Neuropsikiatri Flashcards

Question

Persistent depressive disorder (dysthymia)

Answer 1

Persistent depressive disorder (dysthymia) is a mood disorder characterized by insidious and chronic symptoms of depression that occur most of the day for more days than not. It is different from major depressive episode and chronic depressive disorder. In the former, there is a clear-cut episode of depression with a relatively clear time of onset, and in the latter, there are persistent residual symptoms of depression after onset of a clear-cut major depressive episode. Rather, dysthymic patients often report they have “always” been depressed and express significant symptoms of depression, including hopelessness and anhedonia. Suicidal ideation, however, is not a common occurrence in dysthymic disorder, being much more common in severe depression. Dysthymic disorder is chronic and often difficult to treat pharmacologically

Answer 2

is a psychotic disorder with a concomitant mood disorder. In this disorder, there are periods marked by the co-occurrence of a depressive episode, manic episode, or mixed episode, concurrent with psychotic symptoms, all within an uninterrupted period of time. In addition, there are separate periods of delusions or hallucinations in the absence of prominent mood symptoms. However, mood episodes should be present for the majority of the duration of the active illness. Schizoaffective disorder is distinguished from depression or mania with psychotic features in that in schizoaffective disorder, there must be at least a 2-week period during which psychotic symptoms are present without prominent symptoms of a mood disorder.

Answer 3

symptoms started following a significant stressor and consisted of hallucinations, delusions, and disorganized speech, similar to the symptoms of schizophrenia. However, symptoms lasted less than 1 month, and did not recur, with a return to baseline. Brief psychotic disorder can also occur in the absence of an acute stressor, and can also occur postpartum.

Answer 4

delusional disorder, patients typically are able to function normally, apart from the ramifications the delusion may have on the patient’s function and behavior. Jenis: - erotomanic type. -Grandiose type, in which there are delusions of inflated worth, power, knowledge, or identity. -Jealous type, in which there are delusions that an individual’s significant other is unfaithful. -Persecutory type, in which the delusion is one of being persecuted by someone. -Somatic type, delusions of having a physical defect or medical problem

Answer 5

This is a constellation of emotional and behavioral symptoms that occur in response to a recent stressor, one that occurred within 3 months of symptom onset. The distress exhibited is in excess to what would be expected from the stressor, but symptoms are not as severe as they are in major depression and symptoms do not persist beyond 6 months of the stressor. Adjustment disorder may be further qualified as being accompanied by depressed mood or by anxiety. Bereavement is a diagnosis that is made when an expected response occurs in reaction to the death of a loved one. Adjustment disorder may subsequently be diagnosed if the bereavement reaction is more prolonged than would be expected (longer than 2 months) or more excessive than would be expected

Answer 6

intermittent explosive disorder (IED), an impulse control disorder characterized by several episodes of verbal or physical aggression that is out of proportion to an instigating event. In between episodes, patients may express remorse or regret for their actions. IED typically starts in adolescence or early adulthood and is more common in men. Treatment of IED includes psychotherapy, as well as pharmacotherapy with mood stabilizers

Answer 7

- Intermittent impulsive disorders - kleptomania : recurrent impulses to steal objects because of a sense of pleasure or gratification from the act of stealing, with the object being of little personal use or value. - trichotillomania (recurrent pulling of one’s hair resulting in hair loss and a sense of pleasure or gratification), pyromania (deliberate setting of fires, a fascination with fire, and pleasure or gratification when setting fires or observing their aftermath), and pathologic gambling.

Answer 8

eating disorders include - anorexia nervosa, - bulimia nervosa, - binge eating disorder, - eating disorder not otherwise specified

Answer 9

restricted energy intake relative to the requirements and resulting in a significantly low body weight. In an individual with anorexia nervosa there is disturbed perception of one’s body weight/shape, an intense fear of gaining weight, and an impaired self-perception of weight (such as denial of the seriousness of low body weight). Anorexia nervosa is of two types: The first is a restricting type, which occurs in approximately 50% of patients, in which there is self-induced starvation and often compulsive exercising without binge eating or purging behaviors. The second type is a binge eating/purging type, in which the patient regularly engages in binge eating followed by purging. Anorexia nervosa is treated at least initially in the inpatient setting to allow for medical stabilization and initiation of nutrition under close supervision. Later, outpatient therapy revolves mainly around psychotherapy, with pharmacologic management of comorbid mood or anxiety disorders.

Answer 10

patients binge and subsequently partake in compensatory behaviors to prevent weight gain such as excessive exercise, induction of emesis or misuse of laxatives, diuretics, or other medications. In contrast to anorexia nervosa, patients with bulimia nervosa typically maintain a normal body weight. In patients with bulimia nervosa, self-assessment is unduly influenced by body weight and shape. Treatment of bulimia nervosa involves psychotherapy combined in some cases with selective serotonin reuptake inhibitors

Answer 11

binge eating occurs over discrete periods. During episodes of binge eating, there is a sense of lack of control, embarrassment (by how much one is eating), and/or guilt. Bulimia nervosa is distinguished from binge eating disorder in that in the latter, inappropriate compensatory behaviors do not occur

Answer 12

an autoantibody mediated disorder that may be either paraneoplastic or autoimmune. there are usually prodromal psychiatric symptoms before the frank acute psychosis occurs. Furthermore, and more importantly, they are not typically associated with the cognitive changes, seizures, and respiratory failure as described in this patient. Standard of care dictates consideration of potential secondary causes in patients presenting with primarily psychiatric symptoms particularly when neurologic signs and/or symptoms emerge. Neurologic disorders that may present initially with psychiatric symptoms include (but are not limited to) infectious, autoimmune and paraneoplastic encephalitides, and neurometabolic and neurodegenerative disorders. Usually, other signs and symptoms emerge to suggest one of these, so continued examination and reassessment of patients presenting with acute psychiatric symptoms is essential.

Answer 13

specific learning disability. This is marked by difficulties learning and acquiring academic skills out of proportion to any developmental, mental, or neurologic disorders and despite interventions to target those difficulties. Domains affected include reading, writing, or math skills. Individuals affected with learning disability perform below what would be expected for the individual’s chronologic age. In individuals with specific learning disability, capabilities in other domains are typically average or may be above average, though the various learning disabilities frequently co-occur

Answer 14

Mental retardation is defined by significantly subaverage general intellectual functioning, in more than one domain, as assessed by standardized tests. Mild mental retardation is defined by an intelligence quotient (IQ) of 55 to 70, moderate mental retardation by an IQ of 35 to 55, severe mental retardation by an IQ of 20 to 35, and profound mental retardation by an IQ of less than 20.

Answer 15

personality disorders consist of 10 distinct entities that share in common a chronic and pervasive pattern of inner experiences, thoughts, and behaviors. They affect the domains of cognition, impulse control, affectivity, and interpersonal functioning. Features are present in adolescence or early adulthood and persist over time. They deviate from accepted societal culture and norms and lead to distress or impairment. The caveat to the diagnosis of personality disorders is that the features do not occur in the context of signs or symptoms that are part of a mood, anxiety, impulse control, or psychotic disorder, or any other psychiatric disorder as the primary underlying illness. Personality traits are patterns of behavior or thinking about oneself and the environment that are relatively consistent over time, but they do not lead to a diagnosis of personality disorder unless they are maladaptive or cause functional impairment or distress. The personality disorders are categorized into clusters A, B, and C. Different personality disorders may co-occur in the same individual. cluster A includes paranoid, schizoid, and schizotypal personality disorders cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. cluster B includes narcissistic, antisocial, borderline, and histrionic personality disorders

Answer 16

Paranoid personality disorder is marked by pervasive distrust, paranoia, and suspiciousness of others. Persons with paranoid personality disorders have an increased risk of comorbid major depressive disorder, substance abuse, and agoraphobia Paranoid personality disorder is more common in males and may be an antecedent to paranoid type of delusional disorder

Answer 17

Schizoid personality disorder is marked by blunted range of affect and emotions. There is a lack of interest in or enjoyment of social relationships and intimacy. Individuals with this disorder exhibit little pleasure in social activities, with a preference for solitude, and lack close friends outside of the immediate family. Schizoid personality disorder is more common in males, and may appear as an antecedent to delusional disorder or schizophrenia

Answer 18

Schizotypal personality disorder is marked by odd, peculiar, and eccentric ideas, beliefs, and/or behaviors including magical thinking (such as superstitiousness or belief in clairvoyance or telepathy), paranoid ideation, and constricted affect. Individuals with this personality disorder have social anxiety and are uncomfortable with close relationships; they typically lack close friends outside of immediate family members. Patients with schizotypal personality disorder have comorbid major depression in 30% to 50% of cases.

Answer 19

Munchausen’s syndrome is a chronic, severe form of factitious disorder in which extensive deceptive means are often employed in feigning physical signs, resulting in recurrent hospitalizations in various geographic locations. In factitious disorder imposed on other (previously, Munchausen’s syndrome [or factitious disorder] by proxy), physical signs or symptoms are intentionally produced in another individual who is under the direct care of the perpetrator. In malingering, the secondary gain is an external incentive (such as money). In comparison, the secondary gain in factitious disorder is assumption of the role of a patient.

Answer 20

hypersensitivity to criticism, feelings of inadequacy, and social inhibition. Individuals with this disorder may avoid an occupation or other activity that will involve contact with others because of fear of criticism or rejection. They may show restraint in personal relationships because of fear of being ridiculed, and are willing to get involved with people only if certain of being liked. They often view themselves as socially inept and inferior to others. Unlike persons with schizoid personality disorder , those with avoidant personality disorder want relationships but avoid them because of fear of criticism, whereas those with schizoid personality disorder prefer social isolation. Avoidant personality disorder shares features with panic disorder with agoraphobia but in the latter condition, avoidance is of specific social situations that lead to panic attacks. Avoidant personality disorder begins at an early age, without clear precipitants, and is stable over time. Social phobia and avoidant personality disorder may co-occur.

Answer 21

have a chronic and excessive need to be taken care of. They may be clingy and have fear of separation. They have difficulty making day-to-day decisions without advice and reassurance from others, and prefer for others to assume responsibility for major areas of life. They are submissive and avoid disagreement with others for fear of loss of approval. They lack self-confidence and consequently avoid initiating projects or doing things independently. Individuals with this disorder may feel helpless when alone because of fear of being unable to care of themselves, and may urgently seek a new relationship as a source of care if another relationship ends. Dependent personality disorder is equally common in males and females, and is one of the most common personality disorders.

Answer 22

is marked by a dysfunctional and unproductive preoccupation with orderliness, perfection, and control at the expense of flexibility and efficiency. Individuals with this disorder are perfectionists without this necessarily being productive. They are rigid and inflexible in various aspects of life including in work and in relationships. They often prioritize work at the expense of leisure activities or friendship. Some individuals with this personality disorder have difficulty parting with unneeded objects (to the extent of hoarding in some cases). Although obsessive compulsive disorder may coexist with obsessive-compulsive personality disorder, distinct and definable obsessions and compulsions are absent in the latter, distinguishing the two.

Answer 23

is marked by grandiosity and a sense of self-importance. These individuals are arrogant and preoccupied by perceived positive attributes such as success or beauty, believe that they are superior to others, and have a sense of self-entitlement. On the other hand they have fears of others seeing their flaws. They manipulate others to achieve ends in their own self-interest, often at the expense of the interest of others. Individuals with this disorder also lack empathy. Narcissistic personality disorder is more common in males, and major depression and substance abuse are common comorbidities.

Answer 24

is marked by disrespect of others and the law, starting since age 15. Individuals with this disorder exhibit deceptiveness, impulsivity, aggressiveness, recklessness, and irresponsibility (in the workplace, financially, etc.). They lack remorse, with indifference to harming others. Conduct disorder is a prerequisite for the diagnosis of antisocial personality disorder; antisocial personality disorder cannot be diagnosed in those younger than 18. Impulse control disorder may occur in persons with antisocial personality disorder, but the other features of antisocial personality disorder discussed distinguish the two. Antisocial personality disorder is three times more common in males as compared to females.

Answer 25

is marked by pervasive instability in various aspects including selfimage, relationships, and affect. In their interactions with and perception of others, individuals with this disorder alternate between idealization and devaluation (so-called splitting). They have an intense fear of abandonment and go to extremes to avoid this. They often engage in self-injurious behavior including suicidal gesture or threats, or self-mutilation. The instability and extremism extends to eating behaviors and sexuality. Borderline personality disorder is more common in females. Frequent comorbidities include major depression, eating disorder, and substance abuse.

Answer 26

is marked by attention-seeking behavior, including constant need to be the center of attention and inappropriately seductive or provocative behavior. Individuals with this disorder use their physical appearance to draw attention to themselves, and may be theatrical and dramatic. They also exhibit excessive emotionality and have shallow and rapidly shifting emotions. Histrionic personality disorder is more common in females, and common comorbidities include major depression, conversion disorder, and somatic symptom disorder.

Answer 27

In ADHD, symptoms start before age 12, are functionally impairing, and are not consistent with developmental level. ADHD may present with predominantly inattentive symptoms (such as difficulty sustaining attention on a given task and are easily distractible). ADHD may also present with predominantly hyperactive symptoms (such as fidgetiness, restlessness, and impatience). In some patients, a combination of these occurs. Although the etiology of ADHD is not clear, dysfunction in frontal-subcortical circuits has been implicated. Genetic studies have suggested involvement of genes related to dopamine action or metabolism, though environmental factors play a role as well. Children of parents with ADHD and siblings of children with ADHD are more likely to be affected with ADHD than the general population. The first line of treatment for ADHD are psychostimulants including amphetamines and methylphenidates, of which there are various oral preparations. Common side effects include reduced appetite, weight loss, insomnia, and headaches. An electrocardiogram prior to initiation of stimulant medications is recommended to exclude underlying structural or conduction problems. Other medications used to treat ADHD include the nonstimulant atomoxetine, tricyclic antidepressants, antipsychotics, mood stabilizers, and the α2-agonist clonidine. Psychosocial treatment is also an important part of managing ADHD

Answer 28

folie à deux, a type of disorder in which a psychotic belief develops in an individual that is similar to that held by a close relation

Answer 29

Serotonin, or 5-hydroxytryptamine (5-HT), is synthesized from tryptophan . Serotonin is metabolized by action of monoamine oxidase (MAO) into 5-hydroxyindoleacetaldehyde, which by action of aldehyde dehydrogenase is transformed to 5- hydroxyindoleacetic acid. MAO-A is the predominant isoform in the metabolism of serotonin. In the CNS, the principle site of serotonergic neuronal cell bodies is in the raphe nuclei of the brainstem, with diffuse projections to the brain and spinal cord. Serotonin has various actions both in the CNS and systemically. In the CNS, serotonin has a role to play in the sleep-wake cycle; serotonin deficiency leads to insomnia, and tryptophan (a serotonin precursor) promotes sleep. Serotonin has also been implicated in violent behavior; low CSF levels of the serotonin metabolite 5-hydroxyindole acetic acid (5-HIAA) have been associated with aggressiveness and violent impulsivity. Serotonin deficiency has also been implicated in both anxiety and depression

Answer 30

nonpsychotropic effects of serotonin, the 5-HT1B receptors elicit vasoconstriction and the 5-HT1D receptors inhibit neuronal transmission and trigeminal neurogenic inflammatory peptide release. Triptan medications such as sumatriptan are agonists at these latter receptors. Action of serotonin at 5-HT2A receptors leads to platelet aggregation. Serotonin acts at 5-HT3 in the area postrema and the antiemetic ondansetron is an antagonist at this receptor. Serotonin is released by enterochromaffin cells in the intestines where it increases intestinal motility. It also induces bronchoconstriction, and patients with malignant carcinoid syndrome, in which there is excessive production of serotonin, manifest many of the symptoms of a hyperserotonergic state, including wheezing and diarrhea

Answer 31

Serotonin syndrome results from overstimulation of brainstem serotonin receptors. Symptoms include encephalopathy, autonomic hyperactivity manifesting as hypertension, tachycardia, and diaphoresis, as well as myoclonus, hyperreflexia, and tremor. Serotonin syndrome can occur with any agent that increases serotonin, and has even been reported with monotherapy, but is more likely to occur with a combination of therapies that increase serotonin, and particularly with concomitant use of nonselective monoamine oxidase inhibitors. Treatment generally includes supportive care and withdrawal of the offending agent. Serotonin withdrawal syndrome can occur with abrupt discontinuation of serotonergic medications such as selective serotonin reuptake inhibitors. Symptoms include dizziness, paresthesias, dysphoria, and in some cases encephalopathy. Therefore, gradual tapering of such medications is generally recommended

Answer 32

tricyclic antidepressants (TCAs) are among the oldest antidepressants and are still commonly used to treat depression. The TCAs with a tertiary amine side chain such as amitriptyline, doxepin, and imipramine inhibit reuptake of both serotonin and norepinephrine, whereas some such as clomipramine predominantly inhibit reuptake of serotonin. The TCAs do not directly inhibit reuptake of dopamine, though they may indirectly facilitate the effects of dopamine. All TCAs have some activity at muscarinic, histaminergic, and α1-adrenergic receptors, though to varying degrees. Because of these effects at noncatecholaminergic receptors, they are used for various disorders not limited to depression and anxiety, including urinary retention and neuropathic pain.

Answer 33

Tricyclic antidepressants (TCAs) lead to urinary retention due to inhibition of detrusor function, rather than bladder overactivity. Because the TCAs all have, to varying degrees, activity at muscarinic, histaminergic, and α1-adrenergic receptors, they have various side effects. Antagonism at histamine receptors leads to sedation, xerostomia, and weight gain. Antimuscarinic activity leads to constipation, tachycardia, blurred vision (with increased risk of glaucoma), and urinary retention, and hence imipramine is used to treat overactive bladder and enuresis. α1-Adrenergic antagonism can lead to postural hypotension, which can be particularly detrimental in older adults. Of the commonly used TCAs, amitriptyline has the highest antimuscarinic activity and α1- adrenergic activity. Nortriptyline has the least α1-adrenergic antagonism and is therefore less likely to cause orthostatic hypotension. Doxepin has the highest antihistamine activity, and is therefore the most sedating. At toxic doses, TCAs can cause confusion, seizures, and arrhythmias. TCAs are metabolized through oxidation by various cytochrome P450 isozymes and subsequently undergo glucuronidation. Because their metabolism is strongly dependent on cytochrome P450 enzymes, they have various drug–drug interactions

Answer 34

The SSRIs include fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram. They inhibit reuptake of serotonin through inhibition of the serotonin transporter, leading to increased availability of serotonin at the postsynaptic membrane. The antidepressant and/or anxiolytic effect of SSRIs may not become apparent for several days to weeks because their mechanism of action involves pre- and postsynaptic receptor changes that are not immediate The SSRIs are metabolized by the hepatic cytochrome P450 system and have various drug–drug interactions, with the extent varying with each of the SSRIs. Citalopram and escitalopram have the least potential for drug–drug interactions

Answer 35

Gastrointestinal side effects, including nausea, result in part from action of serotonin at 5HT3 receptors in the area postrema, but also from increased serotonin at the level of the enteric nervous system. Tolerance to this side effect typically develops after a few days of therapy. SSRIs cause sexual dysfunction, particularly leading to erectile dysfunction in men. They can lead to irritability and increased suicidal thoughts, particularly in younger age groups. Some of the SSRIs can lead to insomnia, whereas others are more sedating. Sertraline is one of the least sedating SSRIs. Paroxetine has the highest anticholinergic activity and therefore causes several anticholinergic side effects, including xerostomia and urinary retention.

Answer 36

typical antipsychotics exert their antipsychotic effect predominantly by antagonism at D2 receptors. The typical antipsychotics, first brought into clinical use in the 1950s, include chlorpromazine and thioridazine, which have low potency at D2 (dopamine) receptors and higher antagonism at muscarinic, adrenergic, and histaminergic receptors. They are therefore more likely to cause side effects related to antagonism at these receptors, such as dry mouth, orthostasis, and sedation, respectively. Those with higher potency at D2 receptors, such as haloperidol and fluphenazine, have activity at muscarinic, adrenergic, and histaminergic receptors as well and can lead to similar side effects, but are less likely to do so. On the other hand, they are more likely to lead to extrapyramidal side effects (EPS), which result from D2- antagonism in the nigrostriatal pathway. The EPS can be divided into acute reactions such as acute dystonia, which are in general reversible with treatment with antimuscarinic agents such as benztropine, and tardive dyskinesia (such as the orolingual dyskinesias or tardive cervical dystonia), which are in general irreversible but may be treatable with botulinum toxin or deep brain stimulation to the globus pallidus interna

Answer 37

The second generation of antipsychotics, so-called atypical antipsychotics, includes clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole. These agents do have antagonistic activity at D2 (dopamine) receptors, however, their clinical antipsychotic effect results in large part from antagonism at serotonergic 5-HT2A receptors. Studies to date have not shown overall superior efficacy of the atypical antipsychotics over the typical ones, though atypical antipsychotics may be more effective at treating some of the negative symptoms of schizophrenia. Because they have less antagonism at D2 receptors, they are less likely to cause extrapyramidal side effects (EPS), but certainly can. As a class, the atypical antipsychotics carry with them an increased risk of weight gain, diabetes, and dyslipidemia. Patients being treated with these medications should therefore periodically be assessed for such side effects. Clozapine and olanzapine are most likely to lead to weight gain. Ziprasidone and aripiprazole are less likely to cause weight gain than the others.

Answer 38

Some of the typical and atypical antipsychotics including thioridazine, haloperidol, ziprasidone, and quetiapine have negative ionotropic action on the heart and a quinidine-like effect, leading to QT prolongation with the potential for arrhythmias. Aripiprazole is least likely to do so. Other cardiac side effects include myocarditis, which can rarely be seen with clozapine. The atypical antipsychotics also have activity at muscarinic, adrenergic, and histaminergic receptors, and several side effects result from activity at these sites. Clozapine can lead to agranulocytosis in 1% to 2% of patients, and patients being treated with this medication are required to have periodic complete blood counts checked. Clozapine also leads to a dose-dependent increased risk of seizures. Clozapine is least likely of all the atypical antipsychotics to lead to EPS. Because of the side effect profile of clozapine, its use is usually limited to treatment of patients who have failed trials of other typical and atypical antipsychotics. Among the atypical antipsychotics, olanzapine has the highest antimuscarinic activity, and side effects resulting from this include dry mouth, urinary retention, confusion, and constipation. Clozapine also has significant antimuscarinic activity. Quetiapine has significant antihistaminergic activity, and along with olanzapine, is the most likely to lead to sedation. Dopamine inhibits prolactin release, and treatment with both typical and atypical antipsychotics can lead to hyperprolactinemia and amenorrhea resulting from dopaminergic antagonism in the tuberoinfundibular pathway

Answer 39

Flumazenil is an antagonist of benzodiazepines and other sedative– hypnotic agents such as zolpidem and eszopiclone (the latter two agents are used in the treatment of insomnia). Flumazenil does not however antagonize the action of barbiturates.

Answer 40

bupropion and clozapine have been associated with increased risk of seizure at higher dosages. Olanzapine is less likely to cause seizures, but can do so; other atypical antipsychotics rarely cause seizures. Amitriptyline, which is a tricyclic antidepressant is also associated with increased seizure risk with acute toxicity. Flumazenil, by inducing a state of benzodiazepine withdrawal, can lead to increased risk of seizures, particularly in patients with a prior history of seizures.

Answer 41

Mood-stabilizing agents used to treat bipolar disorder include lithium carbonate, as well as the anticonvulsants including valproic acid, carbamazepine, and lamotrigine

Answer 42

mechanism of action of lithium carbonate is not clear, but does include inhibition of the inositol and glycogen synthase kinase 3 signal pathways and downstream enzyme activity. Serum levels of lithium should be monitored periodically. Common adverse effects of lithium include tremor, thyroid dysfunction, acne, and nephrogenic diabetes insipidus, which can lead to hypernatremia if there is not adequate oral intake of fluids. Lithium is contraindicated in patients with sick sinus syndrome because it has a negative chronotropic effect.

Answer 43

Electroconvulsive therapy can be a highly effective therapy for depression. It is most commonly used for major depression refractory to medications but is also used acutely in depression (without a prior drug trial) when necessary. Suicide is not a contraindication for ECT. Other indications for ECT include schizoaffective disorders, schizophrenia, and mania (particularly in bipolar patients with a mixed episode [of both mania and depression] or rapidly cycling bipolar disorder). In ECT, an electric current is applied to the scalp in an anesthetized patient, with the goal of inducing a nonconvulsive seizure. The mechanism of action of the antidepressant effects of ECT is not well understood. Side effects include retrograde amnesia, which can be partially irreversible.

Answer 44

In TMS, a rapidly changing magnetic field is applied to the scalp and is thought to affect the superficial layers of the cerebral cortex, locally inducing small electric currents. Single-pulse TMS is generally considered safe but seizures are nevertheless a potential risk, even in individuals without a prior history of epilepsy. Application of TMS to the left dorsolateral prefrontal cortex improves symptoms in major depression. In VNS, intermittent electrical stimulation is directly applied via an electrode to the left cervical vagus nerve. The current is provided by a pulse generator, a pacemaker-sized device that is implanted in the chest and is connected to the electrode. Stimulation of the afferent vagus nerve fibers leads to changes in several brainstem nuclei that are involved in the pathophysiology of depression, such as the nucleus of the tractus solitarius and raphe nuclei, leading to alterations in serotonergic activity in cortical and limbic structures. VNS is used as adjunctive therapy for chronic or recurrent depression in individuals with either unipolar depression or bipolar disorder.

Answer 45

Buspirone is an anxiolytic agent without sedative–hypnotic activity. Its mechanism of action involves partial agonism at serotonergic (5-HT1A) receptors. It also has some activity at dopaminergic D2 receptors. The mechanism of action of bupropion is not well understood, but animal studies have shown that it inhibits reuptake of norepinephrine and dopamine and increases presynaptic release of these neurotransmitters, without direct effects on the serotonin system. At high doses, bupropion increases risk of seizures. Bupropion, in addition to its use as an antidepressant, is used in smoking cessation.

Answer 46

benzodiazepines belong to a class of medications known as the sedative-hypnotics by nature of their ability to induce an anxiolytic calming effect and sleep. They include alprazolam, midazolam, chlordiazepoxide, temazepam, triazolam, flurazepam, clorazepate, oxazepam, and diazepam. They act at GABAA receptors, facilitating the action of GABA and increasing chloride conductance. The benzodiazepines may be used in the treatment of acute anxiety, as is seen in generalized anxiety disorder, panic disorder, and agoraphobia. However, chronic use leads to tolerance (decreased response to a specific dose after repeated exposure) as well as physiologic dependence. Other adverse effects include memory disturbance, sedation, and respiratory depression in overdose (or even at therapeutic doses in those with pulmonary disease). Chronic therapy for anxiety disorders therefore includes medications such as the selective serotonin reuptake inhibitors, tricyclic antidepressants, and serotonin–norepinephrine reuptake inhibitors. The latter medications do not have acute effects on anxiety, and in the initial weeks of therapy, benzodiazepines are often used as adjuncts until the anxiolysis takes effect. Of the benzodiazepines, flurazepam and clorazepate have the longest halflives. Triazolam has a rapid onset and short duration of action. Besides the treatment of acute anxiety, benzodiazepines are also used in the treatment of seizures, alcohol withdrawal, spasticity and movement disorders, and insomnia.

Answer 47

Hyponatremia is an established side effect of therapy with selective serotonin reuptake inhibitors (SSRIs). Risk factors include older age, female sex, and concomitant use of diuretics. Hyponatremia resulting from SSRIs typically occurs within the first month of therapy, but may not occur until several months after initiation of therapy. Among the SSRIs, fluoxetine and paroxetine are more likely to lead to hyponatremia. The pathophysiology of SSRIinduced hyponatremia is thought to be at least in part related to the syndrome of inappropriate antidiuretic hormone, resulting from excessive release of antidiuretic hormone mediated by activation of serotonergic receptors. Although there are no definitive data to support routine monitoring of serum sodium in patients started on an SSRI, any change in mentation or other symptoms potentially suggesting hyponatremia should prompt a laboratory evaluation for this complication. In isovolemic hyponatremia due to SSRIs, the treatment is discontinuation of the SSRI along with fluid restriction. In more severe symptomatic hyponatremia, treatment with intravenous sodium chloride may be indicated. Rechallenge with SSRIs may not necessarily lead to recurrent hyponatremia, though it can.

Answer 48

GABA is an amino acid and is the major inhibitory neurotransmitter in the CNS. Glycine is also an inhibitory amino acid neurotransmitter and plays a prominent role in the brain and spinal cord. GABA is synthesized from glutamic acid by action of the enzyme glutamic acid decarboxylase. Disorders of this enzyme lead to a deficiency in GABA and subsequently overactivation in the CNS, as is seen in stiff person syndrome. The GABAA receptor is an example of an ionotropic receptor, activation of which leads to opening of chloride channels. The GABAB receptor is an example of a metabotropic receptor, which is coupled to an inhibitory Gprotein, inhibiting adenylyl cyclase. Baclofen is an example of a selective GABAB receptor agonist; benzodiazepines act at GABAA receptors.

Answer 49

Duloxetine and venlafaxine are serotonin–norepinephrine reuptake inhibitors (SNRIs): They inhibit reuptake of both serotonin and norepinephrine by inhibiting serotonin and norepinephrine transporters, respectively. The SNRIs and tricyclic antidepressants (TCAs), because they increase both norepinephrine and serotonin, are useful in the treatment of pain disorders. Unlike the TCAs, the SNRIs are relatively selective and have little activity at muscarinic, histaminergic, and α-adrenergic receptors

Answer 50

Mirtazapine has complex pharmacology; it acts as an antagonist at presynaptic α2-receptors, increasing release of norepinephrine and serotonin, and also acts as an antagonist at 5-HT2 and 5-HT3 receptors. Its potent antagonism at histamine receptors accounts for its sedating effects.

Answer 51

Trazodone and nefazodone act primarily by antagonism at the 5- HT2 receptor; trazodone was initially used as an antidepressant, but its primary use today is as a hypnotic (sedative) because it is highly sedating and little tolerance develops to its sedating effect over time. An adverse effect that may occur with trazodone therapy is priapism or prolonged painful erection

Answer 52

Phenelzine and isocarboxazid are nonselective monoamine oxidase inhibitors (MAOIs) and are among the oldest antidepressants, rarely used in clinical practice today due to their side effect profile. Because nonselective MAOIs block metabolism of tyramine, found in certain foods such as cheese and wine, a lethal reaction resulting from hyperadrenergic state can occur with use of MAOIs, particularly when taken with other agents that increase serotonin

Neuropsikiatri Flashcards

Depresi, gangguan mood, psikotik (76 cards)