Pyschotherapy and Psychopharm

Question 1

4 types of therapy

Answer 1

1. individual (supportive, insight oriented)
2. behavior (desensitization, substitution, hypnosis)
3. cognitive
4. social (marital, AA)

Question 2

therapy to maintain defense mechanisms for improved function?
Indicated for?

Answer 2

Supportive

adjustment disorders, acute emotional crises

Question 3

therapy to breakdown unconscious maladaptive defense mechanisms?
indicated for?

Answer 3

insight-oriented

depression, anxiety, somatoform/dissociative/personality, neuroses, trauma

Question 4

indications for cognitive therapy?

Answer 4

major depression, self-defeating attitudes

Question 5

3 classes of psychopharm

Answer 5

1. antidepressants / mood stabilizers
2. anti-psychotics
3. anxiolytics / hypnotic

Question 6

3 types of neurotransmitter targets of psychopharm

Answer 6

1. monoamines (norepinephrine, dopamine, serotonin, acetylcholine, histamine)
2. amino acids (GABA)
3. glutamic acid

Question 7

4 categories of antidepressants
Their mechanism
Their side effects

Which is most commonly used?

Answer 7

1. SSRIs / SSNRIs
   reuptake inhibition of 5HT / 5HT-NE
   GI, sexual
2. TCA
   reuptake reduction of NE and 5-HT
   anti-adrenergic - cardiac arrhythmias / orthostatic HoTN, anticholinergic, anti-histamine - weight gain; coma / convulsion / cardiotox
3. MAOI
   breakdown inhibition
   HTN crisis if coupled w tyramine (wine, cheese, liver, smoked foods) - avoid unless atypical depression (overeating, oversleeping, irritability), orthostatic HoTN, somnolence, weight gain
4. Miscellaneous

SSRIs

Question 8

3 commonly used mood stabilizers

Their side effects

Answer 8

1. Li - tremor, NDI, acne, hypothyroidism, cardiac arrythmias, weight gain, edema, leukocytosis, cleared renally thus avoid if low GFR
2. Valproate - thrombocytopenia, pancreatitis, hair loss, NT defects
3. Carbamazepine -slurring, transaminitis, craniofacial defects in newborn, agranulocytosis

Question 9

1st gen antipsychotics
Mechanism?
Most effective for?
Side effects? - CNS, anticholinergic, CV, endocrine, metabolic

Answer 9

• blocks central DA receptors
• reducing pos symptoms of schizophrenia - hallucination and delusions
• CNS: EPS (acute dystonia, akathisia, Parkinsonian), Tardive Dyskinesia, sedation, NMS (rigidity, autonomic dysregulation - tx w dantrolene / bromocriptine)
• anticholinergic: hot as hare (increased temp), read as beet (flushing), blind as bat (mydriasis), dry as bone (dry mouth, no sweating), mad as hatter (delirium); opposite of DUMBBELSS (diarrhea, urination, miosis, bronchospasm, bradycardia, excitation, lacrimation, salivation, sweating)
• CV: a-blockade -> orthostatic HoTN, QT elongation
• Endocrine: hyperPRL -> gynecomastia, galactorrhea, sexual dysfunction
• Metabolic: weight gain

Question 10

2nd gen (atypical) antipsychotics
How diff from 1st gen?

Answer 10

Less likely to have CNS side effects

Question 11

Anxiolytics / hypnotics
mech?
side effects?
withdrawal consequence?

Answer 11

binds GABA receptors

sedation, behavioral disinhibition, psychomotor impairment, cognitive impairment, ataxia; addictive

seizure -> death

Question 12

Stimulants
mech?
indication?

Answer 12

increases NE, DA activity

ADHD

Question 13

tx for OCD

Answer 13

SSRI (fluoxetine, sertraline, paroxetine, fluovaxamine), clomipramine

Question 14

TCA that causes EPS and NMS?

Answer 14

amoxapine (metabolite of loxapine, a 1st gen anti-psychotic)

Question 15

TCA w most favorable side effect profile?

Answer 15

desipramine

Question 16

med combo that leads to serotonin syndrome?

Answer 16

SSRI + MAO; separate by >5wks

Question 17

SSRIs w the following side effects

1. diarrhea
2. anticholinergic
3. n/v
4. fewer sexual side effects

Answer 17

1. sertraline
2. paroxetine
3. fluvoxamine
4. citalopram

Question 18

SNRI for anxiety (general and social)

Answer 18

venlafaxine

Question 19

SSRI for GAD and painful diabetic neuropathy

Answer 19

Duloxetine

Question 20

transdermal MAOI?

Answer 20

selegiline

Question 21

miscellaneous antidepressants: mech?

1. decreased sexual dysfunction but hepatotox
2. priapism, orthostatic HoTN, for sleep
3. weight gain, no sexual / GI
4. seizures, anorexia, for smoking cessation
5. n/v/d/c, sexual dysfunction
6. headache, for GAD and OCD

Answer 21

1. nefazodone - 5-HT
2. trazodone - 5-HT
3. mirtazepine - NE and 5-HT antagonist
4. bupropion - NE and DA reuptake inhibitor
5. Vortioxetine - 5-HT stimulator
6. Vilazodone - 5-HT

Question 22

Mood stabilizer: tremor, hypothyroid, arrythmias, NDI, (benign leukocytosis)
mech?
tox?
monitoring?

Answer 22

• Li
• inhibits AC
• seizure, coma, death
• Thyroid, renal, EKG, pregnancy, Li level

Question 23

Mood stabilizer: thrombocytopenia, pancreatitis, hair loss, NT defects
monitoring?

Answer 23

• Valproic acid / divalproex

- CBC, LFT, pancreatic enzymes, hCG

Question 24

Mood stabilizer: slurring, transaminitis, craniofacial defects in newborn, agranulocytosis
monitoring?
drug drug interactions?

Answer 24

• carbamazepine
• CBC, LFTs, levels
• potent inducer of P450s

Question 25

Mood stabilizer: leukopenia, hepatic failure, SJ syndrome | monitoring?

Answer 25

- lamotrigine | - CBC

Question 26

Mood stabilizer: ataxia, leukopenia, weight gain | drug drug interactions?

Answer 26

Gabapentin | - none

Question 27

Mood stabilizer: psychomotor slowing, memory problems

Answer 27

Topiramate ("dopiramate")

Question 28

1st generation anti-psychotics 1. sedation and orthostatic HoTN very common 2. EPS very common 3. retinitis pigmentosa 4. torsade de pointes 5. IM depot available

Answer 28

1. chlorpromazine 2. haloperidol 3. thioridazine 4. mesoridazine 5. haloperidol, fluphenazine

Question 29

2nd gen anti-psychotics 1. agranulocytosis, NMS 2. hyper PRL 3. somnolence 4. QT prolongation 5. headache 6. tachycardia 7. present in breast milk 8. cataracts 9. diabetes 10. increased mortality in elderly patients

Answer 29

1. clozapine 2. risperidone, olanzapine 3. olanzapine 4. ziprasidone 5. lurasidone 6. paliperidone (invega) 7. risperidone 8. quetiapine 9. aripiprazole 10. lurasidone, paliperidone

Question 30

long or short acting benzo 1. diazepam 2. lorazepam 3. clonazepam 4. alprazolam 5. chlordiazepoxide 6. oxazepam 7. temazepam 8. midazolam 9. triazolam

Answer 30

1. long 2. long 3. long 4. medium 5. long 6. medium 7. medium 8. short 9. short

Question 31

Anxiolytics / hypnotics: 1. for GAD, avoid MAOI 2. increased effect w alcohol or SSRIs 3. amnesia 4. melatonin receptor agonist 5. anxiety, unusual dreams, unpleasant taste

Answer 31

1. buspirone 2. zolpidem 3. zaleplon 4. ramelteon 5. eszopiclone

Question 32

Stimulants: 1. slow children's growth 2. for narcolepsy only 3. for ADHD and narcolepsy 4. SNRI, no abuse potential

Answer 32

1. dextroamphetamine and amphetamine (Adderall) 2. modafinil 3. dextroamphatmine, methylphenidate 4. atomoxetine

Question 33

NMS vs. serotonin syndrome?

Answer 33

both have autonomic dysregulation but - NMS rigidity vs. serotonin clonus - antispychotic fx vs. anti-depressant fx - high CPK vs. seizures - hyperthermia vs. HTN crisis

Question 34

contraindications to buproprion

Answer 34

1. seizure | 2. eating disorder

Question 35

alcohol withdrawal tx? | What else could present like alcohol withdrawal?

Answer 35

1. benzodiazepine | 2. benzo withdrawal

Question 36

dx? 1. diarrhea, restlessness / extreme agitation, hyperreflexia, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death 2. muscle rigidity, autonomic dysregulation, high WBC and CPK

Answer 36

1. serotonin syndrome | 2. NMS

Question 37

Alcohol withdrawal syndrome timeline

Answer 37

``` by: 12hrs: tremors 24hrs: hallucinosis 48 hrs: seizures 96 hrs: delirium tremens (delirium, autonomics) ```