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Psych EOR Complete Question With Correct
Solutions
abnormally elevated, expansive, or irritable mood + INC energy/activity lasting >1 weeks (or any length if requires hospitalization) DIGFAST: need 3, 4 if mood is only irritable: D - distractability I - impulsivity G - grandiose F - flight of ideas A - activity (Inc)/agitation S- sleep (dec) T - talkative
- signficant impairment OR requires hosp OR +psychotic features manic episode abnormally elevated, expansive, or irritable mood + INC energy/activity lasting >4 days
DIGFAST: need 3, 4 if mood is only irritable. obvious change in functioning is uncharacteristic of the individual when not sympto. change observeable by others NO psychotic features, NO significant impairment, no hospital hypomanic episode Mixed episodes (mania/hypo) criteria met for manic (or hypo) episode w 3+ sxs of MDE (SIGECAPS) lasting >1wk 5+ sxs (SIGECAPS), >2 wks. sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation (restlessness/ slowness), suicide 1 sympto must be depressed mood or anhedonia major depressive disorder Bipolar
•aripiprazole, haloperidol, olanzapine, quetiapine, risperidone •Carbamazepine: same efficacy w/ monotherapy vs +AP •valproate & carbamazepine particularly useful for rapid cycling & mixed episodes *NEVER USE ADs AS MONOTHERAPY (activates mania) Maintenance Therapy: typically use same regimen that was effective acutely +therapy (supportive psychotherapy, family therapy, group therapy) Lithium: MOA general idea mood stabilizer -antagonize adrenergic and DA activities while enhancing serotonergic activity MOA: inhibit 5HT/NE reuptake & 2nd messenger systems REDUCES SUICIDE RISK :) Lithium ADRs and considerations
- Top 3 big no nos
- ADRs
- ADR duration related
- drug level changes with?
- neurotoxicity with? *kidney metabolism, AVOID if CrCl <30mL/min Pregnancy: Ebstein’s anomaly w/ use (esp. 1st TM) BOXED WARNING: toxicity, monitor levels (therapeutic range 0.6-1.2mEq/L) ADRs: hypothyroidism, tremor, weight gain, leukocytosis •GI (N/V/D, metallic/salty taste, i.e., dysgeusia) •dermatologic (acne vulgaris, psoriasis) •cardiac arrhythmia (bradycardia, abnormal T waves, edema) •CNS (sedation, lethargy, ataxia, slurred speech, HA) ADRs (duration-related): nephrogenic diabetes insipidus, hyperparathyroidism & hypercalcemia, interstitial nephritis, polyuria/polydipsia •↑ lithium levels: ↓ salt, ACEI/ARB, diuretics, NSAIDs •↓ lithium levels: ↑ salt, caffeine, theophylline •neurotoxicity: verapamil, diltiazem, phenytoin, carbamazepine Warnings/Caution: pseudotumor cerebri, serotonin syndrome, myasthenia gravis
*INEFFECTIVE FOR ACUTE MANIA, better for bipolar depression ADRs: nausea, fatigue, ataxia, dizziness, sedation, back pain ADRs (significant): •aseptic meningitis (rare), blood dyscrasias (agranulocytosis, pancytopenia) •hemophagocytic lymphohistiocytosis(s/sxs: fever, rash, hepatosplenomegaly) BOXED WARNING: SJS/TEN/DRESS (↓ valproate levels Pregnancy: increased risk for cleft lip/palate Carbamazepine
- MOA
- best indication
- what's a better drug with same efficacy?
- ADR
- ADR significant (5) -BBW
- pregnancy
- Drug interactions MOA: blocks Na channels
monotherapy, mixed episodes, rapid-cycling Oxcarbazepine: same efficacy, better tolerance, less r/o rash & hepatotoxicity, monitor Na levels ADRs: N/V/C, ataxia, dizziness, sedation, blurred vision ADRs (significant): •hematologic (aplastic anemia, leukopenia, thrombocytopenia) •cardiac (↑ risk of cardiac failure, tachycardia) •hepatotoxicity (↑ AST/ALT, GGT, alk phos), SIADH & hyponatremia (dose-related) BOXED WARNINGS: SJS/TEN & HLA-B1502 (screen Asian), aplastic anemia & agranulocytosis Pregnancy: teratogenic (NTDs, craniofacial abnormalities, CV malformations) DIs: CYP3A4, 2CP, 1A2 inducer, CYP 3A4 substrate (autoinduces metabolism) •autoinduction: may need dose ↑ in beginning, measure at 0, 3, 6, & 9wks •CYP inhibitors ↑ CBZ levels: risk toxicity (grapefruit juice, protease inhibitors, azoles) •CBZ ↓ levels of CYP450 (BDZs, statins, buspirone, venlafaxine, mirtazapine, Haldol) •synergistic w/lithium for refractory bipolar, but neurotoxicity has occurred w/ combo
*combo of meds + CBT = most success Treatment-Resistant: TCAs, MAOIs, atypical APs, stimulants, carbamazepine, ECT Pharm: should give drug≥6wks at maximum dose before switching •Depressed mood majority of the day on most days lasting ≥2YRS (1y in children/adolescents) •never been without symptoms >2MO at a time •never had manic/hypomanic episode Dx Tx Persistent depressive disorder (Dysthymia) combo treatment w/ psychotherapy & pharmacology more efficacious than either alone Pharmacotherapy: SSRIs, SNRIs, TCAs, MAOIs Psychotherapy: interpersonal, cognitive, insight-oriented
Occurs ≥3X/WK for ≥12MO + NO PERIOD ≥3MO W/O SXS, PRESENT IN 2+ SETTINGS •Recurrent temper outbursts manifested verbally (e.g., verbal rages) &/or behaviorally (e.g., physical aggression) that are out of proportion to situation/provocation & inconsistent w/ developmental level •Mood between outbursts is persistently irritable or angry & observable by others •Symptoms began BEFORE AGE 10 (not diagnosed before 6yo orafter 18yo) Dx Tx Disruptive Mood Dysregulation Disorder (DMDD) •core feature of DMDD is chronic severe, persistent irritability occurring in childhood & adolescence •irritability: frequent temper outbursts + persistent irritable or angry mood between outbursts •psychotherapy (parent management training) first line •medications for symptom control & comorbidities (stimulants, SSRIs, mood stabilizers, second- generation antipsychotics) *PRESENT week BEFORE MENSES ONSET, IMPROVE after a few days of onset, MINIMAL/ABSENT week AFTER MENSES ENDS *must be confirmed by recording of AT LEAST 2 CYCLES
Dx Labs Tx Premenstrual Dysphoric Disorder (PMDD): severe PMS w/ FUNCTIONAL IMPAIRMENT *underlying cause must be ruled out w/ TSH, hCG, CBC, FSH Lifestyle modifications: stress reduction + exercise, limit caffeine, alcohol, cigarettes, & salt, NSAIDs, vitamin B6 & E •SSRIs first line for emotional sxs w/ dysfunction •Fluoxetine, Sertraline, Citalopram •OCPs: drospirenone-containing •Spironolactone: improves sxs of bloating & tender breasts DEATH ≥12MO AGO (≥6mo for children/adolescents) •LASTS ≥1MO PERSISTENT GRIEF RESPONSE (1+):
•intense yearning/longing for deceased •preoccupation w/ thoughts/memories of deceased 3+SXS: •identity disruption (feeling as if part of oneself has died) •sense of disbelief about the death •avoidance of reminders of deceased •intense emotional pain (anger, bitterness, sorrow) •difficulty reintegrating into relationships/activities •emotional numbness •feeling that life is meaningless •intense loneliness Dx Tx Prolonged Grief Disorder
fluoxetine special use/adr use: PMDD, bulimia anorexia/activation (restlessness, anxiety, racing heart) Fluoxetine requires 5wk washout (long t1/2) paroxetine special use/adr use: vasomotor sxs of menopause; premature ejaculation dry mouth, urinary retention, weight gain SNRIs
- Meds
- Indications
- ADR
- CI Venlafaxine, Desvenlafaxine, Duloxetine, Levomilnacipran Indications: first line for MDD & anxiety disorders (GAD, social, panic, OCD, PTSD) ADRs: N/V/D, sexual dysfunction, HA, sedation, weight loss, ↑ HR, dilated pupils/blurry vision, anticholinergic, excess sweating
•↑ lipids (desvenlafaxine), BP △ (venlafaxine ↑, duloxetine ↓) *more “activating” vs SSRIs – can be fatal in OD CI: concurrent use w/ MAOIs Duloxetine special indications and ADRs fibromyalgia, chronic MSK pain, neuropathic pain (diabetes), incontinence (off-label) increase BP, avoid in renal/hepatic disease SSRI/SNRI Serious ADRs Serotonin syndrome Antiplatelet effects/increased risk of bleeding Hyponatremia QTc prolongation (think citalopram) Suicidal ideation/behavior in children and young adults (black box warning) ...trigger manic episode (so screen for bipolar!) TCA
- meds
- MOA
- indications (spec for amitriptyline, doxepin, imipramine, and clomipramine)
Narrow TI, OD concern: lethal dose ≥8x therapeutic dose •cardiac (QT prolongation), convulsions (seizures), coma (AMS) Considerations: do not abruptly D/C (“cholinergic rebound”) CI: use w/ MAOIs, methyldopa & clonidine, acute MI recovery phase AVOID: long QT syndromes, narrow-angle glaucoma, elderly (fall risk) cant use TCAs with which two drugs? DIs: methyldopa & clonidine (alpha2-agonists) •concurrent use associated w/hypertensive crisis MAOI
- meds
- MOA
- Indications
- ADR
- DI + tx
- CI
- OD Selegiline TD patch, Phenelzine, Isocarboxazid, Tranylcypromine
MOA: inhibit MAO = inhibit DA/NE/5HT metabolism •Selegiline: MAO-B selectivity at low-doses (DA) Indications:only Selegiline TD patch approved for MDD, PO Selegiline (Eldepryl, Zelapar ODT) used inParkinson’s Disease *2WK WASHOUT PERIOD ADRs: CNS stimulation (insomnia), anticholinergic, weight gain, orthostatic hypotension, sedation, sexual dysfunction DIs: tyramine (red wine, cheese) hypertensive crisis (massive NE release) •S/SXS: HTN (≥180/120), agitation, seizures, HA, diaphoresis, stroke •TX:phentolamine (alpha-blocker) CI: use w/ meperidine, cyclobenzaprine, dextromethorphan, P-CRABS (serotonin syndrome) OD: hyperpyrexia, HTN, agitation, hallucinations, diaphoresis, convulsions, mydriasis, HA, trismus •TX: supportive trazadone
