B&B 6 Emotion & Personality Flashcards Preview

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Flashcards in B&B 6 Emotion & Personality Deck (124):
1

Papez Circuit

Cingulate Gyrus

⬇︎Cingulum

Hippocampus

⬇︎Fornix

Mamillary Bodies

⬇︎Mammillothalamic Tract

Thalamus Anterior Nuclei

⬇︎Internal Capsule

Cingulate Gyrus

2

What comprises the Limbic system?

►Limbic lobe
(cingulate gyrus, parahippocampal gyrus, uncus)
►fornix
►anterior commissure
►hippocampus
►amygdala

3

Hippocampus

Fx?

Important role in learning and formation of new memories by acting as encoding area for translating short-term memories into long-term memories (important for declarative memory)

• May be initial storage site for memory
• Overlying cortex (uncus, entorhinal cortex) also plays role in memory

• Damage to mamillary bodies results in Korsakoff’s psychosis – memory loss, intelligence intact

4

What is the clinical result of removal of the hippocampi?

• Bilateral removal of hippocampi results in inability to form new memories of facts and events

5

"Emotional State"

How is it defined?

subjective, internal! physiological response.

6

Limbic System

How is defined?

A collection of cortical and subcortical structures that integrate across learning, memory, executive function and emotional systems.

7

Hippocampus

Input

►Amygdala
– Basolateral (BLA)
– sensory part

►Sensory Association Areas
– Temporal lobe
– Insular Cortex

►Entorhinal Area
(via the Cingulum)
– Anterior thalamus!
– Medial Prefrontal / Orbital cortex

8

Hippocampus

Output

►Ascending
(entorhinal cortex)
– Association Areas (Temporal, Insular)

►Descending
(fimbria-fornix)
Mamillary body:
– Anterior thalamus (mammillo-thalamic tract)
– Raphe (mammillo-tegmental tract)

►Descending (fimbria-fornix)
Hypothalamus:
– behaviour, autonomic, endocrine function

9

Paraventricular Nucleus
(PVN)

Regulates the release of the steroid hormone, cortisol from the adrenal gland

This regulation is mediated by a chain of sequentially released hormones; known as the hypothalamic-pituitary-adrenal axis

Cortisol (lipophilic) is highly catabolic and can access almost every cell in the body, including the limbic system

10

Bear in the woods (aka stress event) ... what does it do?

Amygdala is activated
→ induces arousal, adrenaline, HR & BP
→ stimulates PVN to increase cortisol

Normally, careful appraisal by sensory and frontal cortices dampen the amygdala's reaction. The brain's frontal cortex is able to convince the body that the perceived threat is not actually a threat.

Panic is removed and cortisol levels return to normal.

THIS IS NORMAL RESPONSE

11

What happens if Logic fails?

The amygdala will continue to arouse and cause fear and panic.

Left unchecked, chronic elevations in cortisol result in a myriad of disorders.

12

What are the consequences of elevated cortisol?

NOTE:
Acute (adaptive)

... over long term leads to ...

Chronic (maladaptive)

ACUTE → CHRONIC
Mobilize energy
→ Myopathy, DM

Increased Vascular Tone
→ HTN

Suppress Digestion
→ Ulceration

Suppress Reproduction
→ Amenorrhea, Impotence

Immune Suppression
→ Increased Mortality

Sharpen Cognition
→ Neuron Death

13

ICD

ICD
"International Classification of Diseases"
– from the WHO (World Health Organization
– for all diseases including psychiatric illness
– In Canada we use ICD 9 diagnostic codes for billing the provincial medicare plans (1975)
– ICD 10 was endorsed in 1990
– ICD 11 due out in 2015

14

DSM

DSM
The Diagnostic and Statistical Manual of the American Psychiatric Association

– Used for diagnosing psychiatric illness

15

Someone is "retarded"

What is our new term for this?

Intellectual Disability

16

MMSE
...vs...
MSE

MMSE
Mini Mental State Exam
– cognitive examination
– short test /30

MSE
Mental Status Examination
– repeatable, structured assessment of Sx and signs that promotes effective communication among clinicians
– BIG exam!

17

MSE

What is the purpose?

– a systematic documentation of the quality of mental functioning at the time of the interview
– serves as a baseline for future reference
– most of the information recorded in the MSE is acquired at various times in the interview
– helps generate Ddx
– refines your ability to observe and document observations
— MSE is a picture of the individual AT THEN TIME of the interview
— serves as a baseline for future reference

18

5 Axis

Axis I: The major psychiatric disorders
Axis II: The personality disorders and mental retardation
Axis III: The medical problems
Axis IV: Psychosocial and Environmental Problems (Stressors)
Axis V: Global Assessment of Functioning

19

What is "Affect?"

— The experience of feeling or emotion
— Key part of the process of a person's interaction with stimuli.

BATES: An observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor

20

What lab test must women have during a psych work-up?

BHCG

— ß-human chorionic gonadotropin
— produced during pregnancy
— made by cells that form the placenta, which nourishes the egg after it has been fertilized and becomes attached to the uterine wall
— levels will double every 72 hours
— reach its peak in the first 8 – 11 weeks of pregnancy and then will decline and level off for the remainder of the pregnancy

● Day 11: detectable in blood
● Day 12-14: detectable in urine

21

What are the key Neurotransmitters in the Limbic System?

NE
Dopamine
Serotonin

22

Define Personality

complex pattern of deeply embedded psychological characteristics expressed in behaviour

23

5 Dimensions of Personality

"OCEAN"
►Openness to experience
— imaginative, creative, novelty, unconventional

►Conscientiousness
— competent, capable, effective, neat, organized, dutiful, self-disciplined

►Extroversion
— warm, affectionate, friendly, seek social stimulation, high energy, dominant, forceful

►Agreeableness
— trusting, frank, sincere, open

►Neuroticism / emotional stability
— anxious, angry, moody, self-conscious (risk for depression)

24

Personality Disorder

Definition:
enduring pattern of inner experience and behaviour or personality traits that ...

— Deviates markedly from cultural expectations

— Manifested in cognition, affectivity, interpersonal functioning, impulsivity

— Pervasive, inflexible, maladaptive

— Onset in adolescence or early adulthood

— Functional impairment OR subjective distress

25

Mood Disorders

►Depressive (unipolar disorders)
— MDD: Major Depressive Disorder
— Dysthymic Disorder
— Depressive disorder not otherwise specified
— Mood Disorder due to general med condition
— Substance-induced Mood disorder

►Bipolar Disorders
— BAD-1 (hospitalize)
— BAD-2 (out-patients)
— Cyclothymic disorder

26

MDD
"Major Depressive Disorder"

Criteria ...?

NOTE:
Anhedonia = subjective sense that nothing is pleasurable

Must have depressed mood or anhedonia PLUS 5 of the following for >2 weeks

“SIGECAPS” - associated Sx
• Sleep disturbance
• Interest (lack of)
• Guilt / Self-blame
• Energy Loss
• Concentration problems
• Appetite change
• Psychomotor agitation or retardation
• Suicidal ideation

27

What is Dysthymic disorder?

At least 2 years of depressed mood along with associated Sx, but without meeting the full criteria
for major depressive episode (2 rather than 4 additional Sx)

28

BAD-1

Bipolar Affective Disorder Type 1

• one or more manic or mixed episodes (usually but no invariably, accompanied by major depressive
episodes)

• severe dysfunction for discrete episodes for a person’s life

29

BAD-2

• one or more major depressive episodes accompanied by at least one hypomanic episode (elevated,
expansive, or irritable mood lasting at least 4 days that is clearly different from usual non-depressed mood but is not severe enough to cause marked impairment in social or occupational functioning)

• harder to diagnose

• Not severe enough to hospitalize.

30

Cyclothymic disorder


Cyclo-thymic disorder

at least 2 years of hypomanic and dysthymic symptoms

31

Mood disorder due to a general medical condition

● Degenerative neurological conditions
— Parkinson’s Dis
— Huntington’s Dis

● Cerebrovascular disease

● Metabolic conditions
— B12 def

● Endocrine conditions
— hyper / hypo-thyroidism
— hyper / hypo-parathyroidism
— hyper / hypo-adrenocorticism

● Autoimmune conditions
— SLE

● Viral or other infections
— Hepatitis, HIV
— Mononucleosis

● Certain cancers
— carcinoma of pancreas

32

Drugs

What are uppers?

What are downers?

UPPERS
— caffeine
— crystal meth
— cocaine (massive numbers of people use cocaine; assume everyone is on it)

DOWNERS
— alcohol

33

Anxiety Disorders

Lifetime Prevalence (%)

►Separation Anxiety

►Panic/agoraphobia Syndromes 1-2%
— Panic disorder +/- agoraphobia
— Agoraphobia (w/o panic dis)

►Phobic disorder
— Specific Phobia 7-11%
— Social Phobia 3-13%

►GAD 55%

NOTE: the following are separate categories effective DSM-5
►Trauma-related disorders
— PTSD 8%
— Acute Stress Disorder

►Obsessive Compulse Disorder 2.5%
— OCD
— Body Dysmorphic Disorder
— Hoarding Disorder

34

Panic disorder +/- agoraphobia

• Recurrent, unexpected panic attacks
• persistent concern for a month or more about further attacks, which, results in significant change in behaviour

35

Panic disorder +/- agoraphobia

PANIC ATTACKS = abrupt onset of intense fear or discomfort that lasts for ~20min with 4 or more Sx ....

• Palpitations
• Sweating
• Trembling or shaking
• Dyspnea
• Choking sensations
• Chest pain or discomfort
• Nausea or GI distress
• Paresthesias
• Chills or hot flushes
• Dizziness or faintness
• Derealisation or depersonalization
• Fear of losing control or going crazy
• Fear of dying

36

Agoraphobia (w/o panic dis)

• Fear of situations in which escape might be difficult or embarrassing if panic occurs so feared situations are avoided or endured with dread

• Situations commonly feared = travelling, far from home, enclosed / wide open spaces, line-ups, high places, being alone

• Different from specific phobia because these patients have many phobias and they are feared of having a panic attack rather than fear of a specific aspect of the stimulus (e.g. falling from high places)

37

►Phobic disorder
— Specific Phobia
— Social Phobia

►Specific phobia
= severe, excessive, persistent fear evokes by exposure to a specific stimulus
(e.g. animals e.g. pitbulls, heights, water, enclosed space, blood injection injury)

►Social phobia
(social anxiety disorder)
= severe, excessive and persistent fear of social interactions and performance situations

38

►Trauma-related disorders
— PTSD

Post traumatic stress disorder

4 groups of Sx for 1 month or more:
— Re-experiencing (e.g. nightmare, flashbacks)
— Numbing of general responsiveness
— Avoidance
— Hyperarousal

If an individual has a high enough vulnerablity, even relatively mild events can trigger PTSD

39

►Trauma-related disorders
— Acute Stress Disorder

Acute stress disorder
= experienced, witness, or was confronted with event involving actual or threatened death or serious injury, or a threat to physical integrity of self or others in which the person’s response involved fear, helplessness or horror

40

►Trauma-related disorders
— Acute Stress Disorder

What are characteristics?

— Marked avoidance of stimuli that arouse recollections of trauma

— Marked Sx of anxiety or increased arousal

— Disturbance for at least 2 days to max of 4 weeks and occurs within 4 weeks of traumatic event

— Disturbance causes clinically significant distress or impairment in social, occupational, or important areas of functioning

41

OCD

Either obsessions or compulsions

►Obsessions
= recurrent, persistent thoughts, impulses, or images that is intrusive and unwanted

►Compulsions
= repetitive behaviours or mental acts aimed at reducing distress or preventing harm

42

General Anxiety Disorder

• Excessive anxiety and worry that is difficult to control

• Associated Sx
— restless
— tension
— feeling on edge
— concentration difficulties
— irritability
— insomnia

• Lasts at least 6 months

43

Major Depressive Episode

What are classic Sx?

► appetite changes

► sleep disturbances

► psychomotor retardation — hard to get the body to do what you want it to do. Hard to get out of bed.

44

Depression

Extra Notes

Depression is where focus of attention turns inward

If the person still has motivation to engage with the world … they are not depressed

45

Personality Disorders (PDs)

►Cluster A
• Paranoid
• Schizoid
• Schizotypal

►Cluster B
• Borderline
• Histrionic
• Antisocial
• Narcissistic

►Cluster C
• Avoidant
• Dependent
• Obsessive-Compulsive

46

Cluster A

►Paranoid
— Distrust, suspicious, guarded, self-righteous
— May interpret motives as malevolent

►Schizoid
— detached, aloof, restricted emotions
— Indifferent, remote, does not connect


►Schizotypal
— Relational discomfort, cogn / perceptual distortions, eccentric
— Odd, may blur reality & fantasy, difficult to report Sx

47

Cluster B

► Borderline
— Instability in relationships, mood, self-image
— Unpredictable, impulsive, suicide risk

► Histrionic
— Excessive emotionality, attention seeking
— "Everything hurts all over!"

► Antisocial
— Disregard for others, violate others' rights
— Superficially charming, hostile when confronted

► Narcissistic
— Grandiose, need admiration, lack empathy
— "I am special. My problem is unique."

48

Cluster C

► Avoidant
— social inhibition, feel inadequate, hypersensitive
— Hesitant, embarrassed, self-conscious

► Dependent
— Submissiver, clingy, executive need for care
— Seek constant reassurance / feedback

► Obsessive-Compulsive
— Pre-occupied: orderliness, control, perfectionism
— "I have researched my Sx extensively."

49

Diagnosing Personality Disorders (PDs)

What are important

— Be very cautious in diagnosing PD
— requires extensive psychological/psychiatric assessment
— very “sticky,” sometimes stigmatizing dx

50

Mood Disorders

What is the average age of onset?

What is the average number of lifetime episodes?

Average age of onset:
29

Average number of lifetime episodes:
4

51

Depression

What is the lifetime prevalence in the population?

21%

52

Monoamine neurotransmitters

What are they?

— contain one amino group that is connected to an aromatic ring by a two C ring

— derived from aromatic aa's like phenylalanine, tyrosine, tryptophan, and the thyroid hormones by the action of aromatic aa decarboxylase enzymes.

53

What are the Monoamine neurotransmitters?

What synthesizes them?

►Histamine

►Catecholamines:
— E, NE
— Dopamine

►Classical Tryptamines:
— Serotonin (5-HT)
— Melatonin

54

Monoamine Oxidase

What is it?

— Enzyme that oxidases monoamine neurotransmitters
— TURNS them OFF

55

Selegiline

...vs...

Reserpine

Selegiline
— MAO inhibitor (MAOi)
— prevent breakdown of Dopamine
—⬆︎monoamine neurotranmistters
— Tx for Parkinson's

Reserpine
— blocks VMAT: vesicular monoamine transporter
— depletes monoamine neurotransmitters in the synapse
—⬇︎monoamine neurotranmistters
— Historical Tx for HTN & psychosis
— may precipitate depression in some pts
— NO LONGER USED

56

Monoamine Hypothesis of Depression

● Suggested that depression was caused by decreased levels of centrally available monoamines (in particular NE and 5HT)
● Cause unknown (e.g. decreased synthesis, breakdown, receptors)
● The main piece of evidence for this theory was that antidepressants increase monoamine levels
NOTE: this is not great quality of evidence
● Reserpine, which causes depletion of monoamines by irreversibly blocking the vesicular monoamine transporter
● Not clear which monoamine was primarily affected.

57

BDNF

Brain-derived neurotrophic factor

What is it?

• Family of GFs
• Found in brain & periphery.
• Supports survival of existing neutrons
• Enourages growth and differentiation of new neurons & synapses
• Active in hippocampus, cortex, and basal forebrain—areas vital to learning, memory, and higher thinking
• important for long-term memory

NOTE:
• also in retina, motor neurons, kidneys, saliva, prostate

58

What is the effect of Stress on BDNF?

Stress causes BDNF levels to drop

The levels of BDNF drops as a result of stress → atrophy of neurons in hippocampus

59

Mood & Anxiety Disorders

What are Risk Factors?

• Gender (female)

• Environmental adversities (e.g. job loss, martial difficulties, major health problems, loss of close personal relationships)

• Difficulties in childhood (physical / sexual abuse, poor parent-child relations, parental discord / divorce)

• Neurotic personality (level of emotional stability versus the predisposition to develop emotional upset under stress)

• Family Hx (first degree relatives increase by 3X)

60

Mood & Anxiety Disorders

Why do they frequently co-occur?

Generally co-occur due to similar underlying neurochemistry and neuroanatomy, genetic predisposition, stress and social factors

61

Pharmacological Tx
Which drugs?

Mood Disorders
...vs...
Anxiety Disorders

►Mood Disorders
— MAOi
— NaSSA: Mirtazapine
— SARI (Trazadone)
— St John's Wort

►Both Disorders
— SSRI
— SNRI
— NDRI: (Bupropion)
— TCA

►Anxiety Disorders
— Benzos
— Busiprion (5HT receptor agonist)
— Gabapentin
— Pregabalin

62

What are the first-line drugs?

GAD
Panic
Social

SSRIs

SNRIs

Benzos

63

PTSD

First-line drug?

Second-line drug?

First-line
• SSRI
• SNRI

Second-line
• Benzos

64

OCD

First-line drug?

Second-line drug?

First-line
• SSRI

Second-line
• SNRI

65

What must we consider about the delayed onset of action of SSRIs / SNRIs in prescribing it to a patient?

Initially cause increased neurotransmitter. The receptors then get down-regulated, but this takes 3-4 weeks.

In the meantime, the increased NE provides the pt with improved concentration & motivation ... BUT, the pt is still depressed. This is the suicide risk window, particularly in those <25. May also cause anxiety.

We manage this by ...
• patient education
• frequent visits
• Benzo for the short term until SSRI / SNRI takes effect.

66

Why are SSRIs safer than TCAs?

SSRIs have virtually no effect on Na+ channels
(which could cause seizures and arrhythmias)

67

SSRI's

S/E

• Agitation
• anxiety
• panic
• akathisia (restlessness)
• psychomotor retardation
• mild parkinsonism
• myoclonus,
• nocturnal awakenings
• sexual dysfunction
• decreased libido
• nausea
• increased bowel motility
• GI cramps,
• diarrhea

NOTE: can cause QT prolongation ... therefore, do not use in pts with congenital QT prolonged syndrome

68

What is the "cleanest" and most potent of SSRIs?

Escitalopram

69

Dosing maxes for SSRIs

►Citalopram
40 mg max / day
— Celexa
— Cipramil

►Escitalopram
20 mg max / day
— Lexapro

NOTE: About 20% patients that stop SSRIs abruptly may get flu-like symptoms from withdrawal → should taper over few weeks

70

Which SSRI has a very long half-life?

Fluoxetine
(Prozac)

t 1/2 = 2-3 days

71

Which SSRI is notorious for causing withdrawal reaction?

Paroxetine
(Paxil)

72

How do SNRIs compare to TCAs?

SNRIs are basically TCAs without the side-effects

TCA = Tricyclic Antidepressants

73

►Cymbalta

►Effexor

What are these drugs?

SNRIs
►Duloxetine
(Cymbalta)

►Venlafaxine
(Effexor)

74

SNRIs

S/E?

NE related SEs
— tremor
— increase HR
— agitation
— increase BP
— anticholinergic-like effect

75

Benzodiazapines

MOA?

Binds to GABA-A receptors → increase channel open frequency → more Cl enter to hyperpolarize neuron

Benzos are positive allosteric modulators

76

What is Xanax?

What is Valium?

What is Ativan?

Alprazolam (Xanax)

Diazepam
(Valium) —> long-acting

Lorazepam
(Ativan, Orfedil)

77

Which Benzo has a really ...

— short half-life?

— long half-life?

►Midazolam
(Versed)
• short-acting (sedation)

►Diazepam (Valium)
• long-acting

78

Which Benzo could we give someone in dentist chair?

Which one would we NOT want to give?

►Give Lorazepam
(Ativan, Orfedil)

►Diazepam
(Valium)
• long-acting → not good for anxiety


79

Bupropion

What class?

MOA?

NDRI
(NE and dopamine reuptake inhibitor)

(Wellbutrin / Zyban)

MOA: weak inhibitor of dopamine and NE reuptake pumps

80

Trazodone

What is it?

SARI
(Serotonin antagonist and reuptake inhibitor)

• High doses required to inhibit 5HT reuptake transporters → limited usefulness as antidepressant

• Lower doses can antagonize 5HT2A and α2 receptors → good for treating insomnia

• Combine at moderate doses with SSRI or SNRI for synergy

81

What is Mirtazapine?

NaSSA
Noradrengeric Serotonin Specific Antidepressant

MOA: α-2 antagonism

82

Mirtazapine

What is it?

NaSSA
(Noradrenergic and specific serotonergic antidepressant)

• 5HT2A/5HT2C antagonism
→ anxiolytic, antidepressant, sleep-restoring, reduce sexual dysfunction

• 5HT2C antagonism
→ weight gain

• 5HT3 antagonism
→ reduced nausea and GI upset

• H1 antagonism
→ drowsiness, anxiolytic, weight gain

83

TCAs

Drugs?

MOA?

Tricyclic antidepressants

Tertiary amines
— amitryiptyline
— imipramine
MOA: preferentially inhibit 5HT reuptake

Secondary amines
— nortriptyline
— despiramine
MOA: inhibit NE reuptake

84

TCAs

Seldom used because of extensive S/E profile

What are some of these?

H1 antagonism
— sedation and weight gain

M1 antagonism
— anticholinergic (dry mouth, blurred vision, urinary retention, constipation)

Α1 antagonism
— orthostatic hypotension
— dizziness

Voltage sensitive Na channels
— seizures
— coma
— arrhythmias
— cardiac arrest

85

MAOIs (Monoamine oxidase inhibitors)

What are the drugs?

►Irreversible forms
— phenelzine
— tranylcypromine
— isocarboxacid

►Reversible form
— moclobemide

86

Which drug class can result in a Hypertensive Crisis?

►Irreversible forms
— phenelzine
— tranylcypromine
— isocarboxacid

... React with tyramine (potent NE releaser) commonly found in some foods → reduce capacity to metabolize
tyramine → hypertensive crisis (diastolic BP >120mm Hg)

87

Depression Tx

1st line agents?

2nd line agents?

1st line agents
— NDRI (bupropion)
— SSRIs
— SNRIs
— MAOI reversible (moclobemide)
— α2 antagonist (mirtazapine)

2nd line agents
— TCA
— SARI (trazodone)
— Atypical antipsychotic (Quetiapine)

88

Mood Stabilizer Drugs

►Lithium
MOA: unknown

►Valproic Acid
MOA: inhibition of voltage sensitive Na channels by altering phosphorylation of Na channels leading to diminished release of glutamate and therefore less excitatory neurotransmission

►Carbamzepine
MOA: inhibition of voltage sensitive Na channels

►Lamotrigine
MOA: inhibition of voltage sensitive Na channels and may also reduce glutamate release

89

Lithium

MOA: unknown

What are possible MOA?

Inhibition of inositol monophosphatase, Modulation of G proteins, reduction of protein kinase C 
activity, possibly affecting genomic expression associated with neurotransmission

90

Lithium

Common S/E?

Rare, but Serious S/E?

►Common S/E
— tremor
— polyuria
— polydipsia
— diarrhea
— nausea
— weight gain
— sedation

►Rare but serious SEs
— interstitial nephritis
— nephrogenic DI
— arrhythmia
— bradycardia
— hypotension
— seizures

91

Lithium Toxicity

S/S?

1.5-2.0 mM
— ataxia
— coarse tremor
— confusion
— fasciculation
— slurred speech

>2 mM
— coma with hyperreflexia
— muscle tremor
— hyperextension of limbs
— pulse irregularities
— hypertension
— seizures
— acute tubular necrosis

92

Valproic Acid

MOA?

Inhibition of voltage sensitive Na channels by altering phosphorylation of Na channels leading to diminished release of glutamate and therefore less excitatory neurotransmission

Also enhances actions of GABA either by increasing its release or decreasing reuptake and/or metabolism

93

Valproic Acid

Common S/E?

Rare, but Serious S/E?

Common SEs
— sedation
— tremor
— dizziness
— ataxia
— asthenia
— headache
— nausea
— vomiting
— diarrhea
— reduced appetite
— constipation
— weight gain

Rare by serious SEs
— hepatotoxicity with liver failure
— pancreatitis

94

Carbamazepine

MOA?

inhibition of voltage sensitive Na channels

95

Carbamazepine

Common S/E?

Rare, but Serious S/E?

Common SEs
— sedation
— dizziness
— confusion
— unsteadiness
— headache
— nausea
— vomiting
— diarrhea
— benign leucopenia
— rash

Rare by serious SEs
— aplastic anemia, agranulocytosis,
— Stevens Johnson syndrome
— SIADH

96

SIADH

What is it?

"Syndrome of Inappropriate ADH Secretion"

Hyponatremia due to the body pumping out ADH inappropriately.

NOTE: Na+ content is the same, we just have WAY too much water!

Tx: Fluid restriction!

97

Lamotrigine

MOA?

Inhibition of voltage sensitive Na channels and may also reduce glutamate release

98

Lamotrigine

Common S/E?

Rare, but Serious S/E?

Common SEs = sedation, blurred vision, tremor, insomnia
Rare but serious SEs = Stevens Johnson syndrome (mitigated by slow titration)

99

Psychotherapy

What are types?

● Insight oriented therapies
● Interpersonal
● Humanistic
● CBT

100

CBT

Goal?

Help client become his/her own therapist by developing skills in a variety of areas

Training the patient to break unhealthy patterns of thinking and to allow themselves to take control of their thoughts

(i.e. applied relaxation, tolerance of anxiety, thought monitoring, problem solving, social skills development)

101

How do we treat ....

Bipolar?

Unipolar (Depression only)?

Bipolar (depression & mania)
— Mood stabilizer

Unipolar (depression only)
— Anti-depressant …. be aware that it could push them over to mania

102

Anxiety Disorders

Lifetime Prevalence (%)

Panic disorder 1-2%

Agoraphobia 1-2%

Specific phobia 7-11%

Social anxiety disorder 3-13%

GAD 55%

Post-traumatic stress disorder 8%

OCD 2.5%

103

Once a patient has one episode of depression, what is likelihood of re-occurance?

2nd episode = 50%

3rd episode = 70%

After 3 episodes = 90% risk of recurrence

104

Serotonin

What happens when there is too little?

What happens when there is too much?

Too little Serotonin
– depression

Too much Serotonin
– excessive nerve cell activity, causing a potentially deadly collection of symptoms known as "Serotonin Syndrome"

105

Serotonin Syndrome

What causes it?

Can begin within hours of taking a new medication that affects serotonin levels or excessively increasing the dose of one you are already taking.

Our PBL patient got it by combining her Escitalopram 20mg (max dose) with OTC St John's Wort

106

Serotonin Syndrome

Sx?

— Confusion
— Agitation or restlessness
— Dilated pupils
— Headache
— Changes in blood pressure and/or temperature
— Nausea and/or vomiting
— Diarrhea
— Rapid heart rate
— Tremor
— Loss of muscle coordination or twitching muscles
— Shivering and goose bumps
— Heavy sweating

SEVERE CASES:
— High fever
— Seizures
— Irregular heartbeat
— Unconsciousness ... life threatening!

107

Most medical conditions tend to also be associated with depression. What is the exception?

"M&M"

MS & Manic

108

Mnemonics:

• Depression

• Mania

• Suicide Risk

Depression:
SIGECAPS

Mania:
DIG FAST

Suicide Risk:
SADPERSONS


109

Depression:

Mnemonic

SIGECAPS
• Suicidal thoughts
• Interests decreased
• Guilt
• Energy decreased
• Concentration decreased
• Appetite disturbance
• Psychomotor changes
• Sleep disturbance

110

Mania

Mnemonic

DIGFAST
• Distractibility
• Indiscretion
• Grandiosity
• Flight of ideas
• Activity increased • Sleep deficient
• Talkativeness

111

Suicide Risk Assessment

Screen via SAD PERSONS

S: Male sex
A: Age
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness

This score is then mapped onto a risk assessment scale as follows:
0–4: Low
5–6: Medium
7–10: High

112

Suicide Risk

How to explain to patient about my role?

"There is a part of your that wants to live and a part of you that wants to die. My job is to help strengthen that part of you that wants to live."

113

Where does the majority of the serotonergic innervation to the forebrain arise?

raphe

114

Role of Amygdala

Assigning emotional significance to sensory input

Then, it guides emotional behaviour by projections to the hypothalamus, hippocampus, and basal forebrain.

The neocortex then further elaborates the sensory input and it imbues with personal meaning.

115

Bilateral removal of the hippocampal formations will result in:

loss of short-term memory

116

What are the people with panic disorders often very afraid of?

Frightened of body sensations

They tend to avoid activities that induce sensations, such as physical exercise.

they tend to overestimate the dangerousness of sensations such as palpitations, mild SOB, and benign, stress-induced depersonalization and derealization. Agoraphobia typically develops as a consequence or complication of panic attacks.

117

PTSD

Which neurotransmitters are dysregulated?

serotonin
&
noradrenaline

118

PTSD

Which neuroanatomical structures play the MOST IMPORTANT role in producing symptoms?

prefrontal cortex
amygdala
hippocampus

119

What classes do the following drugs belong to?
● Buproprion
● Citalopram
● Fluoxetine
● Mirtazapine
● Venlafaxine

● Buproprion
(Wellbutrin / Zyban)
NDRI

● Citalopram (Celexa)
SSRI

● Fluoxetine (Prozac)
SSRI

● Mirtazapine
NaSSA

● Venlafaxine (Effexor)
SNRI

120

Panic Disorder

What is a key characteristic?

Panic disorder is characterized by recurrent unexpected panic attacks.

121

CBT
...vs...
Insight oriented (psychodynamic) psychotherapy

►CBT
– "here and now" focus.

►Insight oriented (psychodynamic) psychotherapy
– Exploration of past interactions with parents and other key authority figures is often a focus of insight oriented (psychodynamic) psychotherapy

122

In CBT, `automatic thoughts` are BEST described as:

thoughts on the periphery of awareness.

123

Mania

Tx?

Lithium

124

Don't say
"Mary is depressed"

Instead say ...

“Mary has depression”