Psych

Question 1

Clinical Presentation of Generalized Anxiety Disorder

Answer 1

Excessive anxiety and uncontrolled worry
Feeling on edge poor concentration
Restlessness, fatigue, muscle tension
Difficulty sleeping, irritability
Impairment in social or occupational functioning

Question 2

Clinical Presentation of Obsessive-Compulsive Disorder

Answer 2

Obsessions: Recurrent thoughts, imags, and/or impulses
Compulsions: Repetitive activities and/or mental acts that reduce the anxiety caused by the obsessions.

Question 3

Clinical Presentation of Panic Attack/Disorder

Answer 3

Physical symptoms: Chest pain or discomfort, dizziness, SOB, tachycardia, tremor, nausea, palpitations, sweating.

Psychological: Fear of losing control or dying, fear of ability to escape from fearful situations.

Agoraphobia may result from repeated panic attacks.

Question 4

Clinical Presentation of Posttraumatic Stress Disorder

Answer 4

Triad of symptom complexes:
Reexperiencing: Flashbacks of the event, recurring and disturbing memories or dreams
Avoidance: Avoiding thoughts, feelings, conversations, people, or activities related to the event; inability to recall the event, avoiding others (isolating); sense of foreshortened furture.
Hyperarousal: Decreased concentration, insomnia, irritability, easily startled, hypervigilance.

Question 5

Social Anxiety Disorder

Answer 5

Fear of being embarrassed, humiliated, or evaluated by others
Fear of situations: Speaking, eating, or interacting in a group of people or with authority figures; public speaking; talking with strangers.
Physical symptoms: GI upset-Diarrhea, sweating, flushing, tachycardia, tremor.

Question 6

HAM-A Scale

Answer 6

The Hamilton Anxiety Scale (HAM-A) is the gold standard scale for anxiety disorders used in clinical trials and requires a traind rater. A score of 18-20 is significant anxiety.

A clinical response is 50% decrease in Ham-A score, recovery is a score less than 7.

Question 7

Beck Anxiety Inventory

Answer 7

Is a brief, patient-rated scale that can distinguish anxiety symptoms from depression.

Question 8

Non-pharm treatment for anxiety

Answer 8

CBT (Cognitive-behavioral therapy)

Most effective psychotherapy with or without drug therapy in clinical trials.

Underused because of cost, time commitment of patient, and lack of readily available trained providers.

Question 9

Pharmacological Tx of Anxiety

Answer 9

SSRIs (1st line), SNRI, TCA, MAOI (reserved for 3rd or 4th line therapy)

Other Treatments:
Pregabalin- effective for GAD, not FDA approved
Gabapentin, not FDA approved either but can be used for GAD
Topiramate- mixed results for PTSD
Atypicals: limited evidence in augmenting therapy for GAD
Buspirone: FDA approved for GA (takes 2 weeks to see onset)
Hydroxyzine: FDA approved for anxiety
B-blockers: most often used in performance-related social anxiety.
Prazosin/Clonidine: most often used in PTSD to treat nightmares
BZD: all are effective see BZD slide.

SSRI anxiety doses initial doses should be lower than doses used for depression.

Question 10

Benzodiazepines

Answer 10

Alprazolam shows the greatest efficacy for panic attacks and panic disorder

Overall should be avoided in elderly and PTSD population. PTSD d/t high substance abuse potential.

Limited efficacy in OCD

Discontinuation can cause rebound anxiety as well as withdrawal seizures.

If therapy lasts longer than 1 year, taper over 2-4 months. Consider changing to a longer acting BZD diazepam, clonazepam, chlordiazepoxide during the taper.

Short acting LOT
lorazepam, oxazepam, temazepam

Question 11

FDA Approved Indications for Anxiolytics

Answer 11

Paroxetine approved for all indications.

Sertraline approved for all except GAD

Others see table 3 on page 1-8.

Question 12

True or False. In clinical tries drug therapy is more effective thatn CBT for insomnia.

Answer 12

False, CBT is more effective long term than drugs alone.

Question 13

Pharmacologic Therapy for Insomnia-BZD

Answer 13

• Can induce and maintain sleep
• Typical BZD used: flurazepam, triazolam, temazepam, estazolam, quazepam.
• Tolerance can delevelop
• Rebound insomnia reported with abrupt D/C
• Avoid use in elderly

Question 14

Pharmacologic Therapy for Insomnia- Z hypnotics

Answer 14

Zolpidem, zaleplon, eszopiclone

Bind selectively to the GABA-A receptor. Thought to be less disruptive to normal sleep parameters than the BZD class.

Zaleplon (sonata) more rapid onset and shorter duration, may be repeated during the night if the patient has 4 hours left before needing to awaken.

Less hangover than BZD.

Sleep eating and sleep driving have sometimes been reported with this class.

CYP3A4 substrates except zaleplon

Rebond insomnia and tolerance less likely with zaleplong

ADRs: Amnesia, dizziness, HA, GI (Eszopiclone (lunesta) can cause metallic taste)

Question 15

Pharmacologic Therapy for Insomnia- Ramelteon

Answer 15

Melatonin agonists

No abuse potential, not a controlled substance

Improves sleep latency-time to fall asleep; may not affect duration of sleep.

Dose: 8 mg po 30 min before bedtime. Doses above 8mg have no greater efect.

ADRs. Daytime sleepiness, hyperprolactinemia, dizziness, and stomach upset.

Ramelteon is CYP1A@ substrate. (caution with fluvoxamine)

Anticoagulant and this med may inc risk of bleeding.

Brand Name Rozerem (not available in generic)

ONSET MAY TAKE 3 WEEKS.

Question 16

Pharmacologic Therapy for Insomnia-Trazodone

Answer 16

Serotonergic antidepressent commonly used for sleep induction.

Usual doses are much lower than those used for depression.

Starting dose 50 mg QHS

Onset of action slower, duration of action longer..more daytime hangover.

Priapism is possible with higher doses (more than 200mg) (incidence less than 1%)

Question 17

Pharmacologic Therapy for Insomnia-Doxepin

Answer 17

TCA

Recently FDA approved under the brand name Silenor for those with insomnia and problems with sleep maintenance.

Usual dose 3-6 mg orally 30 min before sleep on an empty stomach.

Warmings include suicidal thinking and sleep-driving.

Question 18

Pharmacologic Therapy for Insomnia-Antihistamines

Answer 18

Diphenhydramine/Doxyolamine

Tachyphylaxis to sedative effects is common, drug is usually effective for a few weeks than wears off, drug holiday is needed for continued effect.

Anticholinergic ADRs limit its usefulness.

Question 19

Pharmacologic Therapy for Insomnia-Alternative Therapies (Herbal)

Answer 19

Melatonin (only useful for jet lag, elderly, and shift-work disorders)

Chamomile: theorized to affect the BZD receptor. Caution ragweed allergy.

Valerian: thought to inhibit breakdown of GABA or increase GABA release. no benefit in clinical trials but seems safe. case reports of hepatic toxicity.

Question 20

Treatment for Sleep Apnea

Answer 20

Weight loss
Changing position while sleeping
surgical correction of obstruction
CPAP- continuous positive airway pressure
Modafinil/Armodafinal for excessive daytime sleepiness (does not replace CPAP)

Use sedative-hypnotic agents with caution.

Question 21

Treatment Restless Leg Syndrome

Answer 21

Dopamine agonists are mainstay of therapy (ropinirole and pramipexole)

Ropinirole 0.25 mg 1-3 hours before bedtime, may increase slowly up to 1 mg.

Pramipexole 0.125 mg orally 1-3 hours before bedtime, can increase up to max 0.5 mg/day.

Rotigotine patch (Neupro) RLS dose intially 1 mg/day up to 3 mg day.

ADRs symptom augmentation, insomnia, dizziness, nausea, sleep attacks, psychosis.

Question 22

Shift Work Sleep Disorder

Answer 22

Short acting BZD or Z-hypnotic can be considered to reduce lost sleep time.

Modafinil and armodafinil are FDA approved to treat the daytime sleepiness associated with work sleep disorder.

Modafinil dosing 200mg daily 1 hour before starting shift work.

Armodafinil dosing 150 mg oraly once daily 1 hour before starting shift work.

Both are substrates of CYPE 3A4 and moderately induce 3A4 induce CYP 2C19.

Question 23

Major Depression Dx

Answer 23

Five or more Depression sx present during the same 2 week period and represent a change from previous functioning, at least one of the symptoms is either depressed mood or loss of interest or pleasure.

a. Depressed mood
b. Diminished interest
c. Weight loss
d. Insomnia or hypersomnia
e. Psychomoter agitation
f. Fatigue
g. Feelings of worthlessness
h. Diminished ability to think or concentratie
i. recurrent thoughts of death.

Question 24

Scales to Measure Depression Sx

Answer 24

PHQ- useful in primary care to indentify depression and monitor response. (5=mild sx, 10=moderate, 15= mod-severe, 20=severe)
HAM-D, higher the score more severe depression, gold standard for trials.
Montgomery-Asberg DepressioN Rating Scale (MADRS) (another one used in clinical trials)
Beck Depression Inventory

Question 25

Pharmacologic Treatment of Depression

Answer 25

SSRIs- generally first line. ``` Other options SNRIs TCA Bupropion Mirtazapine Trazodone Vilazodone ```

Question 26

SSRIs

Answer 26

ADRs anxiety, irritability, sedation, sinsomnia, sexual dysfunction (10-30%), HA, seating, abnormal bleeding, hyponatremia, and GI effects. Sertraline- may cause false positive in BZD urine drug screen. Citalopram- not recommended in congenital long QT syndrome; should not be dosed above 40mg/day. Fluvoxamine/Fluoxetine, paroextine (lots of drug interactions)

Question 27

SNRIs

Answer 27

Venlafaxine (only dual inhibitor if doses >150mg/day otherwise primarily Seratonin): May elevate BP Desvenlafaxine (doses above 50mg/day generally do not confer a greater antidepressant efficacy..just more ADRs, also concern with HTN. Duloxetine: (monitor for hepatotoxicity) Milnacipran(only approved for fibromyalgia in US) but studied for depression extensively in europe.

Question 28

TCA

Answer 28

ADRs sedation, anticholinergic and cardiobascular effects. Weight gain and sexual dysfunctioN ADRs limit toleratiblity and adherence. Use caution in elderly Amitriptyline, Imipramine, Doxepin, Clomipramine, Nortriptyline, Desipramine, Protriptyline, Amoxapine, Maproltiline Often used for seation, fibromyalgia

Question 29

MOA-I

Answer 29

Irreversible enzyme inhibitors (take 2 weeks after therapy for new enzymes to form) Do not combine with other antidepressive agents) Must washout for 2 weeks before switching to other drugs like fluoxetine ADRs orthostatic hypotention, HA, GI effects, dry mouth, sexual dysfunction, HTN Avoid Tyramine Foods Avoid decongestants, amphetamines, Dextromethorphan, epinephrine, meperideine. Drugs: isocarboxazide, phenelzine, tranylcypromine, selegiline.

Question 30

Bupropion

Answer 30

weak inhibitor of dopamine and norepi, active metabolite that is a norepi reuptake inhibitor. ADRs (insomnia, anorexia, HA, GI upset, dry mouth) CI in seizure disorders. May be "activating" and should be given in the morning or early afternoon to avoid insomnia.

Question 31

Mirtazapine

Answer 31

Serotonin/Norepi receptors, not an reuptake inhibitor lower doses are more likely to cause sedation than are higher doses. increased appetite and weight gain are common. ADRs constipation, dry mouth, peripheral edema, dizziness.

Question 32

Trazodone

Answer 32

SSRI that affects serotonin receptors. Also has antihistaminic and alpha-blocking effects. Commonly used as sedative agent, does of 50-200mg given at bedtime. Effective antidepressent.

Question 33

Vilazodone

Answer 33

combined SSRI and serotonin 5HT1A partial receptor agonists. The clinical relevance of the second MOA is unknown) Major 3A4 substrate. ADRs similar to other SSRIs

Question 34

True or False. Antidepressent therapy should be tried for 8 weeks before considered a treatment failure.

Answer 34

True: It is imperative that an appropriate dose be used for an adequate duration of at least 8 weeks to provide optimal therapy. If the inital therapy fails the patient may be switched to another agent in the same class or another class.

Question 35

Non-Pysch Meds with Serotonergic Activity

Answer 35

``` Linezolid Triptans St. John's wart, Metoclopramide Ritonavir Ondansetron Meperidine Lithium Amphetamines Cyclobenzaprine Buspirone Tramadol Dextromethorphan ```

Question 36

Which two SSRIs have the greatest evidence of safety in pregnancy?

Answer 36

Sertraline and Fluoxetine Most guidelines recommend the patient stays on their current SSRI unless it's paroxetine which is category D.

Question 37

Bipolar I disorder

Answer 37

Manic or mixed episodes and depressive episodes

Question 38

Bipoolar II disorder

Answer 38

Hypomanic episodes and depressive episodes

Question 39

Manic episode

Answer 39

Abrupt onset with sx escalation over several days Mood is elevated expansive, and/or irritable for at least 1 week. Symptoms include grandiosity, irritability, decreased need for sleep, flight of ideas, or racing thoughts, pressured speech If severe may have psychotic sx Marked impairment in social and occupational functioning.

Question 40

Mixed Bipolar Episode

Answer 40

occurance of manic and depressive sx at the same time higher risk of comorbid substance use/abuse and suicidality Sx of agitation, suicidal ideation, psychosis, insomnia, and changes in appetite.

Question 41

Bipolar Depressive episode

Answer 41

Often misdiagnosed as unipolar depressive episode | Psychotic sx are more common than in unipolar depressive episodes.

Question 42

Hypomanic episode

Answer 42

Less severe form of mania Mood episode that is expansive, irritable, or elevated, lasting at least 4 days similar to manic but not severe enough to affect social or occupational functioning.

Question 43

Rapid Cycling

Answer 43

Four or more mood episodes in 1 year.

Question 44

Bipolar Scales

Answer 44

Young Mania Rating Scale (gold standard for clinical trials) scores >25 indicate severe mania. Clinical Global Impressiosn Global Asssessment of Functioning

Question 45

Pharmacological Tx of Bipolar

Answer 45

``` Lithium Divalproex/Valproic Acid Carbemazepine Oxcarbazepine Lamotrigine Topiramate Atypicals ```

Question 46

Lithium

Answer 46

Therapeutic serum concentration 0.6-1.2 mEq/L (should draw serum level 4-5 days after the first dose) For Mixed/Manic or Depressive not Rapid Cycling. Usual Adult dose 900 mg/day divided BID ADRs Gi upset, tremor, diabetes insipidus, weight gain, acne, alopecia, leukocytosis, and hypothyroidism. Baseline monitoring: Renal Fxn, pregnancy test, electrolytes, thyroid fxn, BCB, urine, ECG, weight. Routine monitoring (above tests every 6-12 months and concentration serum every 6-12 months.

Question 47

Divalproex/Valproic Acid

Answer 47

May be more useful for manic/mixed episodes, only one that really works in rapid cycling. Usual dose 750-3000 mg/day. Serum Concentrations 50-125 mcg/ml ADRs GI upset, weight gain, thrombocytopenia, hyperammonemia, alopecia, tremor, hepatotixcity, PCOS, anenorrhea, leukopenia, osteoporosis and sedation. Neural tube defects when used in pregnancy. BBW for hepatic failure, esp in kids, life threatening pancreatitis, Pregnancy category D(see above) Baseline Monitoring CBC, LFT Weight at each clinic visit, valproate levels, serum ammonia (if symptomatcc acute mental status changes), serum albumin. Drug interactions: Antacids, phenytoin, warfarin, asa, lamotrigine, ritonavir

Question 48

Carbamazepine

Answer 48

XR capsule approved for tx of bipolar d/o usual adult dose 200-1600 mg/day. Autoinducer No serum concentration correlation for Bipolar ADR Rash sedation, anticholingeric effects, weight gain, cardiac conduction abnormalities, hyponatremia, agranulocytosis, osteoporosis, hepatotoxicity. BBW for fatal blood cell abnormalities (aplstic anemia), caution and genetic screening required for asian patients (HLA-B 1502 could inc risk of SJS) Monitoring, CBC, LFTs, ECG, Electrolytes, Pregnancy test Drug interactiosn: oral cotnraceptives, any 1A2 or 3A4 substrave, lamotrigine, keotconazole

Question 49

Oxcarbazepine

Answer 49

Usual dose 300mg BID Less angranulocytosis, but more hyponatremia than carbamazpine Is NOT an autoinducer, just CYP 3A4 inducer. Watch OC may not be effective

Question 50

Lamotrigine

Answer 50

First line therapy for the maintenance treatment of bipolar depression. Long titration schedule to therapeutic dose, therefore not useful for the acute treatment of bipolar depression. BBW for SJS if monotherapy start 25 mg daily x 14 days, then 50 mg/day for 14 days, then 100mg/day for 1 week, then 200mg/day. Must monitoring for discontinuation of interacting drugs if D/C valproate will need to inrease lamotrigine dose, if d/c carbamazipine, will need to decrease lamotrigine dose. ADRs rash, SJS, sedation, HA, GI effects, and blurred vision. DI: Valproic acid Carbamaepine OC: inrease lamotrigine serum concentrations!

Question 51

Topiramte

Answer 51

Adjunctive therapy May cause weight loss Cognitive ADRS such as word-finding difficulties Carbonic anhydrase inhibitor- may lower serum bicaronate ADR include kidney stones, oligohidrosis Pregnancy category D d/t cleft lip/palate malformations.

Question 52

Atypicals for Biopolar

Answer 52

Quetiapine is approved for treatment of bipolar depression Olanzapine/fluoxetine is also approved Long acting injections may be useful in the treatment of Bipolar

Question 53

Antidepressent use in Bipolar

Answer 53

Use is controbersial because of the risk of "swtich" to a manic episode. Only to be used in combo with a mood stabilizer

Question 54

Schizophrenia-Positive Sx

Answer 54

Hallucinatiosn, delusions, disorganized speech, and behavior, and psychomotor agitation.

Question 55

Schizophrenia-Negative Sx

Answer 55

Blunted affect, poverty of speech, alogia ( decrease in word-finding abilities), avolition(lack of motivation), anhedonia (lack of ability to feel happiness or pleasure in previously pleasurable activities), and psychomotor agitation.

Question 56

Schizophrenia-Cognitive and Mood Sx

Answer 56

Cognitive Sx: Decreased attention span, poor memory, declining executive functioning, slower skill acquisition. Mood Sx: Depression, dysphoria, hopelessness.

Question 57

True or False, antipsychotic medications work well for negative symptoms.

Answer 57

False, only work well to treat the positive symptoms of the illness.

Question 58

Dx of Schizophrenia

Answer 58

Sx for 6 months, otherwise called Schizophreniform disorder. Schizoaffective disorder is a combo of schizoprhenia and mood disorder w/o psychosis.

Question 59

Pharmacologic Tx of Shizophrenia

Answer 59

Typical (Conventional first generation) antipsychotics) Atypical (2nd generation) Antipsychotic Agents)

Question 60

Typical (Conventional first generation) antipsychotics)

Answer 60

Act by D2 receptor blockade, may worsen cognitive sx, and lead to EPS All typical agetns are equally effective in treating positive sx of schizophrenia. pick drug based on adr profile, patient tolerability. EPS is more common with higher potency agents (chlorpormazine, thioridazine) QTc Prolongation is a known effect of the antipsychotic agents. Cause hyperprolactinemia. Weight gain, sedation, sexual dysfunction. BBW: Elderly patients with dementia-related psychosis are at an increased risk of death compared to placebo. Thioridazine- dose-related effects on ventricular repolarization...QTc prolongation.

Question 61

Atypical (2nd generation) Antipsychotic Agents)

Answer 61

Possess some activity at the D2 receptor, which provides efficacy for psychotic symptoms, but they also have added serotonergic neurotransmission. All atypicals have similar efficacy in the tx of schizophrinea, except for clozapine. It has been shown to be most effective. But it has lots of side effects, and requires frequent CBC (WBC and ANC) monitoring d/t risk of agranulocytosis. Paliperidone/risperodone: hyperprolactinemia. Risperidone: more EPS sx Ziprasidone/Aripirazole lower on metabolic Side effects and EPS.

Question 62

EPS Sx & Pseudoparkinsonism

Answer 62

EPS: Acute dystonic reactions that usually invovle the muscles of the neck and face. Can be treated with IM anticholingeric agents such as benztropine or diphenjydramine. Pseudoparkinsonism: usually appears within the first 3 months of treatment, cogwheel rigidity, tremor at rest, reduced arm movement, and akinesia (slowing of voluntary movements). Can also use anticholingeric meds, oral agents benztropine, diphenjydramine, and trihexyphenidyl.

Question 63

Akathisia

Answer 63

Feeling of inner restlessness or inability to sit still. Associated with increased risk of suicide. Anticholinergic meds are not effective. First line treatment is low dose propranolol followed by lorazepam.

Question 64

TD

Answer 64

Is often termed EPS but occurs by a supersensitivity of dopamine receptors rather than a blockade of dopamine receptors. Generally irreversible, best tx is to d/c the antipsychotic if an option or switch to a different agent.

Question 65

Hyperprolactinemia Tx

Answer 65

Some studies have suggested that the use of low-dose aripirprazole is helpful in reversing this type of hyperprolactinemia b/c of it's MOA as a dopamine partial agonist.

Question 66

Weight Gain and Metbolic ADRS of Atypicals

Answer 66

weight gain , nutritional and exercising counseling should begin with initiation of the agent. Monitor at each visit. Metabolic ADRs: Clozapine and olanzapine have greatest risk, then risperidone/quetiapine, then ziprasidone, aripiprazole, paliperidone, iloperidone, and asenapine. At the present time lurasidone is considered to have little to no effect on metabolic parameters.

Question 67

Closapine

Answer 67

``` Boxed Warnings: Agranulocytosis Seizures Fatalities by myocarditis orthostatic hypotension. ```

Question 68

True or False. Polytherapy with two or more antipsychotic agents is supported by clinical literature.

Answer 68

False, not supported by literature but is clinically common.

Question 69

ADHD Dx

Answer 69

Must have at least six of the following signs of inattention: Fails to give close attention to details or makes careless mistakes. Often has difficulty sustaining attention int tasks or play activities Often does not seem to listen when spoken to Does not follow through on instructiosn difficulty organizing tasks and activities Avoids, dislikes or is reluctant to engage in activities requiring sustained mental effort Often loses things necessary for tasks or activities easily distracted by external stimuli forgetful in daily activities AND at least six of the following sx of hyperactibity or impulsivity 1. figets with hands or feet or squirms in seat 2. leaves seat in classroom 3. often runs about or climbs excessively when it is inappropriate to do so. 4. Often has difficulty playing or engaging in leisure activities quietly 5. Often is "on the go" or acts as if "driven by a motor" 6. Often talks excessively 7. Often blurts out answers before questions have been completed 8. Has difficulty waiting his or her turn 9. Often interrupts or intrudes on others.

Question 70

ADHD Rating Scale

Answer 70

Conners Parents and Teacher Rating Scale (CPRS and CTRS) ADHD Rating Scale SNAP-IV

Question 71

ADHD Treatment

Answer 71

Non-pharm- therapy interventiosn, psychosocial therapy ``` Pharmacologic: Stimulant meds (first line) Atomoxetine Clonidine/guanfacine Buproprion (off-label) ```

Question 72

Stimulant Meds

Answer 72

Theorized to inhibit norepi and dopamine release to varying degrees) Methylphenidate is most commonly used ADRs decreased appetite, insomnia, anxiety, stomach upset, irritablity, increased HR/BP, growth supression If strong family hx of cardiac issues/defects, get an ECG possible referral to pediatric cardiologist. Growth supression possible BBW Potential for drug dependency Serious CVD events

Question 73

Atomoxetine

Answer 73

slective nihibito of norepi reuptake not as effective, generally second line therapy Monitor LFTS BBW for inreased suicidal thinking in peds patients.

Question 74

Clonidine/guanfacine

Answer 74

Alpha-adrenergic agonists that work presynaptically to afective norepi May be more effective in treating impulsivity and hyperactivity associated with ADHD. Start doses low. Caution with other CNS depressents.

Question 75

Alcohol Dependence Tx

Answer 75

Disulfiram- causes vomitting with alcohol ingestion Naltrexone- reduces cravings Acamprosate- structually similar to GABA and glutamate (warning for suicidal thinking)

Question 76

Opiate Dependence Tx

Answer 76

Methadone (only option for pregnant women) Buprenorphine- partial agonist and u-opioid receptor sub-lingual tab/film Naltrexone maintenance: IM depot formulation approved for use after detox.