychotics? |
|
Definition
| Beta blockers, anticholinergics such as benztropine, or benzodiazepine |
|
|
Term
| What is the relationship between dopamine and acetylcholine? |
|
Definition
Reciprocal relationship in the striatum
Dopamine inhibits the release of ACh
Blockade of DA receptor increases release of Ach which causes EPS
Blockade of ACh receptors can reduce EPS |
|
|
Term
| How is Amantadine used to treat EPS? |
|
Definition
Increases CNS concentrations of dopamine by blocking its reuptake and increasing its release from presynaptic neurons
Thought to restore dopamine/acetylcholine balance in the striatum |
|
|
Term
| What is the primary use for Amantadine? |
|
Definition
| Treating the symptoms of pseudoparkinsonism |
|
|
Term
| What are the side effects of Amantadine? |
|
Definition
| Orthostatic hypotension, ankle edema, GI upset |
|
|
Term
| Other than anticholinergics and amantadine, what else can be used to treat EPS? |
|
Definition
Beta-blockers and alpha-agonists particularly for akathisia
May cause orthostatic hypotension or sedation |
|
|
Term
| What is Tardive dyskinesia? |
|
Definition
A syndrome of long-standing or permanent abnormal involuntary movements most commonly caused by long-term use of typical antipsychotics
Presents as involuntary movements of the tongue, facial and neck muscles, upper/lower extremities, and occasionally muscles involved in breathing and swallowing
20% of patients taking first-generation antipsychotics develop TD |
|
|
Term
| What increases the risk of Tardive dyskinesia? |
|
Definition
Age over 50yo
Rarely develops in patients with less than 3 to 6 months of antipsychotic exposure |
|
|
Term
| What are potential consequences of prolactin elevation due to induced prolactin release in the tuberoinfundibular tract by antipsychotics? |
|
Definition
| Sexual dysfunction, amenorrhea, osteopenia, galactorrhea, impotence, gynecomastia |
|
|
Term
| What is the black box warning associated with antipsychotics? |
|
Definition
Mortality in dementia
Suicide risk |
|
|
Term
| What are other potential side effects of antipsychotics other than EPS and hyperprolactinemia? |
|
Definition
Neuroleptic malignant syndrome
Cardiac toxicity (QTc prolongation)
Sedation
Postural hypotension
Weight gain
Hyperglycemia/diabetes/hyperlipidemia
Hematologic effects |
|
|
Term
| What is Neuroleptic malignant syndrome? |
|
Definition
Muscle rigidity (appears first), fever, autonomic instability, and delirium
Occurs over hours to days following antipsychotic use
Risk of seizure or coma |
|
|
Term
| How is Neuroleptic Malignant Syndrome managed? |
|
Definition
Less common with 2nd gen antipsychotics
Not much else you can do aside from stopping the treatment and giving supportive care |
|
|
Term
| What antipsychotics have the greatest risk for causing QTc prolongation? |
|
Definition
Pimozide and thioridazine
Ziprasidone is cautioned |
|
|
Term
| Sedation occurs with all antipsychotics but to varying degrees. Which are the worst and which are the lease? |
|
Definition
Typicals: Chlorpromazine and thioridazine > haloperidol and fluphenazine
Atypicals: Clozapine > quetiapine > olanzapine > risperidone > ziprasidone and aripiprazole |
|
|
Term
| How do antipsychotics cause postural hypotension? Which ones are the most significant causes of postural hypotension? |
|
Definition
Related to alpha-adrenergic receptor blockade
Most common with chlorpromazine, thioridazine, and clozapine but can occur with others |
|
|
Term
| How is postural hypotension managed in patients taking antipsychotics? |
|
Definition
Hypotension improves when patient supine
Teach patient to get up from recumbency slowly
Consider switching agents to higher potency med |
|
|
Term
| Which antipsychotic causes the most weight gain? Which causes the least? |
|
Definition
Clozapine and Olanzapine have the most
Ziprasidone has the least |
|
|
Term
| Which antipsychotic has the greatest risk of causing diabetes/hyperglycemia/hyperlipidemia? Which has the least risk? |
|
Definition
Olanzapine may have the most
Ziprasidone may have the least |
|
|
Term
| Weekly monitoring of CBCs for agranulocytosis is required for what antipsychotic treatment? |
|
Definition
|
|
Term
| How often do patients discontinue their first line atypical antipsychotic? |
|
Definition
1/3 to ¾ of all patients
94 % of all antipsychotic prescriptions written for atypicals |
|
|
Term
| What is the function of maintenance treatment in schizophrenic patients? |
|
Definition
Prevents relapse
More important than risk of reversible side effects
At least 1-2 years of treatment are recommended following the initial episode because of the high risk of relapse and the possibility of social deterioration from further relapses
Addition of second generation antipsychotic to lithium or valproate reduces risk of relapse |
|
|
Term
| How many years of treatment are indicated for multi-episode schizophrenic patients? |
|
Definition
|
|
Term
| Antipsychotics can be used to treat which bipolar disorders? |
|
Definition
Bipolar mania and mixed episodes
Bipolar depression
Maintenance treatment |
|
|
Term
| True or false, mentally ill persons are more often the victims of violence than the perpetrators |
|
Definition
|
|
Term
| Describe the kind of violence commonly perpetrated against the mentally ill |
|
Definition
More than 25% have been victims of violent crime
20% of personal theft
28% of property crime
etc. |
|
|
Term
| True or false, most mentally ill persons have an increased tendency to commit acts of violence |
|
Definition
| False, most are law abiding and non-violent |
|
|
Term
| What psychiatric conditions have an increased tendency to commit violence? |
|
Definition
Schizophrenia
Mania
Drug or alcohol intoxication or withdrawal
Dementia
Delirium
Brain Injury
Mentally retarded
Intermittent explosive disorder |
|
|
Term
| How does substance abuse, particularly alcohol, increase the risk of violence? |
|
Definition
Causes disinhibition, impaired judgement, decreased cognitive and perceptual alertness
Violence may be involved in activities related to obtaining substances |
|
|
Term
| What is the single best predictor of future dangerousness and violence? |
|
Definition
| A patient's history of violence |
|
|
Term
| What is the mental disorder most frequently associated with violence? |
|
Definition
|
|
Term
| What characteristics of mania can precipitate violence? |
|
Definition
Agitation, impulsivity, and delusional ideation
Can have sudden onset because of lack of inhibitions |
|
|
Term
| Which is a very good predictor of violence as an adult? |
|
Definition
| Childhood aggression seen with a past diagnosis of conduct disorder, delinquent behavior, fire setting, animal cruelty, victim of child abuse, potential biological predisposition |
|
|
Term
| Which personality disorders have a high prevalence among incarcerated persons and a greater probability of committing violent acts? |
|
Definition
Borderline personality disorder
Antisocial personality disorder |
|
|
Term
| What is intermittent explosive disorder? |
|
Definition
A disturbance of impulse in which the acts of aggression are out of proportion to the stimulus, not associated with impulsivity
Possibly related to seizure disorders |
|
|
Term
| Why do the mentally retarded have a lower threshold of aggression and are more prone to be violent? |
|
Definition
Tendency toward impulsivity
Difficulty in communicating needs effectively
Poorly developed coping strategies |
|
|
Term
| What neurophysiological factors increase a person's tendency to be violent? |
|
Definition
Low CSF levels of 5-hydroxyindoleacetic acid (5-HIAA)
Serotonin is hypothesized to keep impulsive behaviors and violence in check
Brain injury |
|
|
Term
| What neurochemical changes are associated with violence |
|
Definition
Serotonin, GABA, and cholesterol are decreased
ACh, Norepi, Dopamine, and Testosterone are increased |
|
|
Term
| What are some strategies when trying to assess a patient's risk of violence? |
|
Definition
Remain calm and speak softly
Avoid towering over patient – try to be seated
May need to avoid direct eye contact
Project a sense of empathy and concern |
|
|
Term
| What kind of subtle clues in patients are associated with violent behavior? |
|
Definition
In ER, staff refusal of meds or services sought by patient
Sudden change in behavior
Use of sunglasses indoors
Agitation, pacing, loud or pressured speech
First days in a hospital |
|
|
Term
| What are the steps in managing violent patients? |
|
Definition
Establishing and maintaining safety
Screening, examination, and diagnosis (look for head trauma)
Management with verbal de-escelation, medication (antipsychotic with benzodiazepine) |
|
|
Term
| What should you do if threatened by a patient? |
|
Definition
Maintain submissive role
Admit feeling frightened
Identify patient’s emotion (“you seem upset”)
Encourage patient to talk
If threats don’t dissipate, leave the situation
Consider telling patient you are going to call for help and do so immediately |
|
|
Term
| How do you manage potentially violent outpatients? |
|
Definition
Monitor risk of violence at every appointment
Remove all firearms from the home
Make sure patients are aware of access to 911
Duty to warn in the case of foreseeable violence, foreseeable victim, identifiable victim, and specific time frame |
|
|
Term
| What are the characteristics of somatoform disorders? How do you differentiate it from malingering? |
|
Definition
Patient reports false symptoms but unlike malingering and factitious disorders, they are not intentionally produced or for personal gain
Physical symptoms are genuine and impairing
Can account for 10-15% of primary care visits |
|
|
Term
| What is the primary gain of somatoform and factitious disorders? |
|
Definition
| Unconscious expression of unacceptable feelings as physical symptoms to avoid facing them |
|
|
Term
| What is the secondary gain of somatoform and factitious disorders? |
|
Definition
| Use of symptoms to benefit the individual (attention, avoid or reduce responsibility, financial reward, avoid legal responsibility) |
|
|
Term
| What must be present in a patient's history in order to make a diagonsis of somatization disorder? |
|
Definition
History of many physical complaints beginning before age 30 that occur over several years and result in treatment being sought or significant impairment
Must have all of the following:
4 pain symptoms
2 GI symptoms (other than pain)
1 sexual symptom (other than pain)
1 pseudoneurological symptom (suggested neurological condition, not limited to pain) |
|
|
Term
| Other than a specific history of symptoms, what else must be present in order to make a diagnosis of somatization disorder? |
|
Definition
After appropriate investigation, each of the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance
OR
When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected |
|
|
Term
| What are common personality characteristics of a patient who has somatization disorder? |
|
Definition
May be inconsistent historians
Anxiety and depression common
May be impulsove, have antisocial behavior
Potential history of suicide and marital discord
May be seeing multiple providers |
|
|
Term
| Somatization disorder is most common among what demographics? |
|
Definition
Rare in men, primarily in women
More common in Greek and puerto Rican men
Usually begins before age 25, chronic but fluctuating |
|
|
Term
| What is unique about how a patient with somatization disorder approaches their ailments? |
|
Definition
Often not overly concerned about any specific diagnosis
Symptoms and treatments become central in patients’ lives |
|
|
Term
| How is somatization disorder managed? |
|
Definition
Antidepressants
Avoid narcotics
Cognitive behavioral therapy
Relaxation techniques
May require frequent appointments/reassurance |
|
|
Term
| What are the characteristics of undifferentiated somatoform disorder? |
|
Definition
One or more physical complaints that, like somatoform disorder, cannot be fully explained by general medicine or substances or are in excess to what would be expected for a related general medical condition
Symptoms not intentionally produced or feigned
Lasts at least 6mo, causes significant distress |
|
|
Term
| What is conversion disorder? |
|
Definition
One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition that is not actually present
Initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors
Not fully explained by general medicine
Not limited to pain or sexual dysfunction
Does not occur exclusively during the course of somatization disorder |
|
|
Term
| How common are conversion disorders? |
|
Definition
20-25% of patients admitted to neurology wards
More frequent in women and lower socioeconomic classes
Usually begins late childhood or early adhulthood |
|
|
Term
| What are the typical symptoms of conversion disorders? |
|
Definition
Paralysis, abnormal movements, inability to speak, blindness, and deafness
Pseudoseizures common, and may occur in patients with genuine epileptic seizures |
|
|
Term
| What is unique about how a patient with conversion disorder approaches their symptoms? |
|
Definition
Conforms to patient’s understanding of disease rather than to physiological patterns
Often display indifference to symptoms |
|
|
Term
| How is conversion disorder diagnosed? |
|
Definition
| By ruling out other medical or neurological illness and by identifying psychological factors involved in the initiation of symptoms |
|
|
Term
| What causes conversion disorder? |
|
Definition
Not well understood
Thought that stress awakens unconscious conflicts, usually involving sexuality, aggression or dependency
High incidence in brain injury patients
More likely in some ethic and social groups |
|
|
Term
| What factors predict a positive outcome for conversion disorder? |
|
Definition
Acute onset
Precipitating stressful event
Good premorbid adjustment
Absence of medical or neurological comorbidity |
|
|
Term
| How likely is it that a patient treated with conversion disorder will experience recurrence of symptoms? |
|
Definition
| Recurrence is approximately 20% each year |
|
|
Term
| How is conversion disorder managed? |
|
Definition
Reassurance
Psychotherapy (stress management)
Hypnosis
Relaxation techniques
Physical therapy to improve physical symptoms
Pharmacotherapy to help depression and anxiety |
|
|
Term
| What are the diagnostic criteria for somatoform pain disorder? |
|
Definition
Pain symptom is predominant focus, severe enough to warrant clinical attention
Psychological factors play important role in the pain symptom
Not intentionally produced or feigned |
|
|
Term
| A somatoform pain disorder patient is more likely to be seen by what kind of physician? |
|
Definition
| Internists and general practitioners rather than psychiatrists due to symptoms of depression or anxiety being minimized or denied |
|
|
Term
| What are the diagnostic criteria for hypochondriasis? |
|
Definition
Preoccupation with fears or idea of having a serious disease based on a misinterpretation of bodily symptoms
persists despite appropriate medical evaluation and reassurance
Belief that they are not suffering from a delusion
Duration of the disturbance is at least 6 months |
|
|
Term
| Hypochondriasis is more common in what demographic? |
|
Definition
Equal in men and women (unlike most other somatoform disorders which are more common in women)
Tendency to “doctor shop”
Can occur at any age
Course chronic with waxing and waning
May be precipitated by sickness in a relative or loved one |
|
|
Term
| What causes impairment in hypochondriasis? |
|
Definition
|
|
Term
| How is hypochondriasis managed? |
|
Definition
Frequent check-ups until condition improves
Have patient make list of concerns between appointments and address all the items on the list
Discuss how everyone has bodily sensations, but most can tune them out
Be empathetic regarding fears
Maintain role of coach
Relaxation, psychoeducation, CBT, SSRI's |
|
|
Term
| What is Body Dysmorphic Disorder? |
|
Definition
| Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive |
|
|
Term
| Body dysmorphic disorder is more common in what demographics? |
|
Definition
Equal in men and women (unlike most other somatoform disorders which are more common in women)
Possible genetic predisposition to obsessional thinking
Onset is in adolescence to early adulthood |
|
|
Term
| How is Body Dysmorphic Disorder managed? |
|
Definition
Education about the condition, CBT, SSRI's
NO evidence for efficacy with antipsychotics
Don't refer to a plastic surgeon |
|
|
Term
| What is characteristic of both factitious disorders and malingering? |
|
Definition
| Conditions in which physical or emotional illness or amnesia are mimicked |
|
|
Term
| What are distinguishing characteristics of factictious disorders? |
|
Definition
Intentional production (or feigning) of physical or psychological symptoms
Up to 10% have fever of unknown origin, pyschological symptoms are less common, no obvious external incentives
Thought motivated by an unconscious desire to occupy the sick role |
|
|
Term
| What is Munchausen syndrome? |
|
Definition
Facticious disorder
Patients who move from hospital to hospital simulating various illness |
|
|
Term
| What is Munchausen proxy? |
|
Definition
Facticious disorder
A parent induces (or simulates) illness in his or her child so that the child is repeatedly hospitalized |
|
|
Term
| What is the most common method used to produce symptoms in patients with facticious disorder? |
|
Definition
Insertion or injection of contaminated substance
2nd most common is misuse of meds |
|
|
Term
| Factitious disorder is more common in what demographics? |
|
Definition
Tend to be chronic
Usually women
Onset early adulthood
Develop in people who have had experience with hospitalization or serious illness
Usually associated with a personality disorde |
|
|
Term
| What distinguished factitious disorder from somatoform disorders? |
|
Definition
| Patients are aware that they are producing the signs and symptoms of an illness but are unaware of motivation for doing so |
|
|
Term
| What are some clues to help in the diagnosis of factitious disorder? |
|
Definition
Lengthy and involved medical history doesn't fit with patient's physical presentation
Symptoms that closely resemble textbook descriptions
Sophisticated medical vocabulary
Demands for specific medications or treatments
History of excessive surgeries |
|
|
Term
| How is factitious disorder treated? |
|
Definition
Make diagnosis to avoid unnecessary procedures
Once sufficient evidence is obtained, patient is confronted by attending and consulting psychiatrist |
|
|
Term
|
Definition
| Intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives |
|
|
Term
| Malingering is more common in what demographics? |
|
Definition
|
|
Term
| What are some clues that someone is a malingerer? |
|
Definition
Legal issues
Discrepancy between claims and objective findings
Lack of cooperation during diagnostic evaluation and lack of compliance with treatment
Presence of antisocial personality disorder
Symptoms often vague and unverifiable |
|
|
Term
| What are the classifications of a bipolar I disorder? |
|
Definition
| One or more manic or mixed episodes, usually accompanied by major depressive episodes |
|
|
Term
| What are the classifications of a bipolar II disorder? |
|
Definition
| One or more major depressive episodes accompanied by at least one hypomanic episode |
|
|
Term
| What are the classifications of a cyclothymic bipolar disorder? |
|
Definition
| At least 2 years of numerous periods of hypomanic and depressive symptoms |
|
|
Term
| What are the classifications of a bipolar disorder that is not otherwise specified?? |
|
Definition
| Does not meet criteria for any specific bipolar disorders |
|
|
Term
| Which bipolar disorder is more common? |
|
Definition
|
|
Term
| Bipolar disorder is more common among what demographic? |
|
Definition
Female predominance
Most commonly has bipolar II, rapid cycling, dysphoric mania, and refractory depressive states |
|
|
Term
| What is the criteria for a manic episode in bipolar disorder? |
|
Definition
Abnormally and persistently elevated, expansive, or irritable mood for at least 1wk and at least 3 of the following (4 if irritable mood):
"DIGFAST"
Distractibility, Indiscretion, Grandiosity, Flight of Ideas, Activity increase, Sleep deficit, Talkativeness |
|
|
Term
| What does the DIGFAST mnemonic for mania stand for? |
|
Definition
Distractibility
Indiscretion
Grandiosity
Flight of Ideas
Activity increase
Sleep deficit
Talkativeness |
|
|
Term
| Manic episodes must not be associated with what in order to be properly diagnosed? |
|
Definition
| Does not meet criteria for a mixed episode |
|
|
Term
| What is the criteria for a hypomanic episode in bipolar disorder? |
|
Definition
Abnormally and persistently elevated, expansive, or irritable mood for at least 4 days and at least 3 of the following:
Distractibility, Indiscretion, Grandiosity, Flight of Ideas, Activity increase, Sleep deficit, Talkativeness
However, symptoms are NOT severe enough to cause significant impairment |
|
|
Term
| What is the criteria for a depressive episode in bipolar disorder? |
|
Definition
Depressed mood or markedly diminished interest or pleasure must be present
Weight loss/gain, insomnia/hypersomnia, fatigue, psychomotor agitation, diminished ability to think, concentrate, make decisions, recurrent suicidal ideation, etc. |
|
|
Term
| What is the criteria for a mixed episode in bipolar disorder? |
|
Definition
| Symptoms meet criteria for both a Manic Episode and a Major Depressive Episode for at least one week |
|
|
Term
|
Definition
Seen in bipolar disorder
4(+) episodes of depression, mania, mixed, or hypomania in previous 12 months demarcated by a period of 2(+) months of full remission or a switch to an episode of opposite polarity
Poor clinical outcome |
|
|
Term
| How often are bipolar disorders misidagnosed? |
|
Definition
| 69% of the time, most often as depression |
|
|
Term
| When does bipolar disorder usually occur? |
|
Definition
Adolescence through early 20
Onset after 40yo is a red flag for substance abuse
Depression more common in spring and autumn
Mania more common in summer |
|
|
Term
| What genetic basis is there for bipolar disorder? |
|
Definition
| Strong genetic correlation and evidence for chromosomal link exists |
|
|
Term
| Describe the possible mental status findings of a bipolar patient during a manic episode? |
|
Definition
Alert, oriented unless psychotic, may be restless, appear dramatic, pressured speech, labile or seductive affect, elevated or irritable mood
Flight of ideas, incoherence, clang associations, paranoia or grandiosity, hallucinations
Often distractible, poor judgement, and poor insight
Memory may be impaired |
|
|
Term
| How does bipolar disorder usually progress? |
|
Definition
1st presentation is usually depressive, cause of mis-dx
Moves to full blown mania then subsyndromal depression which then drops to depression again before becoming hypomanic
May occur over days, weeks, months
Not all patients experience this course |
|
|
Term
How likely is it that a person with a single manic episode will have another episode?
How common are episodes in general? |
|
Definition
90% have another episode
Avg 4 per 10yrs |
|
|
Term
| How often do bipolar patients experience symptoms? |
|
Definition
|
|
Term
| What is the most common type of bipolar episode? |
|
Definition
| Depression is approximately 3x more frequent than mania or hypomania, 5x more than cycling or mixed |
|
|
Term
| What type of bipolar episode predicts greater future illness burden? |
|
Definition
|
|
Term
| What elements are assessed when differentiated unipolar vs. bipolar disorder |
|
Definition
Mania symptoms
Course illness
Treatment response
Family history
Associated features such as relationships, career, substance abuse disorders |
|
|
Term
| What symptoms differentiate bipolar from unipolar disorder? |
|
Definition
Sleep is longer w/more fragment REM, more withdrawn depression, psychomotor retardation, and pyschosis with bipolar
Weight loss is greater in unipolar |
|
|
Term
| How is the course of illness different in bipolar disorder vs. unipolar disorder? |
|
Definition
| Bipolar disorder has earlier age of onset, greater number of episodes or time spent ill, postpartum is more likely, antidepressant-associated cycles, earlier onset, more commonly associated with family history |
|
|
Term
| How common is substance abuse in bipolar disorder patients? |
|
Definition
| Up to 60% demonstrate abuse or dependence |
|
|
Term
| What are the effects of substance abuse on bipolar patients? |
|
Definition
Earlier onset
More rapid cycling and mixed states
Increased hospitalization
Slower remission for mania
Medication resistance/nonadherence
2-3x increased rate of suicide |
|
|
Term
| What symptoms are much more likely in bipolar disorder compared to ADHD? |
|
Definition
Grandiosity
Elevated mood
Daredevil acts
Uninhibited people-seeking
Silliness/laughing |
|
|
Term
| What drugs can cause bipolar mood syndromes? |
|
Definition
| Isoniazid, steroids, disulfram |
|
|
Term
| What neurologic factors can cause bipolar mood syndromes? |
|
Definition
| Multiple sclerosis, closed head injury, CNS tumors, epilepsy, Huntington’s disease, cerebrovascular accident, dementia |
|
|
Term
| What metabolic factors can cause bipolar mood syndromes? |
|
Definition
| Thyroid disorders, postoperative states, adrenal disorders, vitamin B12 deficiency, electrolyte abnormality |
|
|
Term
| What infections can cause bipolar mood syndromes? |
|
Definition
| AIDS dementia, neurosyphyllis, influenza |
|
|
Term
| What are the diagnostic criteria for Cyclothymic Disorder? |
|
Definition
For at least 2yrs, numerous periods with hypomanic symptoms and depressive symptoms that do not meet criteria for a major depressive episode
Person is not without symptoms for more than 2mo at a time
No Major Depressive Episode, Manic Episode Or Mixed Episode |
|
|
Term
| How do you treat acute mania? |
|
Definition
Aggressive somatic therapies
Possible hospitalization
Follow closely for emerging depressive episodes
Familial support |
|
|
Term
| What is first line in the treatment of manic or mixed episodes in bipolar disorder? |
|
Definition
Divalproex (atypical antipsychotic)
Lithium and atypical antipsychotic (olanzapine or risperidone)
May add a short term benzodiazepine |
|
|
Term
| What types of medications are approved in the treatment of mania? |
|
Definition
Mood stabilizers and antipsychotics
Tranquilizers are NOT approved |
|
|
Term
| What is first line in the treatment of acute bipolar depression? |
|
Definition
Lithium
Antidepressant monotherapy should be avoided
Psychotic depressions usually require adjunctive antipsychotics
ECT if life-threatening, treatment-resistant, psychotic or catatonic |
|
|
Term
| What are the mood stabilizers? |
|
Definition
Lithium carbonate (Eskatlith, Lithobid)
Carbamazepine (Tegretol, Equetro)
Oxcarbamazepine (Trileptal)
Valproate (Depakene, Depakote)
Lamotrigine (Lamictal) |
|
|
Term
| What is lithium carbonate used for? |
|
Definition
Bipolar Disorder
Schizoaffective Disorder
Augmentation in Major Depressive Disorder
Impulse control disorders
Aggression in mental retardation or personality disorders |
|
|
Term
| What are the adverse effects of lithium carbonate? |
|
Definition
Thirst, polyuria, tremor, diarrhea, weight gain, edema
Hypothyroidism, test regularly
Elevated calcium, ionized calcium, and PTH
Increased acne, psoriasis, EPS, cognitive slowing
Some symptoms tend to lessen over time |
|
|
Term
| What renal effects does lithium have? |
|
Definition
Excreted through the kidneys and reabsorbed in the proximal tubules with sodium and water
Mimics Na+, hyponatremia leads to increased Li+ reabsorption, can lead to lithium toxicity
Avoid dehydration and Na+ depleting diuretics
Long term use can reduce GFR, assess regularly |
|
|
Term
| What drug interactions are there with lithium? |
|
Definition
Concomitant use of NSAIDs have potential to raise levels
Avoid with Na+ depleting diuretics such as thiazides |
|
|
Term
| What lithium blood level constitutes a medical emergency? |
|
Definition
|
|
Term
| What are contraindications for lithium use? |
|
Definition
Don’t use in severe renal disease
Hold for 10-14 days after MI
Avoid in myasthenia gravis
Use with caution in diabetes, ulcerative colitis, psoriasis, and senile cataracts
May cause Ebstein’s anomaly of the heart if used during first trimester of pregnancy
Secreted in breast milk |
|
|
Term
| Valproate is 1st line in the treatment of what? |
|
Definition
Bipolar disorder
May be more effective than lithium in mixed mania and rapid cycling
Also indicated for seizures and migraine headache |
|
|
Term
| What are the side effects of valproate? |
|
Definition
| Nausea, poor appetite, vomiting, diarrhea, tremor, sedation, weight gain, hepatic transaminase elevations, black box warning |
|
|
Term
| What is the black box warning on valproate? |
|
Definition
| Hepatotoxicity, pancreatitis, teratogenicity |
|
|
Term
| What are the teratogenic affects of valproate? |
|
Definition
| Neural tube defects when used during first trimester; high incidence of mental retar |
|
|
Term
| Cabamazepine is first line in the treatment of what? |
|
Definition
Carbamazepine
May be more effective in rapid cycling |
|
|
Term
| What is unique about carbamazepine metabolism? |
|
Definition
| Induces its own hepatic enzymes, may reduce efficacy of hormones |
|
|
Term
| What are the side effects of carbamazepine? |
|
Definition
Rash, leukopenia, impaired coordination, drowsiness, dizziness, slurred speech, ataxia, black box warning
Taratogenic |
|
|
Term
| What is the black box warning on carbamazepine |
|
Definition
| Aplastic anemia and agranulocytosis; toxic epidermal necrolysis |
|
|
Term
| Lamotrigine is approved for what use in the treatment of bipolar disorder? |
|
Definition
Maintenance treatment
May also be effective for acute bipolar depression |
|
|
Term
| What are the side effects of lamotrigine? |
|
Definition
Benign rash
Stevens-Johnson syndrome (rare, children more vulnerable)
Taratogenicity (cleft lip) |
|
|
Term
| What are the side effects of using antidepressants in bipolar depression? |
|
Definition
May convert depression to mania
May increase cycle frequency
May convert condition to more malignant form |
|
|
Term
| What nonpharmacologic treatments exist for bipolar disorder? |
|
Definition
Psychotherapy
Light therapy for depression (risk of mania/hypomania)
Electroconvulsive therapy for mania and depression
Investigational (sleep manipulation, repetitive transcranial magnetic stimulation, and Vagus nerve stimulation) |
|
|
Term
| How do manic patients usually interact with their physician? |
|
Definition
Often adversarial, often forced there by others
Difficult communication
Physicians may vicariously enjoy patient’s energy and optimism
Physician may feel anger, fear or frustration
Avoid unnecessary confrontations
May establish common ground over psychophysiological symptoms |
|
|
Term
| What is first line the maintenance treatment of bipolar I disorder? |
|
Definition
Lithium or divalproex
Discontinue antipsychotic unless required for control of persistent psychosis
Lamotrigine, carbamazepine, and oxcarbamazepine are 2nd line |
|
|
Term
| What are reasons for noncompliance in bipolar disorder treatment? |
|
Definition
Side effects
Missed the highs (Less creative, Less productive)
Disliked mood control by medications
Felt well
Denial of chronic illness |
|
|
