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RAP E4 Content Review Flashcards

8.01-2, 8.05, 8.07 (99 cards)

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1
Q

Gold standard treatment for recalcitrant treatment-resistant unipolar depression?

A

ECT

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2
Q

Is ECT safe for pregnancy?

A

yes

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3
Q

ECT standard procedure and frequency?

A

3x weekly for 6-12 months
under general anesthesia
induced small generalized seizures

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4
Q

What do you use to treat serotonin syndrome?

A

Benzos OR Cyproheptadine

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5
Q

If a patient comes in confused, with high body temperature, sweating, diarrhea, clonus, and hypertonia that come on over 24 hours, what are you thinking?

A

Serotonin Syndrome

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6
Q

What drugs can increase the risk of serotonin syndrome?

A

Any that increase 5HT (serotonin)
SSRI, SNRI, MAOIs, Linezolid (skin/pneumonia antibiotic), Tramadol (opiate), Triptan (migraines), Zofran (nausea from chemo)

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7
Q

What atypical antidepressant used to treat insomnia?

A

Trazadone

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8
Q

TRAZADONE MOA and ADSE

A

serotonin, alpha 1, and H1 antagonist + weak 5HT reuptake inhibitor
ADSE –> sedation, postural hypotension, priapism (painful persistent erection)

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9
Q

What atypical antidepressant is used to help increase appetite in cancer patients?

A

Mirtazapine

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10
Q

MIRTAZAPINE MOA and ADSE

A

alpha 2, 5HT2/3, H1 antagonist
ADSE –> increased appetite and sleep

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11
Q

BUPROPRION MOA and ADSE

A

Inhibit NE and DA reuptake
less ADSE than most antidepressants BUT can lower seizure threshold

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12
Q

Although Buproprion is an atypical antidepressant that has lower ADSE in sexual dysfunction and weight gain, it is used widely for smoking cessation to improve ADHD symptoms. Who is it CONTRA for?

A

anorexia and bulimia patients –> seizure risk

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13
Q

Antidepressant that can be used to treat Parkinson’s?

A

SELEGILINE

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14
Q

An antidepressant that can be used to treat nocturnal enuresis (“bed wetting”)?

A

IMIPRAMINE

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15
Q

Coma, convulsions, and cardiotoxicity are signs of what?

A

TCA overdose/toxicity

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16
Q

TCA used to treat OCD?

A

CLOMIPRAMINE

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17
Q

An elderly patient, shortly after starting treatment with an old drug for MDD + chronic pain, begins to experience QT prolongation, convulsions, and slips into a coma. What do you use to treat?

A

sodium bicarbonate
(for arrhythmias due to TCA cardiotoxicity from excessive acetylcholine)

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18
Q

ADSE of a drug used to treat atypical or treatment-resistant depression and/or anxiety?

A

hypertension crisis + CNS stimulation
MAOI (nonselective MAO inhibitor)

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19
Q

Ingestion of what is dangerous if the patient is taking an MAOI for parkinsons or treatment-resistant depression/anxiety?

A

wine + cheese + fava beans b/c tyramine –> hypertension crisis

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20
Q

What should a physician recommend for a patient discontinuing their MAOI medication?

A

2-week wash-out period

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21
Q

SNRI is used to treat what generally? Advantages/Disadvantages?

A

2nd LINE depression, GAD, but also effective for diabetic neuropathy and fibromyalgia
similar SSRI side effect profile but extra HTN risk

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22
Q

SSRI is used to treat what generally? Advantages/Disadvantages?

A

1st LINE depression, GAD, social anxiety, OCD, premature ejaculation, PDD, bulimia, panic disorder
Advantage: lots of range and generally well tolerated
ADSE: GI (starting), sex dysfunction, SIADH

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23
Q

How long for SSRIs and SNRIs to take full effect?

A

3-6 weeks

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24
Q

Work up for depression?

A

PHQ-9
Interview
DSM-5-TR Dxg
Rule Out Other: CBC, TSH, Urine tox screen

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25
Highest efficacy treatment for depression?
Therapy + Medication psychotherapy + 1st SSRI or 2nd SNRI/atypical or 3rd TCA or MAOI or Augmentation
26
premenstrual dysphoric disorder criteria
The majority of menstrual cycles, onset a few days before menses and resolves the week after, total of (5) symptoms with at least (1) lability, irritability, anger, conflict, depression, on edge, hopeless, anxiety/tension and another at least (1) anhedonia, poor concentration, decreased energy, changes in appetite or sleep, overwhelmed/feeling out of control, physical symptoms
27
Disruptive Mood Disorder Criteria
severely recurrent disproportionate temper tantrums for OVER 12 months and NEVER WITHOUT for over 3 months, inconsistent with development, x3 per week on average persistent irritable/angry most of the day, most days, noticeable by others in AT LEAST 2 settings (1 severe) Symptoms onset before 10 yo 1st line dxg between 6-18 yo `
28
Persistent depressive disorder criteria
depressed mood for most of the day, most days, OVER 2 years, and NEVER WITHOUT longer than 2 months at a time 2+ symptoms: changes in appetite, changes in sleep, low energy, poor concentration, hopelessness, low self-esteem
29
Major depressive disorder criteria
5+ symptoms over a 2-week period with at least (1) depressed mood or anhedonia SIGECAPS - sadness/sleep, interest, guilt, energy, concentrate, appetite, psychomotor, suicide
30
What symptoms can lead to an MDD "atypical" specifier?
hypersomnia, leaden paralysis, mood reactivity, hypersensitivity, increased appetite, interpersonal rejection
31
What symptoms can lead to an MDD "melancholia" specifier?
anorexia, guilt, worse symptoms in the morning, early morning awakeness, despair, psychomotor symptoms
32
What symptoms can lead to an MDD "peripartum" specifier?
onset within 4 weeks of giving birth
33
What symptom can be seen in a "severe" MDD specifier?
psychotic features
34
What psych disorder do 50% of patients also have MDD?
personality disorder
35
What is the incidence of comorbidities for patients diagnosed with MDD? Implications?
69-76%, incredibly common, and align with worse prognosis
36
What is the most common demographic of depressive disorders?
female (x2), average 30 yo, lower SES, multiracial, younger age
37
What are two criteria that every DSM-5 diagnosis but meet?
1. causes significant distress or impairment 2. cannot be explained by another medical condition, substance abuse, or diagnosis
38
An immature coping mechanism characterized as overcompensating in behavior opposite to personal thoughts/beliefs?
reaction fixation
39
What is the difference between displacement and transference?
Rather than a neutral party (lashing out), the patient is placing their emotions about other people onto the provider (transference)
40
What is the difference between affect and mood?
Physician assessment is affect vs. patient self-reported experience = mood
41
What are the 4 episode types in a mood disorder?
manic, major depressive, hypomanic, mixed
42
What is the monoamine hypothesis for mood disorders? Shortcomings of this theory?
depression and mania can be explained as a deficiency/excess of monoamine neurotransmitters such as NE and 5-HT no clear evidence in research and 6-week delay in drugs that upregulate monoamines
43
What are mood disorders?
spectrum of psych conditions with mania and/or depression characterized by episodes
44
What is the neurotrophic hypothesis for mood disorders?
depression and mania can be explained as a genetic deficiency/excess of brain-derived neurotrophic factor (BDNF) that maintains and enhances neurogenesis, plasticity, and mediation Multiple factors can affect BDNF levels: monoamines, glutamate, and glucocorticoids (HPA axis), with different effects in different brain regions
45
What is the endocrine hypothesis for mood disorders?
stress = HPA axis upregulation = release of glucocorticoids co-localizes on glucocorticoid and monoamine receptors (upregulation), leading to decreased BDNF levels that lead to neuronal atrophy, decreased synapses, and decreased function + impaired amygdala and hippocampal function (chronic)
46
What is the proposed mechanism of glutamate in the neurotrophic model of mood disorders?
increases BDNF levels and is implicated in neuroplasticity it upregulated by AMPA via the ERK/Akt signal cascade
47
Neurotrophic model hypothesis explanation for depression?
decreased BDNF levels in the hippocampus and PFC
48
Neurotrophic model hypothesis explanation for mania?
increased BDNF levels in the amygdala and nucleus accumbens
49
BUPROPION MOA
NRDI: NE and DO reuptake inhibitor
50
What class? FLUOXETINE - PAROXETINE - SERTALINE - ESCITALOPRAM
SSRI: selective serotonin reuptake inhibitors
51
What class? DULOXETINE - LEVOMILNACIPRAN - VENLAFAXINE - DESVENLAFAXINE
SNRI: serotonin and NE reuptake inhibitor
52
Discontinuation syndrome of SSRIs and SNRIs?
"FINISH" flu like - insomnia - nausea - imbalance - sensory disturb - hyperarousal
53
Which drug is implicated the MOST for causing discontinuation syndrome?
VENLAFAXINE (SNRI)
54
Which drug is implicated the LEAST for causing discontinuation syndrome?
FLUOXETINE (SSRI)
55
Who should you especially exercise caution in prescribing SSRIs or SNRIs due to ADSE?
under 25 yo (increased suicidal ideation), people with seizure risks (decreased threshold), hypertensive pts (with SNRIs)
56
Difference between atypical antidepressants: VILAZODONE vs. TRAZADONE/VORTIOXETINE?
VILAZODONE: SSRI and 5HT-R partial agonist TRAZADONE/VORTIOXETINE: SSRI and 5HT-R antagonist
57
MIRTAZAPINE MOA
a2 antagonist (atypical antidepressant) less a2 (brainstem to PFC) = more NT release of 5HT and NE at PFC indirectly
58
What class? BUPROPION - MIRTAZAPINE - TRAZADONE - VILAZODONE - VORTIOXETINE
atypical antidepressants
59
What class? PHENELZINE - SELEGILINE - TRANYLCYPROIMINE
MAOIs
60
MAOIs MOA?
monoamine oxidase inhibitor (A) for antidepressive effects via increased levels of DA, NE, 5HT, and Tyramine, an old school drug that has lots of ADSE and used for recalcitrant depression
61
What class? DESIPRAMINE - IMIPRAMINE - NORTRIPTYLINE - PROTRIPTYLINE
TCAs
62
TCAs MOA?
bind to off-target receptors of NE and 5HT for antidepressant effects, but also receptors having antihistamine, anti-alpha, and antimuscarinic effects nonselective with limited use
63
What drug class can be used to treat recalcitrant depression and chronic pain?
TCAs - DESIPRAMINE - IMIPRAMINE - NORTRIPTYLINE - PROTRIPTYLINE
64
What drugs can be used for GAD?
SSRI/SNRI, Gabapentin/Preglabin, Benzo, Buspirone
65
BUSPIRONE MOA
DIRECT 5HT-R agonist used to treat GAD
66
How are Gabapentin/Preglabin used to treat GAD?
Inhibition of voltage calcium-gated channels in the amygdala to reduce firing and blunt the fear response
67
How are Benzos used to treat GAD?
increase amounts of post synaptic GABA(a) levels to reduce amygdala neuronal firing = blunt fear response; not used 1st line or long term
68
What drug can reduce lithium clearance due to its effects on the nephron?
Thiazides - CLORTHALIDONE, HYDROCHLOROTHIAZIDE, INDAPAMIDE
69
Bipolar pharm TX options?
COMBO lithium + antipsychotic OR COMBO valproate + antipsychotic Lithium (prophylactic)
70
What is the hypothesized Lithium MOA to treat bipolar?
disrupts the GPCR pathway and PEP pathway to increase neuronal plasticity and protection
71
Lithium ADSE
tremor, decreased thyroid function, nephrogenic diabetes insipidus
72
Why is Lithium CONTRA to women shortly AFTER they have given birth?
Pregnancy increases GFR, so a normal dose of lithium runs the risk of increased exposure in the post-natal period
73
GAD CRITERIA
most days of the week for at least 6 months (3/6): restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleeping problems
74
Panic Disorder CRITERIA
persistent worry day to day and recurrent unexpected panic attacks (1+) for at least 1 month panic attack + 4 symptoms
75
Agoraphobia CRITERIA
persistent worry and avoidance of exposure to at least (2) settings: public transport, open areas, closed off areas, outside alone, etc. for at least 6 months
76
Agoraphobia treatment protocol?
pharm same as panic disorder (SSRI, benzo, TCAs) + behavioral therapy*
77
Specific phobia CRITERIA?
marked fear and anxiety day-to-day of a specific entity out of proportion for at least 6 months
78
Specific phobia treatment protocol?
behavioral therapy (exposure, insight-oreinted, virtual)
79
Most common psych diagnosis among women, with the most common incorporates blood, injury, and injections?
specific phobia
80
Social anxiety CRITERIA
grossly disproportionate anxiety and fear of 1+ social situations in order to avoid potential negative criticism for at least 6 months
81
Social anxiety treatment protocol?
propranolol (performance), SSRIs (1st line), benzos, buspirone, etc. + CBT
82
Separation anxiety CRITERIA
at least (3): extreme distress, excessive worrying of harm/loss, excess worry of separation, reluctance to leave alone, reluctance to be alone, reluctance to sleep away from, refusal to sleep, physical symptoms for over 6 months (adult) or over 4 weeks/1 month (child)
83
selective mutism CRITERIA
Failure to speak in specific social situations despite intact ability/comprehension for at least 1 month
84
Selective mutism treatment protocol?
CBT AND Pharm: SSRIs + buspirone OR benzos (short term) OR propranolol (event) OR ADJUNCT antipsychotic (low dose)
85
What condition has a high genetic association with Tourette's syndrome? So much so that "tic-related" is a specifier in the DSM-5?
OCD
86
What is the difference between OCD and OCPD?
OCD = ego-dystonic vs OCPD = ego-syntonic
87
OCD CRITERIA
obsessives compulsive behavior >1hr/daily or significant day-to-day distress
88
OCD implicated pathological neurological circuits?
cortico-striatal-thalamo-cortical fronto-limbic
89
OCD treatment protocol, FDA approved vs off-label?
Exposure and response therapy + CBT FDA approved: SSRIs + TCA (CLOMIPRAMINE) Off-Label: SNRI (VENLAFAXINE)
90
Body dysmorphia treatment protocol?
CBT, Accept and Commit Therapy
91
Body dysmorphia CRITERIA & Specifier
preoccupation with 1+ flaws or defects in appearance not observed (or slight) by others, repetitive behaviors, not better accounted for with body fat/weight specifier: muscle dysmorphia
92
Who is at increased risk of body dysmorphia?
genetic + environmental disposition: childhood abuse/neglect and cosmetic/dermatology patients
93
Difference between hoarding as DSM-5 criteria and collecting?
hoarding = shame/sadnesses/significant distress due to lack of discarding or accumulation of items regardless of value, causing hazard/ lack of living space (and not by secondary defect of energy/ability) collecting = budgeting and pride
94
What is a common differential diagnosis of hoarding that shows many of the same features but has a different root cause?
OCD (1 in 4 hoard)
95
Trichotillomania can cause subtle changes to the brain in which regions?
cortical anterior cingulate putamen cerebellum right inferior frontal gyri
96
Trichotillomania treatment protocol?
CBT + CLOMIPRAMINE (TCA)
97
Workup to diagnose Excoriation Disorder and rule out a medical or substance-induced cause?
HPI + PE (scabies) + Labs: CBC, BMP, TSH, Urine Drug Screen
98
Excoriation Disorder treatment protocol?
therapy, lifestyle, psychosocial, medication
99

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