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MUSM Block 2 Module 2 > Post-Mid Mod > Flashcards

Post-Mid Mod Flashcards

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1
Q

What are the characteristics of a psychotic patient

A

-Demonstrating a loss of reality
-Experiencing delusions/hallucinations/thought disorders

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2
Q

What are the differential diagnoses for psychotic patients

A

-Schizophrenia
-Brief psychotic
-Delusional
-Schizophreniform
-Schizoaffective
-Substance/medication-induced psychosis
-Mood disorders
-Other medical conditions inducing psychosis

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3
Q

Symptoms of hallucinations, delusions, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms (emotional blunting) WITH loss of social/occupational functioning

A

Schizophrenia

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4
Q

Symptoms of hallucinations, delusions, disorganized speech, disorganized/catatonic behavior, and negative symptoms for at least 1 month and less than 6 months; less socially/occupationally impaired

A

Schizophreniform Disorder

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5
Q

Symptoms of a major depressive/manic episode concurrently with the core symptoms of schizophrenia; must be present without prominent mood symptoms for at least 2 weeks

A

Schizoaffective Disorder

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6
Q

Symptoms of persistent but relatively circumscribed delusions for at least one month in the absence of other schizophrenia symptoms; able to function in daily life normally

A

Delusional Disorder

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7
Q

Symptoms of psychosis, delusions, hallucinations, disorganized speech/behavior that are persistent for at least one day by for less than one month; return to full premorbid functioning

A

Brief Psychotic Disorder

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8
Q

Symptoms of hallucinations, delusions, gross disorganization that are directly caused by the effects of a medical illness (neurological, endocrine, metabolic, autoimmune, delirium)

A

Psychotic Disorder due to another medical condition

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9
Q

What is the presentation difference between delirium and schizophrenia

A

Delirium has fluctuating levels of alertness/orientation; schizophrenia patients are consistent and usually well-oriented

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10
Q

What drugs can induce psychosis

A

Adrenocorticosteroids
Atropine/Anticholinergics
Ketamine
NMDA receptor antagonists

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11
Q

Symptoms of psychosis, hallucinations, delusions, as a direct result of substance intoxication/withdrawal

A

Substance/Medication Induced Psychotic Disorder

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12
Q

What illicit substances can cause psychosis

A

Alcohol
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
Opioids
Phenylcyclidine
Sedatives

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13
Q

What are the positive symptoms of schizophrenia

A

Delusions and hallucinations

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14
Q

Fixed ideas based on incorrect perceptions of reality and do not stem from a shared system of cultural beliefs (i.e. internal to the individual)

A

Delusions

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15
Q

What are Schneider’s first-rank symptoms of schizophrenia (3)

A
  1. Thought broadcasting- believe that their thoughts can be perceived by others (no privacy)
  2. Thought insertion- believe that their thoughts are not their own but of someone else who inserted it into their heads
  3. Thought withdrawal- believe that thoughts are being removed from their heads (typically paranoid)
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16
Q

What is the most common perceptual symptom of schizophrenia

A

Auditory hallucinations

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17
Q

Are visual hallucinations more indicative of schizophrenia or delirium

A

Delirium

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18
Q

What are the negative symptoms of schizophrenia

A

Affective blunted/flattened expressions (robot-like)

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19
Q

How is the blunted/flattened affect of schizophrenia defined

A

Loss of volition + development of apathy (but NOT depressed)

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20
Q

What are the disorganized symptoms of schizophrenia

A

Bizarre/idiosyncratic thought processes
Loosening of associations
Clanging
Word salad (incoherent word patterning)
Disturbed word choices
Neologisms
Thought-blocking
Catatonia/Wavy flexibility

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21
Q

What are the chances of inheritance of schizophrenia

A

10% in siblings
13% in children (one parent- two parents is 30-40%)

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22
Q

What is a major risk factor for inheriting risk genes for schizophrenia

A

Advanced paternal age

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23
Q

What is the general mechanism of antipsychotic drugs

A

Block postsynaptic dopamine receptors > decrease activity in the dopamine pathways of the brain (the opposite of Parkinson’s drugs)

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24
Q

What is the action of dopamine on the tuberoinfundibular tract

A

Inhibits prolactin secretion from the posterior pituitary gland (responsible for many of the side effects of antipsychotics)

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25
What part tract of the brain are affected by the dopamine signaling in schizophrenia
Mesolimbic (increase in DA) and mesocortical (deficiency in DA) tracts *Mesocortical acts as feedback inhibitor of mesolimbic*
26
What is the state of cortical and mesolimbic activity in Schizophrenia (aka what causes the positive and negative symptoms)
Hypodopaminergic mesocortical activity > negative symptoms Hyperdopaminergic mesolimbic activity > positive symptoms
27
What are the initial (prodromal) signs of schizophrenia and when do they typically emerge
Negative symptoms (similar to schizotypal personality disorder) in adolescents
28
What usually precipitates the long-lasting (residual) symptoms of schizophrenia
Social changes; major life changes; stress
29
What is usually the pattern of schizophrenia symptoms
A first episode followed by extended period of time in remission, then can be followed by multiple/continuous episodes; variable time tables, but symptoms progressively worsen; will eventually plateau at a variable level Positive symptoms typically lessen over time, while negatives worsen
30
What are the common side effects of antipsychotics
Cardiometabolic effects (weight gain, elevated glucose/cholesterol > cardiovascular disease, metabolic syndrome) *most people with schizophrenia die of cardiovascular disease*
31
What is the primary mechanism of second-generation antipsychotic drugs
5-HT2A-receptor (activated by serotonin) inverse agonists > inhibit cortical and limbic dopamine release
32
What is the primary mechanism of first-generation antipsychotic drugs
Blocks dopamine D2-receptors in the mesolimbic and striatal-frontal system
33
What diseases are first-generational (typical) antipsychotics used for
Schizophrenia (positive symptoms) Psychosis Bipolar Disorder Delirium Tourettes Huntington Disease OCD
34
What are the side effect mechanism of low-potency first gen antipsychotics
Anticholinergic Antihistamine Anti-A1 adrenergic Increased prolactin
35
What are the side effects of high-potency first gen antipsychotics
Pseudoparkinsonsim Akathisia- treat with B-blockers Acute Dystonia- treat with benztropine Neuroleptic malignant syndrome- treat with Bromocriptine/Dantrolene Tardive dyskinesia- treat with benztropine
36
Which antipsychotic has a high risk for agranulocytosis
Clozapine *Largely used for refractory schizophrenia*
37
Why might atypical antipsychotics be associated with less side effects
Atypical antipsychotics block the D2 receptor as well, but at a lower affinity (does not interfere with DA needed for voluntary movement)
38
What antipsychotic has been used to reduce risk of suicide in schizophrenic patients
Clozapine
39
What antipsychotic is the most commonly prescribed in the US
Aripiprazole
40
If a patient develops tardive dyskinesia when using a typical antipsychotic, which atypical antipsychotics should they be switched to
Clozapine or Quetiapine
41
What are the symptoms and causes of Neuroleptic Malignant Syndrome
Typical Antipsychotics > truncal rigidity, hyperpyrexia, and altered mental status
42
Symptoms of persistent, distinct, depressed mood* or loss of pleasure/interest in normal activities*; can include significant weight loss/gain, insomnia, psychomotor agitation, fatigue, guilty/worthless/pessimistic/angry feelings/ideations, loss of focus, recurrent thoughts of death/suicide; present for at least 2 weeks
Major Depressive Disorder
43
What emotions are included in the feelings of sadness associated with depression
Hopelessness Helplessness Worthlessness
44
Loss of ability to experience pleasure
Anhedonia
45
Depressed patients that cannot sense or articulate their sadness, and instead focus on their loss of interest
Alexithymia
46
What sleep abnormalities are associated with depression
Sleep onset insomnia (trouble falling asleep) Sleep maintenance insomnia (waking in middle of night) Terminal insomnia (waking early in the morning) Also: hypersomnia is common *Decreased REM latency, Increased REM duration*
47
What is the differential for patients presenting with dementia symptoms, withdrawal, apathy, and/or irritability)
Pseudodementia associated with depression
48
What are the two patterns of depressive symptoms
Diurnal variation: Consistently at one particular time of the day Mood reactivity: Inconsistent; temporarily relieved by good things
49
Symptoms of mild depression characterized by low mood, lack of energy/interest, low self-esteem, and irritability; lasts for at least 2 years with little/no remission
Dysthymic/Persistent Depressive Disorder
50
What are the characteristics of chronic depressive disorders
Last for more than 2 years Associated with poor response to treatment Slower rate of improvement Younger onset Longer episodes Greater burden High rates of comorbidity High rates of suicidality
51
Symptoms of mild depression with long-standing personality difficulties, irritable/gloomy/complaining; hardworking, eager to please, cheerful yet fearful of making mistakes
Depressive personality
52
Symptoms of 1 manic episode with/without 1 depressive episode
Bipolar I Disorder
53
Symptoms of 1 hypomanic episode with 1 depressive episode
Bipolar II Disorder
54
Irritability or abnormal euphoria, high energy (grandiose), impaired insight for at least one week; often a decreased need for sleep, increased sexual drive, cognitive hastening/impulsivity
Mania
55
What can mania be confused for and why
Schizophrenia- loosening of associations, clang associations, and thought-disordered speech
56
Energetic with heightened cognitive and sensual alertness- creates a slightly euphoric feeling > will develop into unrealistic expectations and questionable judgement > depression and despair
Hypomania
57
Symptoms of alternating mild depression and hypomanic symptoms of short durations, and continue for several weeks to several months; complaints of chronic depression with fluctuating sleep patterns, agitation, and irritability
Cyclothymic Disorder
58
Symptoms of depressed mood/anhedonia in women associated with breast tenderness, headaches, bloating (during last week of luteal phase) in a cycle-pattern for 2 consecutive months
Premenstrual Dysphoric Disorder
59
What is the difference between normal bereavement and major depression symptoms
Bereavement has no pervasive low self-esteem, and symptoms will resolve naturally within 2-3 months (up to 1-2 years); no psychosis
60
What personality disorders typically are comorbid with depression
Borderline Histrionic Narcissistic
61
What is the major difference between personality disorders and mood disorders
Personality disorders are long-standing and consistent, mood disorders are abrupt and change pre-existing social functioning
62
What neurotransmitters might be associated with depressive symptoms
Decreased levels of norepinephrine and serotonin *Serotonergic system modulates dopaminergic neurons in VTA*
63
What is the (rate-limiting) metabolic precursor to serotonin
Tryptophan
64
What structures of the brain are affected by depression
Hippocampus Amygdala Pre-frontal cortex Anterior cingulate/medial orbital frontal cortex *Antidepressants increase BDNF levels- which promote neuronal growth/survival/maturation in these areas*
65
What is the pathogenesis of damage to the brain by depression
Acute stress exposure causes prolonged glutamate release in the prefrontal cortex and hippocampus > neuroexcitotoxicity
66
What evidence has suggested the connection between prolonged stress and depressive disorders
Elevated serum cortisol, increased adrenal mass, decreased glucocorticoid receptor mRNA expression *Possibly explains why hx of childhood abuse can cause depression in adults*
67
What hormones are decreased in patients with depression
Thyroid hormones Estrogen Testosterone
68
Which mood disorders are especially genetically-linked
Bipolar Disorder! Depression Disorders *Likely has to do with biological vulnerability + trigger factors*
69
What are the pertinent atypical features of depression
Increased sleep/appetite Extreme fatigue/leaden limb paralysis Mood reactivity
70
What are the pertinent psychotic features of mood disorders (esp. bipolar)
Delusions/Hallucinations that are mood-congruent (themes of guilt, pessimism, deserved punishment)
71
What are common features of seasonal recurrent depression
Lethargy and fatigue; hypersomnia and overeating
72
Symptoms of depressive symptoms (no psychotic features) for up to one year post-partum
Major depression with peripartum onset
73
What does "mixed feature" mood depression describe
Mixtures of mood, thought, and behavioral symptoms that can be simultaneous/out of sync (ex: mania, hypomania, and depressive symptoms happening concurrently and without order) *High risk of suicide*
74
What type of patients is electroconvulsive therapy used for
Depressed patients who are psychotic, extremely suicidal, or medically ill; delusional depression
75
What is the treatment for life-threatened manic episodes
Electroconvulsive Therapy
76
What is the mechanism of electroconvulsive therapy
Downregulation of NE receptors Increase 5-HT receptors Regulate Ca2+ entry into neurons
77
What is a common symptom of depression in elderly patients
Pseudodementia- lack of comprehension, memory loss, lack of recognition; transient in nature
78
What is a major risk in geriatric patients with depression
Increased incidence of cardiovascular and cancer-related deaths (high risk for MI)
79
What is the cognitive theory of depression
Proposes that the primary defect in depression is not a mood issue, but rather distorted thinking- unrealistic, pessimistic, negative views of oneself, the world, and the future
80
What is the mechanism of action of Lithium
Inhibits inositol signaling (IP3-DAG pathway) (via depleting intracellular inositol); inhibits glycogen synthase kinase-3 Blocks a-adrenergic and muscarinic transmission (which are increased during a manic episode)
81
What is the optimal maintenance serum level of Lithium
Between 0.6 and 0.9 mEq/L
82
What type of drugs reduce renal clearance of lithium
Diuretics (by about 25%) NSAIDs *Also avoid with typical antipsychotics- will worsen EPS*
83
What are the common side effects of lithium
Tremor (use propranolol and atenolol) Decreased thyroid function Polydipsia/Polyuria/Diabetes insipidus Edema SA depression Teratogen Leukocytosis
84
Which antiepileptics can be used to treat bipolar disorder
Valproic Acid (often combined with lithium) Carbamazepine (acute mania/prophylactic therapy)
85
What drugs are SSRIs
Fluoxetine Sertraline Citaprolam Paroxetine Fluvoxamine Escitalopram
86
Are antidepressants lipophilic or hydrophilic
Lipophilic
87
What is the general rule of prescribing fluoxetine
It must be discontinued >4 weeks before starting a MAOI
88
Which SSRIs are CYP2D6 inhibitors
Fluoxetine and Paroxetine
89
What is the MOA of SSRIs
Inhibit (allosterically) serotonin transporter (SERT), and DO NOT effect histamine/acetylcholine/a adrenoreceptors
90
What are the notable drug interactions of SSRIs
CYP2D6 Inhibition Interactions with MAOIs can cause serotonin syndrome
91
What are the notable side effects of SSRIs
Nausea GI upset Diarrhea Diminished sexual function/interest/arousal Weight gain (paroxetine) Teratogen
92
What drugs are SNRIs
Venlafaxine Desvenlafaxine Duloxetine
93
What are some of the uses of SNRIs
Major Depression Neuropathy/Fibromyalgia Generalized anxiety Stress urinary incontinence Vasomotor menopause symptoms
94
What is the MOA of SNRIs
Bind to serotonin (SERT) and norepinephrine (NET) transporters; DO NOT have affinity for other receptors (histamine, a-adrenergic, cholinergic)
95
What are the side effects of SNRIs
All the SSRI side effects Increased BP + HR Insomnia/Anxiety/Agitation Cardiac toxicity (venlafaxine)
96
What drugs are TCAs
Desipramine Imipramine
97
What is the MOA of tricyclic antidpressants
Inhibit serotonin and norepinephrine reuptake; imipramine is highly anticholinergic; anti-muscarinic; anti-histamine (H1)
98
What are the pertinent side effects of TCAs
Dry mouth/constipation/urinary retention/blurred vision/confusion Orthostatic hyotension Convulsions/Coma/Cardiotoxicity
99
What drugs are 5-HT2 receptor modulators
Trazodone Nefazodone
100
What is the most common use of trazodone
Hypnotic/Sedative
101
What is the MOA of trazodone/nefazodone
Inhibit the 5-HT2 receptor > antianxiety/antipsychotic/antidepressant effects
102
What are the side effects of 5-HT2 antagonists
Hepatotoxicity (nefazodone) Sedation GI Disturbances Priapism (trazodone) Orthostatic hypotension
103
What drugs are tetracyclics/unicyclics (more of a catch-all for other antidepressants)
Mirtazapine Amoxapine Maprotiline Bupropion Vilazodone *It says these are not often used... so yeah*
104
What drugs are MAO Inhibitors
Phenelzine Isocarboxazid Tranylcypromine Selegiline
105
What are the uses for MAO inhibitors
Depression Anxiety Panic Disorder Parkinson's Disease (selegiline)
106
What is the MOA of MAOI's
Inhibit MAO-A and MAO-B > increase monoamine content by inhibiting their metabolism (dopamine, norepinephrine, and serotonin)
107
What are the common side effects of MAO inhibitors
CNS Stimulation Hypertensive Crisis Serotonin Syndrome
108
What class are the most commonly used antidepressants
SSRIs and SNRIs
109
What do SERTs reuptake
5-HT
110
What does sustained NE or 5-HT signaling do to BDNF
Increases expression of BDNF
111
Which antidepressants have been used to treat anxiety disorders
SSRIs and SNRIs
112
What antidepressants have been used to treat pain disorders
TCAs Duloxetine (SNRI) Milnacipran (SNRI)
113
What antidepressants have been used to treat premenstrual dysphoric disorder (severe PMS)
Fluoxetine and Sertraline (SSRIs)
114
What antidepressants have been used to treat eating disorders
Fluoxetine (SSRI)
115
What antidepressant is used to treat seasonal depression/smoking cessation
Bupropion
116
What is used to treat TCA overdoses
Sodium bicarbonate
117
What are the three signs of TCA overdoses
Cardiac toxicity (malignant arrhythmias) Convulsions Coma
118
Which antidepressant can cause seizures
Bupropion
119
What family history is a risk for SSRIs
Bipolar Disorder (can precipitate manic episodes)
120
What drug is used in severe cases of serotonin syndrome
Cyproheptadine (antihistamine, anticholinergic, antiserotoninergic)
121
When is the threshold for when anxiety becomes maladaptive
When it is out of proportion to the threat Persists after the threat has been resolved Impairs personal functioning
122
Symptoms of tachycardia, palpitations, chest pain, difficulty breathing, restlessness, insomnia, headaches, GI issues, paresthesia, dizziness, nausea
Anxiety
123
Anxiety symptoms that are prolonged and excessive, not focused on a specific source; for at least 6 months
Generalized Anxiety Disorder
124
What is the treatment for Generalized Anxiety Disorder
First line: SNRIs/SSRIs, CBT Second line: buspirone
125
Symptoms of recurrent, debilitating panic attacks w/ or w/o a trigger for at least 1 month
Panic disorder
126
What is the treatment for acute and long-term management of panic attacks
Acute: short-acting benzodiazepines (alprazolam) Long-term: SSRIs, SNRIs, CBT, TCAs
127
What are the symptoms of a panic attack
Palpitations Shortness of breath Paresthesias Depersonalization/Derealization GI distress Intense fear of dying Intense fear of losing control Dizziness Diaphoresis
128
What are the requirements to diagnose panic disorder
Symptoms of recurrent panic attacks + persistent concern/worrying/behavioral change dictated by panic attacks
129
Symptoms of pronounced anxiety of social situations that involve scrutiny from others (fear of social interaction/performance; for at least 6 months
Social Anxiety Disorder
130
What is the treatment for Social Anxiety Disorder
CBT; SSRIs/SNRIs
131
Symptoms of persistent and intense fears of particular situations and objects for more than 6 months
Specific phobias
132
What is the treatment for specific phobias
CBT (desensitization therapy) Benzodiazepines SSRIs
133
Symptoms of pronounced fear/anxiety of situations that are perceived to be difficult to escape from; lasts for > 6 months in > 2 situations
Agoraphobia
134
What is the treatment for agoraphobia
CBT SSRIs
135
Symptoms of prominent anxiety or panic attacks after using/stopping a substance/medication
Substance/Medication-induced Anxiety Disorder
136
What substances are typically causative of anxiety disorder
Alcohol Caffeine Corticosteroids Amphetamines Cannabis
137
What is the treatment for substance-induced anxiety disorder
Discontinue substance use CBT SSRIs/SNRIs
138
What is the characteristic triad of panic disorder
Acute panic attacks Anticipatory anxiety Phobic avoidance
139
What age group is most likely to experience onset of panic disorder
Between late adolescence and mid-30s
140
What are the comorbidities of panic disorder
Major Depressive Disorder Substance Abuse Disorders
141
What situations/locations are diagnostic for agoraphobia
Lines/Crowds Public Transport Open Spaces Closed Spaces Being alone outside of home
142
Describe the course of symptoms of Generalized Anxiety Disorder
Usually constant anxiety across multiple domains, but can be waxing/waning, and exacerbated during times of stress
143
What is an important differential to consider in symptoms of anxiety
Hyperthyroidism
144
How long does it take for the symptoms of alcohol withdrawal to appear
24-48 hours
145
Symptoms of jitteriness, nervousness, mild tremor, and mild increase in HR and BP; also can cause panic attacks
Classic withdrawal
146
Symptoms of anxiety with mild nervous, tremor, and HR/BP increase along with insomnia
Nocturnal withdrawal syndrome
147
What is the cause of nocturnal withdrawal syndrome
Wearing off of depressants (usually decrease REM), results in rebound effect of increasing REM
148
What is the difference in presentation of benzodiazepine and alcohol withdrawal
Benzodiazepine withdrawal is more rapid and more intense- mild tremulousness; anxiety disorder symptoms
149
Symptoms of tachycardia, elevated BP, mydriasis, restlessness, vomiting/diarrhea, hyperthermia, hyperalgesia and respiratory depression associated with 8-12 hours after withdrawal of what?
Opioid withdrawal
150
What patient groups are at risk for paradoxical reactions of benzodiazepines and barbiturates (cause anxiety)
Elderly and children
151
Symptoms of intrusive/recurrent/persistent thoughts/urges that cause marked anxiety, and then lead to repetitive behaviors that alleviate the symptoms
Obsessive-Compulsive Disorder
152
What is the degree of insight in patients with OCD
Some can have good insight to their situation, but others are more delusional
153
What is the typical demographic of a patient with OCD
Male adolescent/young adult
154
Symptoms of intrusive re-experiencing, avoidance, mood disorders, and changes in arousal, depersonalization, distorted cognition/memory associated with direct/indirect exposure to a traumatic experience, particularly one that is harmful
Posttraumatic Stress Disorder
155
What is the timeline for PTSD
Symptoms usually begin within 3 months of the event (can be years), and symptoms must be present for 6 months
156
What are the differentiating factors between acute stress disorder and PTSD
Acute Stress Disorder symptoms appear more rapidly post-trauma and are resolved within 1 month
157
What are the differentials to include for Acute Stress Disorder
Delirium Substance-induced Anxiety Disorder Brief Psychotic Disorder Primary anxiety disorders Adjustment Disorder
158
What are the neurotransmitter mechanisms of treatment for anxiety disorders
Increase serotonin availability (SSRIs) Block noradrenergic signaling (a2 agonists) Increase GABA signaling (benzodiazepines)
159
What is the basic goal of therapy-based treatment for anxiety disorders
Extinction of conditioned responses associated with traumatic memories
160
What cognitive distortions are usually present in patients with anxiety disorders
Catastrophizing Overestimating
161
What are the key components of CBT
Psychoeducation Somatic management Mindfulness Identifying distorted ways of thinking Exposure therapy Coping skills Problem solving
162
What is the difference in usage of sedatives and hypnotics
Sedatives reduce anxiety (minimal CNS depression) Hypnotics produce drowsiness/sleep (more CNS depression)
163
Are sedatives/hypnotics usually more lipophilic or hydrophilic?
Lipophilic
164
Describe the process of clearance of benzodiazepines
CYP450 in the liver oxidize the benzos (phase I) > conjugated to glucuronides (phase II)
165
What is the product of the oxidization (via CYP450) of chlordiazepoxide, diazepam, prazepam, and chlorazepate; and why is it notable?
Desmethyldiazepam; has a half-life of over 40 hours
166
Which benzodiazepines have a longer half-life and which ones have a shorter half-life
Longer: Diazepam, prazepam, flurazepam Shorter: Alprazolam, triazolam, lorazepam, oxazepam
167
Describe the general rate of hepatic metabolism of barbiturates and which group is the exception to this
Slow; thiobarbiturates (phenobarbital)
168
Which hepatic enzyme is used to metabolize the hypnotic drugs
CYP3A4
169
What are the effects of decreased hepatic function on drug elimination
Increases drug half-life (can build up after multiple successive doses)
170
What is a major difference between the metabolization of benzodiazepines/hypnotics and barbiturates
Barbiturates can increase the rate of hepatic metabolism; benzos/hypnotics do not do this (with continuous use)
171
Describe the MOA of sedative-hypnotic agents
GABAa receptor agonists > pumps Cl- ions into the neuron > IPSP
172
How does the difference in binding of sedatives and hypnotics to the target receptor have different results in function
Hypnotics are very selective of the alpha-1 subunit-containing isoform Benzos/Barbs can bind to multiple isoforms of the receptors *Recall that benzos inc. frequency, and barbs inc. duration of channel opening*
173
Why are barbiturate associated with more CNS depression than benzodiazepines
Barbs are less selective- also depress AMPA receptor functioning *Can be used to induce surgical anesthesia*
174
What is the function of flumazenil
Blocks benzo and Z-hypnotic action (but not barbiturates or ethanol) *Used for benzo overdoses, but must be given repeatedly due to low half-life*
175
What are the effects of benzodiazepines/older sedative-hypnotics on sleep
Decreased sleep latency Decreased Stage 2 sleep Decreased REM sleep Decreased Stage 4 sleep
176
What are the effects of newer hypnotics on sleep
Decrease sleep latency Decrease REM sleep No change on slow-wave sleep Increases Stage 2 sleep
177
What side effect is associated with higher doses of zolpidem and zaleplon
Rebound insomnia
178
Which sedative agents are often used for induction of anesthesia and why
Thiopental and methohexital; very lipid-soluble and rapidly absorbed
179
What sedative agents are used in adjunct to general anesthesia for persistent post-anesthetic respiratory depression
Diazepam, lorazepam, and midazolam
180
What are the symptoms of sedative-hypnotic withdrawal
Increased anxiety Insomnia CNS excitability Seizures
181
What are common adverse effects of sedative-hypnotics
Drowsiness, diminished motor skills Anterograde amnesia Confusion Behavioral inhibition Respiratory/Cardiovascular depression (high-doses) *Do NOT use with alcohol, opioids, anticonvulsants, anti-histamines, or phenothiazines*
182
Which benzodiazepine is the "most toxic" and at risk for overdoses
Alprazolam
183
Which benzodiazepine is most often associated with behavioral disinhibition
Triazolam
184
What is a notable contraindication of barbiturates
Porphyria
185
What is the timing for the onset of postpartum depression
Within 4 weeks of delivery; does not resolve within 2 weeks post-delivery
186
What is the mechanism/use of buspirone
Parial 5-HT receptor agonist; used for Generalized Anxiety Disorder (more mild than barbs and benzos)
187
What is the difference between substance abuse and intoxication
Abuse is a pattern that results in significant impairment/distress Intoxication is acute or chronic, and has maladaptive behavioral/psychological changes
188
What is the difference between substance dependence and withdrawal
Withdrawal is a symptom of dependence
189
What drug is associated with most drug-related ER visits
Cocaine (~40%) Heroin (~30%) Meth (~8%)
190
What method of treating substance abuse disorder has been becoming more popular; describe it
Harm reduction model- promotes less frequent, lower doses, and safer environments for drug use *Transtheoretical model is also in play here*
191
What are some common triggers of drug abuse relapse
Re-exposure to the addictive drug Stress Context that recalls prior drug use (classical conditioning)
192
What is the difficulty with diagnosing substance use disorder in elderly patients
Usual progressive neurological impairment secondary to aging can mask substance use symptoms
193
Describe the brain system that is targeted by addictive drugs
Mesolimbic dopamine system- ventral tegmental area > nucleus acccumbens/amygdala/hippocampus/prefrontal cortex
194
What is the basic mechanism of opioids
In the VTA, u-opioids bind to and inhibit GABAergic inhibitory interneurons > disinhibit the dopaminergic neurons
195
What are some commonly abused opioids
Morphine Heroin Codeine Oxycodone Meperidine
196
Symptoms of intense dysphoria, nausea/vomiting, muscle aches, rhinorrhea, mydriasis, respiratory depression, sweating, diarrhea, and fever
Opioid withdrawal
197
What drug is used to reverse the effects of opioid overdoses
Naloxone *Will cause an acute withdrawal syndrome*
198
What drug is used for relapse maintenance in opioid users
Naltrexone
199
What are some longer-acting opioids that are substituted for MAT use
Methadone Buprenorphine
200
What is the mechanism of exogenous cannabinoids
Inhibit GABA neurons in the VTA > Disinhibits dopaminergic neurons
201
Symptoms of restlessness, irritability, mild agitation, insomnia, nausea, and cramping (very mild and short-lived)
Cannabinoid withdrawal
202
What are some uses of therapeutic cannabinoids
Nabilone- Chemo-induced emesis Nabixmols- MS
203
Symptoms of euphoria, enhanced sensory perceptions, social elevation, amnesia > sedation and coma
GHB intoxication
204
What is the mechanism of GHB
Binds to GABAb receptors (weak agonist) > inhibits GABA neurons
205
Symptoms of psychosis-like manifestations, reality distortion, dizziness, nausea, paresthersias, and blurred vision
Hallucinogen intoxication (LSD, Mescaline, Psilocybin) *Not typically associated with dependence or addiction?*
206
What is the mechanism of hallucinogens
Enhance presynaptic serotonin receptors (5-HT2A) > increase glutmate release in the cortex
207
What is the addictive mechanism of nicotine
Agonist of nicotinic acetylcholine receptor (on dopaminergic neurons of the VTA)
208
Symptoms of irritability, insomnia, depression, muscle cramps, and seizures
Benzodiazepine withdrawal
209
What is the mechanism of ketamine/PCP
Non-competitive antagonism of NMDA receptor *Do not cause addication/dependence*
210
What substances are often abused as inhalants
Nitrites Ketones Aliphatic/aromatic hydrocarbons
211
What is the mechanism of Cocaine
PNS- inhibits voltage Na+ channels > blocking action potentials CNS- block uptake of DA/NOR/SER via transporters > inc. in NOR causes activation of sympathetic nervous system
212
Symptoms of hypertension, tachycardia, ventricular arrythmias, loss of appetite, hyperactivity, insomnia, hyperthermia, coma, and death
Cocaine intoxication
213
What is the treatment for Cocaine overdoses
Benzodiazepines and a-adrenergic antagonists *DO NOT give B-blockers*
214
What is the mechanism of amphetamines
Indirect sympathomimetics that cause release of endogenous amines (reverse the transporters)
215
Symptoms of increased arousal, reduced sleep, abnormal movements, hyperthermia, hallucinations, and psychotic episodes
Methamphetamine intoxication
216
What is the mechanism of MDMA-ecstasy
Reverse serotonin transporters > inc. extracellular serotonin
217
Which addictive drugs are notably irreversibly neurotoxic
Amphetamines MDMA-Ecstasy
218
What is the progression of alcohol withdrawal symptoms
Tremors/insomnia/GI distress/diaphoresis/agitation > seizures > visual hallucinations > AMS, autonomic hyperactivity
218
What is the treatment for alcohol withdrawal
Chlordiazepoxide (benzo) Diazepam if seizures occur
219
What drugs are used to treat alcohol use disorder
Disulfiram- inhibits alcohol dehydrogenase Naltrexone- reduces cravings *avoid in liver disease* Acamprosate- reduces cravings
220
What kind of genetic factors are involved in predisposition to alcohol abuse
Genes affecting personality traits Genes affecting alcohol metabolism
221
Why do women generally have high blood-alcohol levels after consuming a drink than men
They have less ADH activity (becomes even greater with chronic consumption) *Women also typically have less water space*
222
What is the danger of using alcohol with acetaminophen
Alcohol induces CYP2E1, which increases acetaminophen metabolism to toxic NAPQI
223
What is the danger of using alcohol with the barbiturate phenobarbital
Ethanol inhibits P450 metabolism of phenobarbital, which can accumulate in the blood
224
What are the pharmacological treatments for nicotine addiction
Nicotine replacement Varenicline (partial agonist w/ high affinity) Buproprion (inhibits NOR and DA reuptake)
225
What are the strategies for acute pain management
Relaxation/Immobilization Analgesics (NSAIDs) Massage TENS
226
What type of pain are narcotics liberally used for
Malignant chronic pain (often associated with cancer)
227
What is the emphasis of treatment for benign chronic pain
Increased activity (NOT narcotics)
228
Symptoms high levels of anxiety about health, disproportionate thoughts about seriousness of one's symptoms, excessive time/energy devoted to these symptoms for more than 6 months; disrupts daily life; commonly experiences psychogenic pain
Somatoform Pain Disorder
229
Multiple, unexplainable symptoms; patients often undergo excessive unneeded testing, and have catastrophic/magical thinking about their illness; believe that others are blowing them off; high comorbidity with anxiety/depression
Multisomatoform Disorder
230
Increased fear of pain returning that results in drug-seeking behavior
Pseudoaddiction
231
What is the most common comorbidities for patients with chronic pain
Major Depressive Disorder Anxiety disorders
232
What are some common conditions associated with chronic pain
Postherpetic Neuralgia Diabetic Peripheral Neuropathy Parkinson's Disease Central Postroke Pain/Spinal Cord Injury Migraine/Chronic Daily Headache Fibromyalgia Phantom Limb Pain Complex Regional Pain Syndrome Trigeminal Neuralgia Lower back pain
233
What is a common cause of rebound headaches
Overuse of analgesics
234
Ongoing spontaneous pain in a region of the body that is characterized by burning sensation that is precipitated by a specific noxious trauma or cause of immobilization; hyperalgesia
Complex Regional Pain Syndrome
235
Widespread musculoskeletal pain in all four limbs/trunk, stiffness and exaggerated tenderness
Fibromyalgia
236
Episodic, unilateral, orbital headache that is described as excruciating; lasts minutes to hours
Cluster Headaches
237
What is the function of endogenous opioid pathways
Activation of postsynaptic opioid receptors hyperpolarizes the dorsal horn interneurons to reduce the duration of an EPSP for the pain pathways
238
What are the endogenous opioid peptides and where are they located
Enkephalin and Dynorphin; located in the interneurons of the dorsal horn
239
What drugs have been used to treat neuropathic pain
Gabapentin (Ca2+ channel blocker) Lidocaine (membrane stabilizer) Baclofen (GABA inhibitor) Ketamine (NMDA antahonist) Opioids
240
What genes have been found to be associated with difference in perception of pain
KCSN1 (K+ channel subunit) GHC1 (GTP cyclohydrolase)
241
What is the central tenet of the cognitive behavioral approach to pain
Perceived control over pain (and associated/underlying life aspects) *Coping skills*
242
What is the guidelines for prescribing opioids for acute use
Prescribe lowest effective dose of immediate-release opioids; 3 days should be sufficient, very rarely more than 7 days
243
What drug is contraindicated for use with opioids
Benzodiazepines
244
What type of receptors are all three types of opioid receptors
Inhibitory G-protein coupled receptors (inhibit cAMP production)
245
What is the mechanism of opioid tolerance (i.e. morphine)
A lack of receptor internalization (recycling) > is rather, phosphorylated + down-regulated (degraded)
246
Which opioids are mild-moderate mu agonists (often combined with acetaminophen to treat moderate pain)
Oxycodone Hydrocodone Codeine
247
What are the risk factors for chronic pain
Older age Female sex Anxiety/Depression Obesity Heavy Lifting Nicotine use Lower socioeconomic background Veterans Rural areas
248
What are some medications used to treat chronic pain
NSAIDs/Acetaminophen Opioids Topicals (Capsaicin, Lidocaine) Anticonvulsants (Gabapentin) TCAs (Topiramate, Valproate) Corticosteroids Muscle relaxants (Cyclobenzaprine) Sedatives (Benzodiazepines) Medical Marijuana
249
What are the indications for co-prescribing naloxone
-Taking >50 morphine milligram equivalents per day -Existing respiratory conditions -Taking benzodiazepines -Have another substance use disorder
250
What drugs are given in cases of acute-on-chronic pain
Parenteral opioids (acutely)/Epidural anesthesia NSAIDs Gabapentinoids
251
Which opioid receptors do the endogenous opioids- endorphins, enkephalins, and dynorphins bind to
Endorphins- mu Enkephalins- delta Dynorphins- kappa
252
Which opioid receptors are responsible for respiratory depression
mu
253
Which opioid receptors are responsible for psychotomimetic effects
delta
254
What is the primary metabolism route of opioids
Hepatic CYP450 (CYP2D6 enzyme)
255
What are the two synaptic effects of opioids
1. Close presyn voltage Ca2+ channels (inhibits neurotransmitter release) 2. Opens postsyn K+ channels (hyperpolarizes neurons)
256
What are the two sites of opioid activity to produce an analgesic effect
Ascending pathway (peripheral nociceptive terminals) Descending pathway (activates inhibitory neurons)
257
What are the CNS effects of opioids
Analgesia Sedation Respiratory depression** Cough suppression Miosis** Truncal rigidity Nausea/vomiting Hyperthermia Sleep disturbances
258
What is a major peripheral effect of opioids
Constipation
259
Which opioid is generally safer to use during child labor
Meperidine
260
Which opioid is commonly used to treat cough
Codeine
261
What are the major symptoms of opioid withdrawal
Rhinorrhea Yawning Hyperventilation/hyperthermia Mydriasis Anxiety/Hostility
262
What is the general onset of morphine/heroin withdrawal timeline
Starts 6-10 hours after last dose, and peaks 36-48 hours after last dose
263
Describe the formulations of the following opioid-NSAID combinations: Percocet, Percodan, Vicodin/Lortab, Vicoprofen
Percocet: oxycodone + acetaminophen Percodan: oxycodone + aspirin Vicodin/Lortab: hydrocodone + acetaminophen Vicoprofen: hydrocodone + ibuprofen *P=Oxycodone, V=hydrocodone*
264
alpha-2 agonist used to treat opioid use disorder
Clonidine
265
What is the recommended course for a pregnant patient with opioid detoxification
Not recommended (can precipitate dangerous withdrawal in child) > treat with methadone/buprenorphine
266
Centrally acting muscle relaxants
Spasmolytics/Antispasmodics
267
What is the MOA of baclofen
GABAb agonist > Inhibits action potentials (pre and post-synaptically)
268
What are the side effects of high-dose baclofen
Somnolence Respiratory depression Coma
269
What drugs can be used to treat spasticity
Baclofen Benzodiazepines Tizanidine Gabapentin Riluzole Succinylcholine
270
What is the MOA of tizanidine
a2-adrenergic agonist > decreases cAMP and increases K+ conductance
271
What is the major use for riluzole
Amyotrophic Lateral Sclerosis
272
What is the MOA of riluzole
Blocks glutamate neurotransmission > reduces cytotoxicity to upper motor neurons
273
What is the MOA of succinylcholine
Create a high concentration of ACTH in the synaptic cleft
274
What are some side effects of succinylcholine
Muscle soreness Hyperkalemia Bradycardia Malignant hyperthermia
275
What drug should be used in cases of suspected malignant hyperthermia
Dantrolene
276
Which spasmolytic is typically used for relief of acute muscle spasm caused by local tissue trauma/muscle strains
Cyclobenzaprine
277
What is the difference in the mechanism of depolarizing vs non-depolarizing neuromuscular blocking agents
Depolarizing: Inc. ATCH in synapse Non-Depolarizing: Block ATCH binding
278
What is the treatment for Neuroleptic Malignant Syndrome
Remove offending agent (usually typical antipsychotic) Bromocriptine (DA agonist) Dantrolene
279
What are the symptoms of serotonin syndrome
AMS Autonomic dysfunction Neuromuscular excitation GI dysfunction Hyperrflexia Myoclonus Hyperthermia Muscular rigidity (last two are less severe than in NMS)
280
What drugs can precipitate hyperthermia
Typical antipsychotics Antidepressants Cocaine, meth, ecstasy, PCP Succinylcholine
281
What are two labs used to indicate malignant hyperthermia
Elevated serum creatine kinase Myoglobinuria
282
What drugs are used to treat acute muscle spasm pain (cramps)
NSAIDs/Acetaminophen
283
Physical symptoms and related fears that are disproportionate to object medical findings; not intentionally produced; disruptive to daily functioning
Somatic Symptom Disorder
284
Patients intentionally stimulate/produce symptoms of illnesses in themselves/others for the purpose of appearing ill/impaired/injured
Factitious Disorder
285
Intentionally producing/mimicking symptoms that is motivated by external rewards
Malingering Disorder
286
What are the three subtypes of somatic symptom disorders
Somatic Dissociative Obsessive/Cognitive
287
What are key psychosocial criteria for somatic symptom disorders
Symptoms must be disruptive to daily functioning Patients must have excessive thoughts/feelings/behaviors related to the somatic symptoms
288
How long should symptoms of Somatic Symptom Disorder persist
More than 6 months
289
Neurological symptoms affecting their voluntary motor/sensory function that cannot be fully explained physiologically
Conversion Disorder
290
Pseudocyesis
Symptoms and signs of pregnancy, despite there being no actual pregnancy
291
Preoccupation for >6 months with the fear or belief that they have or might acquire a serious disease, to the point that it interferes with daily functioning
Illness Anxiety Disorder
292
What disorders do most hypochondriacs fit into
Somatic symptom disorder (75%) Illness anxiety disorder (25%)
293
Preoccupation with a perceived defect in physical appearance that is markedly out of proportion to objective findings
Body Dysmorphic Disorder
294
Multiple hospitalization with repeated invasive testing and surgical procedures due to factitious disorder
Munchausen's Syndrome
295
Note that factitious disorder by proxy, imposed on a minor, is a form of child abuse (*)
*
296
What about the course of Conversion Disorder is different than the other somatic disorders
Course is short, with full resolution
297
What are the comorbidities for somatic disorders
Depression Anxiety Suicidality Medication abuse Borderline, narcissistic, OC, and histrionic personality disorders
298
What is the first option in the differential for somatic symptoms
An unrecognized illness or coexistence with known illness
299
What is a major difference between the presentation of factitious disorder and schizophrenia
Factitious disorder does not have psychosis
300
What is a major precipitator of Illness Anxiety Disorder
Experience with a medical condition (in self or in loved one) > creates fear/anxiety, as well as dependence on the physician to diagnose
301
What is the first step in treating somatic disorders
Careful medical and parallel psychosocial history (screen for depression, bipolar, schizophrenia, neurocognitive disorders, and personality disorders)
302
What is a helpful strategy for managing care for a patient with somatic symptom disorder
Limit contact with other physicians- maintain strong ties to patient to avoid overprescribing; empathy and involvement
303
What medications have been shown to be effective in treatment somatic symptom disorder
SNRIs TCAs Gabapentinoids Ketamine
304
What is the treatment for Illness Anxiety Disorder
SSRIs CBT
305
What is the treatment for Body Dysmorphic Disorder
SSRIs CBT
306
What is the treatment for Factitious Disorder
We don't really have one Avoid unnecessary/dangerous procedures
307
What is the difference between primary and secondary headaches
Primary- not caused by underlying conditions Secondary- precipitated by another underlying condition
308
What are the different types of primary headaches
Migraine headaches Tension headaches Cluster headaches
309
Symptoms of headache and increased ICP often in adolescent, obese females
Pseudotumor cerebri
310
Symptoms of headaches in elderly patients with an enlarged/sensitive temporal artery
Temporal arteritis/Giant cell arteritis
311
What are some physiological mechanisms of secondary headaches
Compression of adjacent brain tissue Raising intracranial pressure Shift nervous system structures from one compartment to another (herniation) *Can present with seizures, vasogenic edema, and hydrocephalus*
312
What is the mechanism of acute headache medicaitons
5-HT receptor agonists
313
Symptoms of bilateral, band-like pain across the forehead; not associated with nausea or vomiting, not usually associated with photophobia; more commonly in females
Tension-type headache
314
How long do tension headaches usually last
Constant, usually 4-6 hrs (>30 minutes)
315
Symptoms of unilateral, pulsating pain on the forehead/periorbital area; associated with nausea, photophobia; more commonly in females
Migraine headaches
316
How long do migraine headaches usually last
4-72 hours (the longest of the primary headaches)
317
Symptoms of unilateral, excruciating periorbital pain along with lacrimation, rhinorrhea, conjunctival injection, and Horner Syndrome; more commonly in males
Cluster headaches
318
How long do cluster headaches typically last
Repetitive over 15min-3hrs
319
What is the MOA and use of sumatriptan
Use: acute moderate/severe migraine headaches; cluster headaches; *NOT prophylaxis* MOA: 5-HT agonist
320
What are the side effects of sumatriptan
Bitter taste; paresethesia; asthenia; dizziness/fatigue/nausea Rarely- MI, angina, cardiac arrythmia, stroke
321
What are the contraindications of sumatriptan
-Any kind of arterial disease (vasoconstrictive) -Any other triptan/ergot use -MAOI/SSRI/SNRI/TCA use (serotonin syndrome)
322
What is the MOA and use of Ergotamine
Use: acute moderate/severe migraine headaches, especially if triptan don't work MOA: Nonspecific serotonin agonist
323
What are the side effects of ergotamine
Nausea/vomiting Rare- vascular occlusion
324
What are the contraindications of ergots
-Using other ergots/triptans -Uncontrolled hypertension/arterial disease -Beta blockers; dopamine; nicotine; CYP3A4 inhibitors
325
What is the MOA and use of timolol and propronalol
Use: Migraine headache prophylaxis MOA: Beta blockers
326
What are the side effects of timolol/propranolol
Fatigue Orthostatic hypotension
327
What are the contraindications for timolol/propranolol
Heart failure Asthma Depression
328
Which antiepileptic is used for migraine headache prophylaxis
Valproate
329
What antidepressants are used for migraine prophylaxis
Amitriptyline (TCA) Nortriptyline (TCA) Duloxetine (SNRI) Venlafaxine (SNRI)
330
What are the monoclonal antibodies used for severe/frequent migraine prophylaxis and what is the MOA
Erenumab, Fremanexumab, Galcanezumab MOA: anti-CGRP receptor (proinflammatory mediator)
331
What is the specific use of botox in treatment of headaches
Used for chronic migraine prophylaxis (>15 per month) NOT effective for preventing episodic migraines
332
What is the acute and prophylactic treatment for tension-type headaches
Acute: NSAIDs, acetaminophen Prophylactic: Amytriptyline
333
What is the acute and prophylactic treatment for migraine headaches
Acute: NSAIDs, sumatriptan, ergotamine, antiemetics Prophylactic: B-blockers, amitryptiline, topiramate, valproate, botox, monoclonal antibodies
334
What is the acute and prophylactic treatment for cluster headaches
Acute: sumatriptan, 100% O2 Prophylactic: verapamil
335
What is the MOA and function of aspirin
COX-1 inhibitor > blocks TXA2, PGA2 synthesis Anti-pyretic, anti-inflammatory, and analgesic
336
What is the MOA and function of acetaminophen
Reversible COX inhibitor > blocks PGA2 synthesis Anti-pyretic, analgesic (NOT an anti-inflammatory)
337
What is the MOA and function of NSAIDs
Reversible COX inhibitor > blocks PGA2 synthesis
338
What is often used to treat migraines during pregnancy
Acetaminophen (NSAIDs until end of 2nd trimester)
339
What are some signs of drug abuse among physicians
Physical/Social/Emotional changes Diet changes Anxiety/Depression Defensiveness/Disruptive behavior Unusual drug orders Domestic distress *Inaccessibility and social withdrawal*
340
What are some factors that are associated with higher levels of alcohol dependence in medical students
Burnout Depression Lower quality of life Also: younger and single (and in hella debt lol)

MUSM Block 2 Module 2 (2 decks)

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