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PMHNP > 8005 final > Flashcards

8005 final Flashcards

1
Q

EPS cause

A

exposure to dopamine antagonist med

blocks D2 receptors means inhibiting dopamine and blocking ACH

this leads to more ACH release which turns into EPS

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2
Q

4 EPS symptoms

A

Dystonia
Akathesia
Parkinsonism
Tardive Dyskinesia

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3
Q

Dystonia sx

A

torticollis
sustained muscular contraction
oculogyric crisis

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4
Q

Dystonia tx

A

anticholinergic med

benztropine***
biperiden
diphenhydramine

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5
Q

Akathesia sx

A

restless
tapping
pacing

can’t sit still – psychomotor restlessness

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6
Q

Akathesia tx

A

Treatment (beta blocker) – propranolol***

mirtazapine
cyproheptadine
BZDs

i. Avoid polypharm or rapid dose increases to avoid akathisia

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7
Q

Parkinsonism sx

A

bradycardia
postural instability
tremor
rigidity
shuffling gait

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8
Q

Parkinsonism tx

A

Treatment (anticholinergic med) –

reduce dose or switch to lower risk med

***benzotropine (caution in elderly),

amantadine (good for elderly)

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9
Q

Tardive Dyskinesia sx, MOA

A

chronic manifestation

– involuntary movements of lower face, limbs, trunk –

reversibly inhibits VMAT2

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10
Q

Tardive dyskinesia risk factors

A

early presence of EPS

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11
Q

Tardive Dyskinesia tx

A

stop Rx

Valbenazine, deutetrabenazine, clozapine,
gingko biloba

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12
Q

serotonin syndrome vs NMS

onset

A

SS more rapid

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13
Q

serotonin syndrome vs NMS

which is deadly

A

NMS

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14
Q

serotonin syndrome vs NMS

3 similar sx

A

fever
Tachy
HTN

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15
Q

serotonin syndrome vs NMS

reflexes

A

SS: Clonus (hyperreflexia 4+)

NMS: rigidity

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16
Q

serotonin syndrome vs NMS

SS sx not in NMS

A

diarrhea

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17
Q

serotonin syndrome vs NMS

identifying labs

A

not SS

But NMS: inc CK, WBC, rhabdo

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18
Q

serotonin syndrome vs NMS

rx associations

A

SS: SSRI/SNRI, MAOI, linezolid, triptins, analgesics, cough med, St John wort, tryptophan

NMS: Antipsychotics though 1st gen more

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19
Q

serotonin syndrome TX

A

support flux BP and P,

avoid restraints

BZDs
cyproheptadine, olanzapine

DO NOT USE: propranolol, dantrolene, bromcriptine

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20
Q

NMS tx

A

DC med

Dantrolene, bromocriptine, amantadine
(too much DA is blocked, give some back)

Cooling measures (tyl & ibu ineffective)

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21
Q

SS to avoid

A

use wash out of 2 wk between SSRIs to TCAs unless it is fluoxetine, then it is 5 wks

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22
Q

NMS risk for recurrence

A

30% - start low and slow

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23
Q

SS acronym

A

Shits – diarrhea

Shivering
Hyperreflexia
Increased Temp
Vital signs instability Encephalopathy Restlessness
Sweating

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24
Q

Dopamine Pathways

A

Mesocortical
Mesolimbic
Nigrostriatal
Tuberinfundibular

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25
Q

mesocortical pathway

A

neg sx of schiz

dec d2 activity

impaired cognitions and flattening affect

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26
Q

mesolimbic pathway

A

pos sx of schiz

brain responds to dec D2 by inc activity in mesolimbic

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27
Q

Nigrostriatal pathway

A

regulates coordination and movement

major dec in parkinsons which is why antipsych can cause parkinsonism

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28
Q

tuberoinfundibular pathway

A

responsible for actions of pituitary (prolactin)

If Da is dec then inc prolactin
–causing galactorrhea, amenorrhea which means dec FSH

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29
Q

Dopamine made in the

A

VTA

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30
Q

5HT made in the

A

raphe nuclei

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31
Q

NE made in the

A

Locus Ceruleus

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32
Q

Ach regulated by the

A

parasympathetic nervous system

(side effect: dry mouth, itchy eyes, blurry vision, urinary retention,
memory impairment, elevated temp)

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33
Q

NT on and off switch

A

on is glutamate–excitatory

off is GABA–inhibitory

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34
Q

dopamine hypothesis

A

D2 receptor presynaptic autoreceptors (gatekeepers)

occupancy provides negative feedback.

Diseases or meds that ↑ DA will enhance or produce positive symptoms.

AntiΨ that ↓ DA activity will ↓ or stop psychoses.

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35
Q

how AntiΨ = ↓ DA

A

= mesolimbic – improve + symptoms

= mesocortical – may worsen negative sympomts

= nigrostriatal – risk EPS inducing movement disorders

= tuberinfundibular – risk of galactorrhea, amenorrhea

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36
Q

defining characteristic of schiz

A

psychosis

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37
Q

psychosis associated with

A

schiz
mania
depression
cognitive disorders

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38
Q

psychosis definition

A

Set of symptoms which a person’s

mental capacity,
affective response
capacity to recognize reality
communicate,
relate to others

is impacted

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39
Q

Schizophrenia dx to know

A

Disorganized speech
Negative sx

PLUS

hallucinations
delusions
and/or
disorganized speech

6+ mo with at least 1 mo of :

  1. Delusions
  2. Hallucinations
  3. Disorganized speech or behavior
  4. Catatonic behavior
  5. Negative symptoms
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40
Q

target of most meds for schiz

A

positive sx

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41
Q

negative sx (5)

A

a. Alogia – reduced speech

b. Affective blunting - ↓emotional response

c. Asociality -↓social drive, limited eye contact

d. Anhedonia - ↓interest in pleasurable things

e. Avolution - ↓motivation, poor grooming

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42
Q

mesolimbic pos or neg

A

positive

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43
Q

mesocortical pos or neg

A

neg

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44
Q

antipsychotic neurotransmitters

A

DA
5HT
NE
His
Ach

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45
Q

Antipsych 1st vs 2nd NT focus

A

1st: D2 antagonist
2nd: D2/5HT2A antagonist

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46
Q

Antipsych 1st AE diff from 2nd

A

High EPS and NMS rates

2nd has lower affinity on D2 so lower risk of EPS

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47
Q

Antipsych 1st receptors and what they cause

A

D2

Alpha 1
(orthostasis, hypotension, priapism)

histamine 1
(wt gain, sedation),

muscarinic
(dry mouth, vision changes, constipation, difficulty urinating)

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48
Q

AIMS

A

used to assess for AE of antipsych

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49
Q

2 high potency 1st gen antipsych

A

Haloperidol
Fluphenazine

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50
Q

1 low potency 1st gen antipsych

A

Chlorpromazine

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51
Q

Haloperidol notes to know

A

highest rate of EPS

QT prolongation, torsades

less wt gain/metabolic

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52
Q

2nd gen antipsych AE

A

wt gain
so risk of:

inc cholesterol
DMII

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53
Q

Clozapine 4 points to know

A

REMS reporting
for tx resistant
frequent labs for agranulocytosis
watch for constipation

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54
Q

antipsych with highest rate of increased prolactin

A

risperidone

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55
Q

active metabolite of risperidone

A

paliperidone

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56
Q

2nd gen antipsych good for bipolar depression

A

lurasidone

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57
Q

common antipsych for peds

A

risperidone, aripiprazole

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58
Q

Antipsych rx SL

A

asenapine

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59
Q

Antipsych that cause sedation and which are less

A

PINES

less in pip, rip, done

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60
Q

Antipsych that cause wt gain and which are less

A

PINES

less in pip, rip, done

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61
Q

antipsych that cause anticholinergic

A

Pines

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62
Q

antipsych that cause EPS

A

DONES

less in pines

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63
Q

antipsych that cause hypotension

A

Pines and dones

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64
Q

antipsych that cause QTc

A

Pines and dones

less in pip, rip, zole

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65
Q

MDD patho

A

dysregulation of emotion in response to stress

dysregulation of 5HT, NE, DA

stress= release glucocorticoids, corticotropin, cytokines which all interfere with the NT more

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66
Q

MDD monoamine hypothesis

A

mood improved with adding MAOI and TCA

=deficiency 5HT, NE, and/or DA

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67
Q

MDD tx approach if partialk or no response

A

assess adherence

inc dose as tolerated

after 8 wks can inc dose, switch alternative, augment with antiD/atypical, psychotherapy

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68
Q

AE for MDD tx options

A

elderly: hyponatremia

SS

discontinuation syndrome: flu like

SI

Sex dys

dec Sz threshold: Buproprion

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69
Q

SSRI MOA

A

inhibition of presynaptic 5HT receptors by interfering with intracellular 5HT transporters

inhibits reuptake of 5HT which ↑ amount of 5HT active and available in synaptic cleft leading to increase 5HT in synaptic cleft

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70
Q

SSRI AE

A

HA, wt gain, GI upset, sexual dysfunction, agitation/anxiety when starting

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71
Q

SNRI MOA

A

inhibits presynaptic 5HT and NE transporters leading to ↑5HT and HE in synaptic cleft

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72
Q

SNRI AE

A

same as SSRIs plus HTN, nausea/diarrhea, sweating, dry mouth, dizziness, fatigue

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73
Q

TCA reserved for

A

Tx resistant depression

les tolerable and more deadly in OD due to cardiac

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74
Q

TCA MOA

A

inhibition of presynaptic 5HT and NE reuptake by inhibition of these transporters leading to ↑5HT and NE in synaptic cleft and antagonizes Ach and His,

also Na and Ca channel inhibitor (may result in some mood stabilization effects),

also binds to α and muscarinic receptors

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75
Q

TCA alt use

A

pain

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76
Q

TCA AE

A

more sedation,

anticholinergic effects of confusion, constipation, wt gain

Tertiary amines – more sedation and anticholinergic effects (amitriptyline, imipramine, clomipramine, doxepin)

Secondary amines – more cardiac effects (nortriptyline, desipramine, amoxapine)

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77
Q

TCA toxicity

A

Toxic levels reached at 7x/therapeutic dose. Monitor for QRD widening (tell tale sign of TCA OD)

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78
Q

TCA toxicity tc

A

Treatment is Sodium bicarb

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79
Q

MAOI MOA

A

irreversibly inhibits monoamine oxidase preventing metabolism of NE< 5HT, and DA which
Allows the levels to increase

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80
Q

MAOI AE

A

HTN crisis – avoid aged cheese, wine, soy, draft beer as well as amphetamines,
carbamazepine, decongestants, ephedrine, cough meds

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81
Q

MAOI use

A

tx resistant MDD

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82
Q

SSRI 1srt sx to improve

A

sleep problems

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83
Q

SSRI function of 5HT

A

Depression Obsession
Migraines
Anxiety
Intestines
Nausea
Sexual

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84
Q

SSRI longest half life

A

fluoxetine

good for if you forget meds

but careful with switch to another SSRI cuz of 5 wk washout need

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85
Q

Fluoxetine careful when switching to another SSRI due to

A

need of 5 wk washout

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86
Q

SSRI worst AE sex

A

paroxetine

due to rapid absorption

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87
Q

Paroxetine contraindication

A

pregnant

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88
Q

SSRI most GI AE

A

Sertraline

so take with food

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89
Q

SSRI safe from pregnancy

A

Sertraline

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90
Q

SSRI high tolerability and lack enzyme interactions

A

citalopram and escitalopram

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91
Q

citalopram and escitalopram AE

A

Qtc

EKG yearly

get genetic testing

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92
Q

citalopram interaction

A

omeprazole inhibits metabolism

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93
Q

SSRI approved for OCD

A

fluvoxamine

high number of interactions though

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94
Q

SNRI 2 common rx

A

venlafaxine and duloxetine

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95
Q

TCA rx for depression

A

Amitriptyline & Nortriptyline – Tertiary amine

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96
Q

TCA used for sleep

A

doxepin

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97
Q

Amitriptyline & Nortriptyline

which for elderly

A

Nortriptyline

less sedating so less fall risk and less hypotension

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98
Q

3 atypical antidepressants

A

Mirtazapine
Buproprion
Trazadone

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99
Q

Mirtazapine MOA

A

↑synaptic concentration of 5HT & NE through presynaptic α2 Antagonism – also 5HT2a and 5HT3 antagonists (better tolerability) and His antagonist.

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100
Q

Mirtazapine AE

A

Sedation
wt gain
agranulocytosis

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101
Q

Bupropion MOA

A

boosts DA & NE but lacks 5HT involvement.

Inhibits DA & NE transporters = ↑DA and NE in synapse

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102
Q

Bupropion contraindication

A

bulimia

can cause sz

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103
Q

Trazadone MOA

A

5HT antagonist and reuptake inhibitor. Weak inhibition of 5HT and NE
reuptake, 5HT2a antagonist, weak α-1 antagonist and His antagonist

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104
Q

Trazadone AE

A

priapism

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105
Q

MAOI combo with SSRI/SNRI

A

can cause SS

needs 2 wk washout
5 wks for fluoxetine

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106
Q

5 Antidepressants with superior efficacy:

A

Escitalopram
Mirtazapine Sertraline Venlafaxine Citalopram

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107
Q

MDD tx avoid if worried about wt gain

A

avoid mirtazapine

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108
Q

MDD tx avoid if worried about sex AE

A

SSRI

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109
Q

when to augment MDD tx

A

after 2+ antidepressants

AE issues with effect that can be targeted

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110
Q

augmentation options for MDD

A

lithium
thyroid hormone
Antipsych: aripiprazole, quetiapine
stimulants: ritaline/adderall
ECT

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111
Q

MDD tx duration of therapy for 1st, 2nd, 3rd episode

A

6+ mo
12+ mo
lifetime

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112
Q

MDD tx with pain issue

A

SNRI

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113
Q

MDD tx with concentration issue

A

Bupropion
duloxetine
fluoxetine

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114
Q

Bipolar disorder etiology

A

Genetic
Neurological: NTs etc
Prenatal infxn

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115
Q

Bipolar DDX

A

SUD
rx induced
thyroid
other psych (schiz)

remember to r/o Bipolar in those with depression

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116
Q

Bipolar risk factors

A

abuse/neglect
psych stress
SUD

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117
Q

Bipolar patho (need to know?)

A

alterations in GABA, glutamate, and monoamines (NE, DA, 5ht) transmission

Ca dysregulation - ↑intracellular calcium signaling

DA hypothesis – intrinsic dysregulation in homeostatic regulation of dopaminergic functions

Hypothalmic-pituitary axis dysregulation - ↑glucocorticoids, ↓glucocorticoid receptor sensitivity

Autonomic dysregulation - ↑sympathetic activity, ↓parasympathetic activity

Monoamine hypothesis - ↓NE, DA, 5HT = depression

Monoamine receptor hypothesis - ↓NE, DA, 5HT = ↑receptors = depression

Glutamate –major excitatory neurotransmitter

GABA – major inhibitory neurotransmitter

5HT1A – agonism of receptor = ↑DA – antagonism of receptor = ↓DA

5HT2A – agonism of receptor = ↓DA – antagonism of receptor = ↑DA
↑amines = mania

Autoreceptors – regulate the release of the monoamine that acts on it – in the presence of the
monoamine, will turn off release of that monoamine NE: α2 receptor
DA: D2
5HT: 5HT1A, 5HT1B and D

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118
Q

Bipolar goals of tx

A

eliminate episode

prevent reoccurrence

minimize AE

pt compliance

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119
Q

BP1 DSM

A

mania+psychosis

elevated, expansive, or irritable mood most of the day

1+ wk with 3+ sx

w/wo psychotic episode

120
Q

BP rapid cycling

A

rapid switch from mania to depression and back – mania recurs 4+/yr

121
Q

BPII DSM

A

hypomania+ depression

elevated, expansive, or irritable mood most of the day

4+ days

3+ sx

at least 1+ hypomanic episode and 1+ major depressive episode

122
Q

cyclothymia DSM

A

(hypomania + dysthymia) cyclic disorder

Brief episodes of hypomania and dysthymia

No full manic or major depressive episodes

chronic

123
Q

cyclothymia sx

A

Distractibility
Irritability
Grandiosity
Flight of ideas
Activity increased
Sleep - ↓need Talkativeness

124
Q

Bipolar tx options

A

1st: antipsychotics

Mood stabilizers

anti sz

125
Q

BP tx options that need close monitoring

A

lithium
VPA

126
Q

BP tx mania vs depression

A

All antipsychotics work for mania.

For depression: quetiapine, lurasidone,
olanzapine-fluoxetine

127
Q

BP tx for depression

A

quetiapine, lurasidone,
olanzapine-fluoxetine

128
Q

BP med choices

A
  1. Lithium – effective for manic episodes and maintenance of reoccurrence
  2. Quetiapine
  3. Lamotrigine – preferred for bipolar depression
  4. Lurasidone
  5. Cariprazine
129
Q

BP tx preferred for depression

A

lamotrigine

130
Q

BP tx valproate vs lithium

A

Valproate better for rapid cycling

131
Q

BP and carbamazepine

A

for acute mania and maintenance

132
Q

BP mania tx

A

lithium,
valproic acid, carbamazepine

2nd line – quetiapine, risperidone, olanzapine, ziprasidone, aripiprazole, asenapine

133
Q

BP tx maintenance

A

lithium

valproic acid

quetiapine

134
Q

1st line tx for mania

A

lithium, quetiapine, valproate, asenapine, aripiprazole, paliperidone >6mg, risperidone,
Cariprazine

135
Q

1st line x for acute mgmt of BP1 depression

A

quetiapine, lurasidone + lithium/valproate, lithium, lamotrigine, lurasidone, lamotrigine adjunct

136
Q

1st line x for acute mgmt of BPII depression

A

quetiapine

137
Q

1st line tx for maintenance for bipolar depression

A

lithium,
quetiapine,
valproate,

lamotrigine, quetiapine + lithium/valproate, asenapine,
aripiprazole (daily or monthly), aripiprazole + lithium/valproate

138
Q

how to take lithium

A

with food

139
Q

lithium AE

A

Lithium – monitor levels

Movement – toxicity = tremor

Nephrotoxicity – resolved with hydration and dialysis

hypOthyroidism – with long term use (6-18mo)– can be treatment with levothroid

Pregnancy – teratogen – can cause low implanted tricuspid valve

140
Q

Lithium drug drug interactions

A

caffeine and theophylline = ↓levels

HCTZ, NSAIDs, ACE inhibitors = ↓renal
clearance = ↑effects of lithium

141
Q

lithium monitoring

A

TSH, renal function, calcium, lithium levels, UA, CBC w/ diff, wt, pregnancy

142
Q

lithium MOA

A

Inhibits GSK preventing cell death and creating neuroprotection

143
Q

VPA MOA

A

Inhibits voltage-gated Na channels (anticonvulsant component)

↑amount of GABA (benzo like sedation)

144
Q

VPA tx and prevents:

A

manic episodes

145
Q

VPA AE

A

nausea, drowsiness, skin changes, wt gain, hair loss, dizziness

In women: PCOS, hyperandrogenism, menses changes

Teratogen in Pregnancy – neural tube defects (due to folate deficiency) – not recommended
In women of childbearing age

At high levels: vomiting, sedation, cognitive dulling

146
Q

lithium and VPA clearance

A

renal

hepatic

147
Q

VPA monitor

A

VPA level

LFT

CBC

pregnancy tests

148
Q

Lamotrigine helps with

A

bipolar depression with little effect on mania

149
Q

Lamotrigine MOA

A

blocking α unit of VSSC

150
Q

Starting lamotrigine

A

slow and titrate over weeks to avoid SJS

151
Q

lamotrigine AE

A

10% widespread itchy rash (1% turn into SJS)

sedation, HA, dizziness, ataxia, nausea

152
Q

Lamotrigine drug drug

A

Valproate = ↑serum lamotrigine levels by double

Carbamazepine and phenytoin = ↓lamotrigine levels

OCPs and estrogens = ↓lamotrigine levels

153
Q

Carbamazepine used for

A

tx and prevent manic episodes

also sz

154
Q

Carbamazepine MOA

A

inhibits voltage-gated sodium channels and augments GABA transmission

155
Q

Carbamazepine monitor

A

Agranulocytosis and SJS

genetic test asias for HLA

CBC, retic, Fe, fast cop

156
Q

Carbamazepine AE

A

GI, rash, sedation, anticholinergic effects, dizziness, transient elevated LFTs

Serious side effects: diplopia, ↓Na, birth defects, SJS, aplastic anemia, agranulocytosis

157
Q

Anxiety NT

A

5HT

158
Q

Anxiety sx

A

1st symptom of anxiety is fear and 2nd is worry

↓concentration, sleep changes, fatigue, arousal, irritability, muscle tension, compulsions, phobic
avoidance, panic attacks

159
Q

Anxiety patho

A

Amygdala (fear) – integrates sensory and cognitive information to determine fear response – emotions, motor response, endocrine response, autonomic responses, anxiety

CSTC Loops (worry) – cortico-striato-thalamo-cortical loops
–Regulates recurrent thoughts
–Involved 5HT, GABA, NE, DA, glutamate, voltage-gated ion channels
–↓COMT activity = ↑DA in circuits
–↑DA activity and ↓efficiency of info process under stress = worry and anxiety
–GABA – main inhibitory neurotransmitter
Main target for BZDs, barbiturates, sedative hypnotics, ETOH
–5HT and NE –
5HT regulates fear and worry
Excess NE creates nightmares, hyperarousal, flashbacks, panic attacks

160
Q

Anxiety tx BZD MOA

A

enhance GABA actions to dec anxiety

161
Q

Anxiety tx Buspirone MOA

A

– no withdrawal effects, no sedation

– can take weeks to level off

– not for PRN use

– can counteract sexual side effects from SSRI

162
Q

Anxiety tx prazosin

A

most common a1 inhibitor

163
Q

Anxiety tx propranolol

A

βblocker and low doses – crosses blood-brain barrier

164
Q

Anxiety tx SSRI/SNRI to know

A

at start of SNRI, anxiety may worsen
– needs time for post synaptic receptors to down regulate and desensitize = ↓fear and worry in the long-term

Start low and slow

165
Q

PTSD rx tx is based on

A

increasing GABA and decreasing Glutamate

166
Q

acute stress disorder timing

A

sx <1 mo

167
Q

Acute PTSD timing

A

1mo to 40+ yrs

168
Q

Chronic PTSD timing

A

6 mo to 40+ yrs

169
Q

Broad DSM def of PTSD

A

must have traumatic event with psych distress sx

exposure

presence of 1+ intrusion sx assoc with event

persistent avoidance

negative alteration in cognition or mood

marked alteration in arousal and reactivity

1+ mo sx

170
Q

PTSD tx 1st line generally

A

SSRI/SNRI

171
Q

PTSD tx for combat

A

fluoxetine better than sertraline

172
Q

PTSD SSRI?SNRI options for tx

A

fluoxetine, paroxetine, sertraline, venlafaxine

173
Q

PTSD alt tx for chronic nightmares

A

prazosin

174
Q

PTSD tx for psychosis

A

antipsychotics

augment with olanzapine, quetiapine, or risperidone

175
Q

why no BZD for PTSD

A

potentiate effect of GABA – AVOID – may worsen outcomes

176
Q

catatonia s/sx

A

catalepsy (gesture held against gravity)
agitation
posturing
grimacing
resistance to
movement
stupor
mutism
mannerisms,
negativism
mimicking speech, mimicking movements, repetitive movements

177
Q

catatonia as comorbidity

A

30% w/ schiz
43% with bipolar

may also be seen in autism, OCD, PTSD, withdrawal from ETOH, BZD

178
Q

catatonia patho

A

dysfunction or interference in frontal cortex-basal ganglia circuitry

↓in GABA and DA activity

Localized seizures in frontal lobe and anterior limbic system

179
Q

catatonia test

A

Bush-Francis Catatonia Rating Scale – score of 2+ = positive finding

180
Q

catatonia tx 1st line

A

BZD- Ativan trial

181
Q

Other catatonia tx

A

ECT

Antipsychotics – depends on pt

Zolpidem (GABA agonist) – alternative to lorazepam challenge

Dopamine Agonist – Amantadine, memantine

Supportive Care

182
Q

Wake promoters r/t sleep

A

Ach, corticotropin factors, DA, His, NE, Orexin, Substance P

183
Q

Sleep promoters

A

Adenosine, GABA, melatonin

184
Q

Insomnia criteria

A

difficulty falling asleep, staying asleep, waking early

3+ nights for 3+ months

Not explained by another medical condition or SUD

Needs to cause clinical distress

185
Q

Insomnia 1st line tx

A

CBT-I and sleep hygiene – try before meds

186
Q

Insomnia rx tx options

A

Melatonin and valerian

Diphenhydramine, unisom, hydroxyzine

BZDs

NonBZDs – z-meds

Belsomra, Dayvigo (orexin receptor antagonist) – avoid ETOH and CNS depressant (opioid)

Antidepressants: Elavil, doxepin, mirtazapine, trazodone – good for BZD avoidance

Gabapentin, tiagabine

Antipsychotics – quetiapine (insomnia assoc w/ schiz, bipolar, depression), olanzapine

187
Q

ADHD 1st line tx

4-5
6-12
12-18yo

A

4-5 yo – PTBM, classroom interventions (these are for all ages)

6-12 yo – Methylphenidate, amphetamines

12-18 yo – FDA approved meds w/ collaborative agreement with pt

188
Q

methylphenidate MOA

A

selectively blocks/inhibits presynaptic reuptake of DA and NE (more NE & DA Available in synapse = ↑action)

189
Q

psych rx in pregnancy and lactation needs dose adjustment because (4)

A

bodily changes

inc in free drug levels

serum concentrations can drop up to 50%

some liver enzymes can go up or downn or not change

190
Q

body changes in pregnancy mostly occur ___ and reverse ___

A

2nd and 3rd tri

1-2 wks post partum

191
Q

major congenital malformations happen when

A

1st tri up to 14 wks

192
Q

most fetal anomaly deaths come from

A

structural anomalies

193
Q

VPA and pregnancy

A

Neural tube defect

194
Q

functional defect

definition

A

altered function with no change in structure

195
Q

when do learning problems and functional deficits and hearing loss issues occur during pregnancy

A

2nd and 3rd tri

196
Q

risk of untreated mental illness to pregnancy

A

poor compliance with tx which risks later fetal/baby issues

SUD and misuse

impaired bonding

suicide and infanticide

psychiatric relapse (BP, MDD, Schiz, Anx etc)

197
Q

risk of relapse with d/c of antidepressant

A

75%

198
Q

risk of mood episodes with d/c of mood stabilizer

A

85%

199
Q

risk of relapse with d/c of schiz rx tx

A

50%

200
Q

The body’s response to untreated anxiety in pregnancy

A

vasoconstrictive stress hormone

reduced placenta blood flow
=
problems with nutrient and o2 delivery

201
Q

% chance of major congenital malformation in gen pop

A

3%

202
Q

if on psychotropic rx when initially pregnant, avoid___ and consider

A

abrupt d/c

past responses, exposures, med risk/benefit

203
Q

if poss change in meds should be done ___ pregnancy

A

before

204
Q

ideally wait for stabilization ___ months before trying to conceive

A

3

205
Q

FDA pregnancy categories

A

Pregnancy, Lactation, and Females and Males of reproductive potential

206
Q

RID and definition

A

relative infant dose

Quantifies risk of Rx use in breastfeeding

207
Q

relative infant dose equation

A

drug ingested by infant during exclusive breastfeeding/kg

208
Q

RID % probably safe

A

<10%

209
Q

2 antidepressants not ideal in pregnancy and why

A

fluvoxamine and paroxetine

high number of drug interactions

210
Q

preferred SSRI in pregnancy

A

sertraline and paroxetine

210
Q

probably safe rx in pregnancy

A

nortriptyline, imipramine, escitalopram, duloxetine, doxepin, amitriptyline

210
Q

bupropion and pregnancy

A

low in breast milk but potential for sz

211
Q

Characteristics that change rx placental transfer and transfer into breastmilk

A

high protein bound= less transfer to milk

Increased lipophilicity - <800 Dalton crosses into milk

Low molecular weight - <500 Dalton=readily diffuse across the placenta

Decreased protein binding - Rx protein bound do not cross placenta or epithelia – only free
unbound drug is able to cross cell membranes

longer half lives

Poorly ionized drugs diffuse readily across placenta – a degree of ionization depends on PK and pH of maternal blood

Weak acids are ionized and held in maternal plasma – since fetal plasma and amniotic fluid are more acidic than maternal pH, weak bases, free drug becomes ionized. and trapped in fetal circulation and amniotic fluid

212
Q

most common psych rx that affect pregnancy and lactation are those that

A

affect the CNS as they can inc the free rx concentration

Also those that cause sedation, lethergy, apnea, seizures, tremors, irritability, resp depression, hypotonia
—Caused by opioids, BZDs, antiepileptics, antipsychotics

213
Q

Antidepressants and pregnancy

A

no confirmed birth defect but 1st tri paroxetine did should poss cardiac

modest risk of miscarriage early

slight inc risk of persistent pulm HTN in newborn

poor neonatal adaptation syndrome 3rd tri

214
Q

BZD and pregnancy

A

highly lipid soluable and unionized – causes rapid and complete diffusion across placenta

but no teratogenesis - possible cleft palate during 1st trimester (avoid during 1st trimester)

Not CI but can cause sedation, poor wt gain, apnea, irritability in infants

short acting preferred: lorazepam, oxezapam

215
Q

maternal sedation does not equal

A

infant sedation

216
Q

gabapentin and pregnancy

A

poss preterm birth

in breastmilk

217
Q

z meds and pregnancy

A

no major malformations, preterm delivery possible

– zolpidem & zalepion have low
milk levels and short halflife (likely OK)

218
Q

trazadone and pregnancy

A

major malformations unlikely – limited data

219
Q

insomnia in pregnancy recommendations

A

sleep hygiene and CBT are 1st line prior to any meds

220
Q

antipsychotics and pregnacy

A

no major congenital

some risk with risperidone

potential floppy baby with clozapine

Risk of GDM and increased wt in mom and baby with clozapine and olanzapine

221
Q

placental pressure highest to lowest (4)

A
  1. Olanzapine,
  2. haloperidol,
  3. risperidone,
    4 (lowest) quetiapine
222
Q

SGA with most reproductive safety data

A

Quetiapine, olanzapine, and risperidone

223
Q

hyperprolactinemia and pregnancy

A

can impair fertility in males and females – consider switching to lower risk agent PRECONCEPTION

224
Q

highest to lowest risk of hyperprolactinemia and pregnancy

A

risperidone & paliperidone -> FGAs -> olanzapine ->ziprasidone -> quetiapine -> clozapine -> aripiprazole

225
Q

clozapine and pregnancy

A

appropriate tx should be continued (benefits outweigh risks) with weekly
monitoring for severe neutropenia in mom and baby x6 mo post partum

226
Q

Long acting injections and pregnancy

A

continue if benefits outweigh risks

227
Q

antipsychotics and lactation

A

generally compatible with lactation EXCEPT clozapine (neutropenia, seizures) women should continue to breast feed unless on clozapine

Monitor infant for sedation, poor feeding, motor abnormalities, neurodevelopmental abnormalities – especially premies who are at greater risk

228
Q

low RID antipsych rx

A

olanzapine and quetiapine

229
Q

moderate RID antipsych

A

risperidone and aripiprazole

230
Q

Bipolar in pregnancy rx tx pref

A

antipsych preferred to mood stabilizers

231
Q

carbamazepine and pregnancy

A

give high dose folate before and during prengnacy

potential for neural tube defects, hypospadias, diaphragmic hernia, skelatal/facial abnormalities, neonatal hemorrhage

lower risk than valproic acid

232
Q

carbamazepine and lactation

A

safe but monitor for sedation and poor sucking

233
Q

lamotrigine and pregnancy

A

likely no risk of major malformation, poss cleft palate

serum concentrations dec significantly in pregnancy so have to monitor monthly and divide dose to reduce peak exposure

234
Q

lamotrigine and lactation

A

consider alternative

D/c if skin rash in baby

235
Q

lithium and pregnancy

A

rate but poss ebstein anomaly

avoid in 1st tri with 4 wk taper before conception

when resume divide doses to limit peak exposure

montly monitor x3-6 wks then weekly until delivery

reduce/hold 24-48 hrs before labor

prepregnancy dose should be resumed post partum

236
Q

lithium and lactation

A

not preferred but monitor levels in mom

237
Q

VPA and pregnancy

A

neural tube and cardiac defects, cleft palate, craniofacial anomalies, cognition/brain volume, hypospadias
—also poss association with autism

should NOT be prescribed to women of child-bearing potential or pregnant women unless viable alternatives to not exist

taper over 4 wks in planning pregnancy

if you have to cont rx, use as monotherapy with lowest effective dose. If combo or higher doses= inc malformation rate

need folic acid supp before and during

238
Q

VPA and lactation

A

safe but caution with high doses

239
Q

stimulants and pregnancy

A

not recc due to inc risk for spontaneous abortion/miscarriage/neonatal withdrawal syndrome

no major congenital

240
Q

stimulants and lactation

A

not recc, monitor for infant wt gain and AE

Methylphenidate/amphetamines may impair milk production via reductions in prolactin levels

241
Q

smoking tx and pregnancy

A

non pharm is 1st line

NRT preferred to smoking

Bupropion and varenciline not recc

242
Q

smoking tx and lactation

A

NRT pref, may consider bupropion but consider Sz risk

no varenciline due to psych AE

243
Q

alcohol dependence and pregnancy tx

A

send for inpatient withdrawals

once inpatient: Chlordiazepoxide and diazepam preferred

insufficient data on acamprosate, naltrexone, disulfiram

244
Q

alcohol dependence and lactation

A

pharmacotherapy not recommended due to limited data

245
Q

BZD dependance and pregnancy

A

need inpatient withdrawal

consider taper with long acting BZD but may inc fetal exposure

taper 20-30% per day as tolerated until d/c

246
Q

opioid dependence and pregnancy

A

1st line: opioid agonist

neonatal adaptation syndrome seen w/ buprenorphine and methadone

Buprenorphine – no major congenital malformations – inpt detox typically required for exposed infants

shorter neonatal abstinence syndrome vs methadone

Limited data for buprenorphine/naloxone (switch to buprenorphine)

Methadone – historically drug of choice – no major congenital malformation Inpt detox

Naltrexone – no major congenital malformations – risk of spontaneous abortion, premature labor, fetal distress

may hinder use of pain rx in delivery

NOT preferred due to opioid withdrawal and fetal complications at initiation may occur

247
Q

opioid dependence and lactation

A

Breastfeeding encouraged w/ MAT – small amounts of buprenorphine and methadone pass into milk

Discourage breastfeeding in women on illicit substances

248
Q

BPD etiology

A

inheritable

mixed gene and environment

249
Q

BPD sx

A

affective instability/negative

poor coping

rumination/anger

impulsivity

instability in personal relationships

sustained behavior and dependent on environmental triggers (unlike bipolar/depression)

250
Q

1st line tx for all personality disorders

A

psychotherapy

251
Q

Rx tx options and personality disorder

A

no rx is FDA approved and should be adjunct and not the sole tx

lack of consensus but generally based on domains:

Affective instability: SSRI/SNRI

Impulsive/self injury: SSRI or mood (lithium/VPA/CBZ)

Cognitive/perception disturb: low dose antipsych: FGA (halo), olanzapine, risperidone, clozapine

emotional dysregulation: SSRI/mood

Impulsivity/aggression: Antipsych (olanzapine), mood

252
Q

personality disorders and adherence and comorbidity

A

adherence is poor

comorbid guidelines underdeveloped and many likely face social adversity make response/drop out worse

anxiety/SUD, depression more common

253
Q

Antisocial personality disorder rx tc

A

only Rx antipsychotics or sedatives for short-term crisis management

254
Q

Schizotypal rx tx

A

some evidence for SGA (risperidone, olanzapine) and low dose FGA (haloperisol, thiothixene) - no reliable evidence for antidepressants

255
Q

avoidant personality disorder rx tx

A

may consider SSRI, SNRI (venlafaxine), MAOI, gabapentin, pregabalin NO BZDs

256
Q

restricted diet and neurotransmitter

A

less tryptophan so less 5HT

257
Q

anorexia nervosa patient presentation

A

perfectionist

obsessed with food

ritualized

258
Q

Bulimia severity

A

Mild – 1-3/wk
Mod – 4-7/wk
Severe – 8-13/wk
Extreme – 14+/wk

259
Q

Bulimia tx 1st line

A

CBT

260
Q

Bulimia and rx tx

A

rx shows poor efficacy

maybe low dose olanzapine or SSRI with comorbid anx/dep

261
Q

Bulimia and rx wt gain

A

Dronabinol
DHEA
D-Cycloserine

262
Q

Bulimia and rx for binging/purging

A

high dose fluoxetine is FDA approved with goal to dec # of occurences

263
Q

Bulimia patient presentation

A

driven to restrain food intake

loss of control with overeating occurs intermittently

extreme fear of wt gain

high impulsivity/impulse dysregulation as compared to anorexia

– novelty seeking – more likely to have substance abuse issues than anorexia

264
Q

Binge eating tx

A

same as bulimia but may also use amphetamine

antiD and topamaz may enhance CBT effective

265
Q

OCD assessment

A

Yale-Brown Obsessive-Compulsive Scale –

Gold standard but needs training to perform

2 others reliable

266
Q

OCD patho

A

dysregulate DA, 5HT, Glutamate

267
Q

OCD tx mild, mod, severe

A

Mild – CBT including exposure therapy

Mod – SSRI or intensive CBT

Severe – SSRI + CBT

268
Q

OCD 1st line rx and for how long

A

SSRI (fluoxetine, fluvoxamine, paroxetine, sertraline)

high dose associated with better outcomes

max tolerated for 8-12 wks as trial

note w/d associate with major relapse risk

Cont Rx for 1-2 yrs before tapering with periodic CBT booster sessions for 3-6 mo after acute tx or 12 months after remission

269
Q

OCD if SSRI inadequate

A

switch or augment with SGA

270
Q

OCD tx monitoring

A

suicide

ECG with high dose citalopram

clomipramine: anticholinergic/arrythmia/Sz

271
Q

Body dysmorphic disorder clinical appearance

A

appearance preoccupations

delusionality and referential thinking (poor insight, worse
than OCD pts, 50% are deluded)

compulsive and safety behaviors (time consuming behaviors to
diminish distress)

effects males and females equally

272
Q

Body dysmorphic disorder tx 1st line

A

CBT

Rx SSRI (fluoxetine, fluvoxamine for 6-9 wks, citalopram and
escitalopram for 5 wks), clomipramine

12-16 wks then switch to another SSRI if no response

273
Q

Trichotillomania & Excoriation

onset

A

onset is early puberty

then relapsing/remitting

274
Q

Trichotillomania & Excoriation tx

A

CBT

poor evidence for SSRI/ other rx

CBT much superior

275
Q

Hoarding disorder tx

A

CBT (group and indiv)

rx: venlafaxine/paroxetine

276
Q

Addiction patho

A

impulsivity and compulsivity dysregulation

PFC inhibits activity of ventral striatum

drugs cause mesolimbic to release DA to inc pleasure

DA stop responding to drug and instead to conditioned stimulus associated with drug causing cravings and compulsive use

277
Q

AUD patho

A

short term ETOH inc GABA and dec Glut

long term: brain tries to restore equilibrium by doing opposite

ETOH w/d has no compensation and shift is toward hyperexcitation

278
Q

AUD DSM w/d dx

A

need cessation or dec ETOH and have distress

Sx 2+

-insomnia
-increased hand tremor
-anxiety
-seizures
-autonomic symptoms (sweating, tachycardia) -nausea/vomiting
-psychomotor agitation (tapping, pacing, rapid talking)
-hallucinations/perceptual disturbances (auditory, tactile, visual)

279
Q

AUD w/d stages

A

1st stage – fairly mild - within 8 hrs– N/V, stomach pain, tiredness, depression

2nd stage – begins 24 hrs after last drink – HTN, anxiety, irritability, mood swings

3rd stage – severe – can last about 72 hrs – symptoms include stages 1 & 2

280
Q

assess acute w/d AUD

A

CIWA

Mild = <10
Mod = 10-18
Severe = >19
Complicated = >19 – includes hallucinations, seizures, delirium

281
Q

AUD w/d tx 1st line

A

BZD- dec w/d including Sz/delirium and agonist at GABA

front load with long acting- diazepam
- pref for severe CIWA <19

282
Q

AUD tx options

A

Naltrexone

acamprosate

disulfiram

283
Q

AUD and naltrexone

patho
versions
black box
monitor

A

antagonist and multiple receptors

dec mesolimbic reward = dec consumption

ok if cont to drink

LA inject: vivitrol

black box for hepatotoxicity

monitor LFT before and every 6 mo

avoid opioids

many stop due to AE N/D

284
Q

acamprosate and AUD

MOA
indication
contra
AE

A

MOA: blocks NMDA and inc GABA and dec Glut to restore balance

indication for maint of abstinence, ok if hepatic disease or on opioid tx

contra: kidney

AE: D/anxiety/insomnia but usually well tolerated

285
Q

Disulfiram and AUD

MOA
reaction time
AE
CI
population

A

MOA: inhibit aldehyde enzyme leading to rapid accumulation and toxic reaction

drinks ETOH and gets sick

reaction 10-30 min and can last for hours

AE: flushing, nausea, thirst, palpitations, CP, hypotension somnolence, metallic after-taste and peripheral neuropathy

CI: severe cardiac, severe hepatic, psychotic

population: support other rx, mod-sev AUD

286
Q

non FDA AUD rx tx

A

topiramate
gabapentin
baclofen
zofran

287
Q

nicotine 5As

A

ask, advise, assess, assist (create tx plan), arrange (for f/u)

288
Q

nicotine behavioral tx model

A

transtheoretical model

289
Q

nicotine 1st line tx

A

NRT monotherapy consistently (not PRN)

Bupropion/chantix

can use in combo with NRT

290
Q

nicotine tx rx CI

A

pregnant, smokeless tobacco, light smokers, adolescents MI in last 2 wks, serious arrhythmia, worsening angina

291
Q

bupropion for nicotine

MOA
start
Dose
CI

A

MOA: blocks NE/DA reuptake to mimic nicotine

Start 7 days prior to quit

Dose AM and early PM to avoid insomnia

CI: Sz, head injury, eating disorder

292
Q

Varenicline for nicotine

MOA
Start
precaution

A

MOA: nAChR partial agonist/antagonist. Basically some relief while blocking nicotine effect

Start 1 wk before quit date

precaution: poss inc agitation, SI, mood swings

Dose change in renal

293
Q

why abuse gabapentin/pregabalin

MOA
tx

A

pregabalin 6x more potent and faster peak

self tx pain, euphoria

can boost cocaine, BZD< opioid, caffeine, ETOH

MOA: inc GABA

w/d poss, more craving with pregabalin and similar to opioid

Tx: taper slow. No BZD. Poss efficacy with haloperidol/benadryl

294
Q

types of pain

A

Nociceptive pain – somatic: well localized, aching, throbbing – bone, skin, soft tissue

Visceral – poorly localized, deep aching, cramping, pressure – hollow and solid organs

Neuropathic pain – tingling, numbness, radiating pain – due to pathologic damage to nervous system - occurs after disease or traums – fibromyalgia

Chronic pain syndrome – Pain for 3+ months and has a psychological impact

PMHNP (24 decks)

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