Midterm Exam Study Guide

Question 1

LITHIUM

USES

Answer 1

• Lithium is the drug of choice for controlling acute manic episodes in patients with bipolar disorders AND for long-term prophylaxis for against recurrence for mania and/or depression. Gotta stabilize that mood fam.
• Reduced euphoria, hyperactivity, BUT does not cause sedation.

Question 2

LITHIUM

DANGER

Answer 2

• DANGER DANGER: Because lithium is excreted by the kidneys, watch out for patients who have renal problems! If ya can’t piss it out, we in trouble.
• Dehydration will cause lithium retention , so increase fluids!
• Taking diuretics and drinking alcohol increases your serum lithium levels

Question 3

LITHIUM

LEVELS

Answer 3

• Maintenance (What we should keep it around): 0.4 - 1.0 mEq/L
• What dose should we give: 900 to 1200 mg
• TOXICITY: Lithium levels must be kept under 1.5 mEq/L, levels above this can produce significant toxicity.
• So make sure, you gotta draw lithium blood levels to see how your body handles it!

Question 4

LITHIUM

SIDE EFFECTS

Answer 4

• GI effects such as nausea, vomiting, abdominal bloating, and diarrhea.
• Tremor (Produce fine hand tremor)
• POLYURIA - You piss alot, like a bunch. Some patients almost 3 L a day.
• Renal Toxicity (Assess kidney function before treatment
• Goiter & Hypothyroidism
• Teratogenesis
• Use in lactation (Lithium goes into breast milk. So no no lithium guys)
• Rare chance of leukocytosis.

Question 5

LITHIUM

TOXICITIES TABLE

Answer 5

Question 6

SIDE EFFECTS OF

MOOD-STABILIZERS

(ANTI-CONVULSANTS)

Answer 6

• Anticonvulsant medications also are used as mood stabilizers.
• DANGER WILL ROBINSON, DANGER! Life-threatening side effect is Stevens-Johnson Syndrome (SJS), a severe rash which can affect the trunk OR mucous membranes can occur with anticonvulsants, esp. lamotrigine (Lamictal). Advance dose VERY SLOWLY:
• Patient needs regular blood draws to measure therapeutic levels. Can cause weight gain, sleepiness, N&V. May increase the risk of suicidal thoughts.
• • -Hives, a rash, fever, or swollen glands.
• -Signs of Stevens-Johnson syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids.
• -Confusion.
• -Slurred speech.
• -Nausea, vomiting, and diarrhea.
• -Trembling.
• -Increased thirst and increased need to urinate.
• -Weight gain in the first few months of use.
• -Drowsiness.

Question 7

WHICH NEUROTRANSMITTERS

ARE AFFECTED BY

WHICH FAMILIES

OF ANTIDEPRESSANTS (SSRIs, SNRIs)

Answer 7

• SSRI’s (Guys its in the name!!) - Selective SEROTONIN reuptake inhibitors
• SNRI’s - SEROTONIN and NOREPINEPHRINE reuptake inhibitors
• NDRI’s- NOREPINEPHRINE and DOPAMINE reuptake inhibitors
• Monoamine Oxidase Inhibitors (TRICK QUESTION), it doesn’t affect a neurotransmitter directly. Monoamine oxidase is an enzyme responsible for breaking down the three (Serotonin, Norepinephrine, and Dopamine). SO by inhibiting the enzyme, we increase the levels of all three! Tho its a bad medication lol…

Question 8

EPS and Metabolic Syndrome

Which drugs are they associated with

Answer 8

• EPS (Extrapyramidal Symptoms): rigidity, persistent muscle spasms, tremors, restlessness . Parkinsonianism is another type of EPS.
• Metabolic Syndrome: significant weight gain, increased blood sugar, increased triglycerides . This increases risk for CVD and diabetes . Some people get gynecomastia & galactorrhea. Patient’s weight, glucose levels, prolactin levels and lipid levels should be monitored regularly.

FOR ANTIPSYCHOTICS!!!

• First Gen Antipsychs: Causes EPS
• Second Gen Antipsychs: Metabolic syndrome AND a little bit of EPS as well!!

Question 9

CLOZAPINE

TOXIC EFFECTS

Answer 9

Agranulocytosis

(Must be in registry for it) Make sure neutrophil count above 1500

Question 10

LITHIUM

TOXIC EFFECTS

Answer 10

DEATH - GAME OVER

convulsions, oliguria.

TOXIC to kidneys and thyroid

Question 11

ANTIPSYCHOTICS

TOXIC EFFECTS

Answer 11

all antipsychotic medications was determined, that death rates are higher for elderly people with dementia when taking this medication

Question 12

FGA

FIRST GENERATION ANTIPSYCHOTICS

TOXIC LEVELS

Answer 12

Extrapyramidal Symtoms (EPS)-rigidity, persistent muscle spasms, tremors, restlessness

especially Tardive Dyskinesia - causes repetitive, involuntary movements, such as grimacing and eye blinking (Give Cogentin!)

Question 13

SGA

SECOND GENERATION ANTIPSYCHOTICS

TOXIC LEVELS

Answer 13

Metabolic Syndrom: significant weight gain, increased blood sugar, increased triglycerides . This increases risk for CVD and diabetes .

Extrapyramidal Symtoms (EPS): rigidity, persistent muscle spasms, tremors, restlessness

Question 14

SSRI

SELECTIVE SEROTONIC REUPTAKE INHIBITOR

TOXIC LEVELS

Answer 14

Celexa (Citalopram) : Can cause cardiac problems above 40 mg daily dose

Question 15

ANTIDEPRESSANT

TOXIC LEVELS

Answer 15

Serotonin syndrome

• Agitation or restlessness
• Confusion
• Rapid heart rate and high blood pressure
• Dilated pupils
• Loss of muscle coordination or twitching muscles
• Muscle rigidity
• Heavy sweating
• Diarrhea

Question 16

MONOAMINE OXIDASE INHIBITOR (MAOI)

TOXIC LEVELS

Answer 16

• Mixing MAOIs with other antidepressants or tyramine foods can cause a hypertensive crisis which can lead to stroke .
• Foods and medicines that contain high levels of tyramine are dangerous for people taking MAOIs . Tyramine is found in some wines, and pickles, smoked meats & cheeses, draft beers.
• This makes me sad, i love my beer and cheese :(

Question 17

TRI-CYCLIC ANTIDEPRESSANTS (TCA)

TOXIC LEVELS

Answer 17

Can cause cardiac problems in older individuals.

Question 18

ANTICONVULSANT MEDS

TOXIC LEVELS

Answer 18

DANGER WILL ROBINSON, DANGER!!

Steven-Johnsons syndrome (Eww bad bad)

Question 19

BENZODIAZEPINE

TOXIC LEVELS

Answer 19

Very addictive, can cause that crack addiction

Question 20

BENZODIAZEPINE

like drugs (Z-drugs)

TOXIC LEVELS

Answer 20

Cause sleep sex, driving, and sleepy eating!

Question 21

BENZODIAZEPINE

Answer 21

Benzos are anti-anxiety drugs!!

Benzos promote GABA in the brain. These bad boys work fast and well for anxiety BUT they are physically addictive and cause psychological dependence.

Tolerance can develop quickly. You can get addicted even if you only take them a few times per week. It can take weeks, months or years to detox from them.

SE: They can cause death from respiratory depression when combined with alcohol or opiods. Other possible side effects include: Drowsiness, dizziness, upset stomach, blurred vision, headache, confusion.

Can be used on inpatient psych units for alcohol detox, catatonia and as take-down meds. Patients should not be discharged with them.

DO NOT USE WITH ALCOHOL OR OPIOIDS (and any cns depressants). You. WIll. Die.

BENZOS only really differ from each other by its potency! Like Xanax is 10 times more potent than valium! Its crazy!!!

Question 22

CLOZARIL (CLOZAPINE)

Answer 22

Clozapine (Clozaril) can sometimes cause life-threatening agranulocytosis.

People who take clozapine must get their white blood cell counts ( esp. ANC or absolute neutrophiil count) checked every week or two. Patients must be in a “Clozapine Registry” in order to receive the medication.

Clozapine is potentially helpful for people who do not respond to other antipsychotic medications .

Important blood draws and levels

Because risk of agranulocytosis, make sure to monitor both WBC and ANC

IF WBC below 3000/ mm3 - STOP treatment

IF ANC below 1500/ mm3 - STOP treatment

Dangerous side effect is agranulocytosis

METABOLIC SYNDROME and EPS as well!!

Question 23

WHAT IS

ANXIETY

Answer 23

Anxiety and depression are often two sides of the same coin

A feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome. BASICALLY me before every exam

Question 24

GAD (Generalized Anxiety Disorders)

Answer 24

Experiences excessive or unreasonable worry or apprehension.

• Patients have great difficulty controlling their anxiety. You basically worry about everything- Help
• Medications: Include Benzos (SHORT TERM ONLY!), Busiprone, and Antidepressants for long term care (SSRI or SNRI)

Question 25

PANIC DISORDER

Answer 25

**Pt. who have recurrent panic attacks or worried about having panic attacks** A panic attack is an abrupt surge of intense fear or discomfort that peaks at 10 mins. (FEELS like you having a heart attack) Medications: SSRI and SNRI’s. Benzo’s to immediately reduce somatic symptoms until the antidepressants start working (So short term!)

Question 26

AGORAPHOBIA

Answer 26

**Agoraphobia - Anxiety triggered by real life situations or anticipated exposure such as open areas, small areas, public transportations** Can start panic like symptoms Social phobia-Fear of social or performance situations in which embarrassment may occur, such as public speaking, going to parties. Specific phobias - Animal type: snakes, insects, etc. (childhood onset) - Natural environment type: heights, water, storms (childhood onset) - Blood, injection, injury type (familial, strong vasovagal reaction) - Situational type: airplanes, elevator (bimodal peaks in childhood & in 20’s) - Other: fear of choking, vomiting, illness **Medications: ALL PHOBIAS TREAT WITH SSRIS**. Can give clonidine or propranolol before social situations. Also, cognitive behavioral therapy and systematic desensitization really helps :)

Question 27

OCD ## Footnote OBSESSVIE COMPULSIVE DISORDER

Answer 27

A common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts **(obsessions)** and behaviors **(compulsions)** that he or she feels the urge to repeat over and over. Compulsions are rituals or repetitive behaviors that MUST be done for that individual to function. MEDS: SSRIs such as fluoxetine (Prozac) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (paxil)

Question 28

PTSD ## Footnote (Post traumatic stress disorder)

Answer 28

**A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. This is usually associated with War vets or sexual trauma.** First line treatment for PTSD: SSRIs Paroxetine, sertraline and fluoxetine Secondline treatmetns: Tricyclic antidepressants and monoamine oxidase inhibitors Trazadone to help sleep. Benzo’s for short term anxiety (Risk of dependence). Can give clonidine or propranolol. Finally, atypical antipsychotics such as olanzapine, risperidone, and quetiapine.

Question 29

OVERALL TREATMENT for anxiety disorders

Answer 29

* Behavioral therapies: systematic desensitization * Medication: SSRIs, benzodiazepines (ADDICTIVE), buspirone, hydroxyzine * Psychotherapy & Psychoanalysis * Hypnosis * Cognitive Behavioral Therapy * Benzo’s are a dirty band aid, I guess they good for use. But they will cause problems later

Question 30

BIPOLAR DISORDER

Answer 30

* Bipolar I: Manic & depressed symptoms are present Most patients are depressed most of the time (More common in men) * Bipolar II: Hypomania and depression (more common in females) * Cyclothymic Disorder: The “lite” version of Bipolar II

Question 31

BIPOLAR DISORDER SIGNS & SYMPTOMS MANIA

Answer 31

**DIGFAST** ## Footnote * *D**istractibility * *I**nsomnia (decreased need for sleep) * *G**randiosity * *F**light of ideas or racing thoughts * *A**gitation * *S**peech pressured, talkative * *T**aking risks without regard for consequences

Question 32

BIPOLAR DISORDER SIGNS & SYMPTOMS DEPRESSION

Answer 32

* depressed mood * psychomotor retardation * anhedonia * anxiety * psychomotor agitation * vegetative signs: changes in bowel movement and eating habits, sleep disturbance, disinterest in sex, poor concentration & judgment, guilt, indecisive * somatic complaints: chronic or intermittent pain

Question 33

BIPOLAR DISORDER KEY CONCEPTS & DRUGS

Answer 33

* *Manic people like to be manic; depressed people don’t like to be depressed.** This affects motivation for treatment - Mania is euphoric mood **Medications:** Antidepressants: SSRIs (Prozac), SNRIs (Effexor), NDRIs (Wellbutrin), tricyclic antidepressants (Trazodone), MAOIs (Emsam) Lithium for BIPOLAR Disorders. Help stabilize mood.

Question 34

SCHIZOPHRENIA

Answer 34

* a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation. * Delusions * Hallucinations * Disorganized speech * Disorganized catatonic behavior * Psychotic symptoms more pronounced and disruptive than in other psychotic disorders * Schizophrenia does NOT mean split personality or multiple personality * There are 2 types of symptoms seen in schizophrenia: negative and positive.

Question 35

SCHIZOPHRENIA POSITIVE SYMPTOMS

Answer 35

* caused by excessive dopamine in mesolimbic tract; Type I: symptoms are an embellishment of normal cognition and perception...symptoms are additional…believed to be a result of elevated dopamine levels affecting limbic areas of the brain * Abnormal thoughts, Agitation, Bizarre behavior, Delusions, Excitement, Feelings of persecution, Grandiosity, Hallucinations, Hostility, Illusions, Insomnia, Suspiciousness

Question 36

SCHIZOPHRENIA NEGATIVE SYMPTOMS

Answer 36

* caused by too little dopamine in mesocortical tract; Type II: symptoms are essentially an absence or diminution of normal cognition and perception (ex: lack of energy)..Type II is related in part to hypodopaminergic process. * Alogia (Poverty of speech), Anergia (lack of energy), Asocial behavior, Attention deficits, Avolition (decrease in the motivation to initiate and perform self-directed purposeful activities), Blunted affect (reduction in the intensity of an individual's emotional response), Communication difficulties, Difficulty with abstractions, Passive social withdrawal, Poor grooming, hygiene, andt rapport * FGA’s target positive symptoms, but don’t do much for negative symptoms. SGA’s target both types of symptoms. * * Symptoms of schizophrenia, such as agitation and hallucinations, can diminish within 1-2 weeks. Delusions can diminish within a few weeks . The average patient can expect only a 30-50% reduction in symptoms with treatment. If the patient stops taking meds, the symptoms will return. * Medications: FGA, SGA, and last resort is clozapine.

Question 37

TBI TRAUMATIC BRAIN INJURY

Answer 37

* Disruption of normal brain function that occurs when the skull is struck, suddenly thrust out of position, or penetrated * Symptoms may appear right away or may not be present until days or weeks or months after the injury * TBI can affect a single, specific region of the brain (focal injury), be distributed throughout the brain (diffuse injury), or both * * Open wound injury: BAM a bullet to my head, or a pole * Close Wound Injury: BAM I fell and hit the concrete (No penetration of the skull) * Deceleration Injury: Shaken Baby syndrome. Occurs with differential movement of the skull and the brain when the head is struck * * BASED on loss of consciousness of how severe it is * Mild: Loss of consciousness under 30 mins * Moderate: More than 30 but less than 24 hours * Severe: Shit…. Alot lol. Over 24 hours of no consciousness * * Always, look for risk for suicide!! Chance increases and substance abuse * * NO MEDICATIONS FOR TBI!!