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53 Cards in this Set

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DSM IV TR

what is it

what are the axis (I-V)
diagnostic ref. for inital assess

Axis I- principle disorder - schizo, bipolar etc

II- Personality disorder- asshole, cant give meds

III-physical disorder - HTN etc

IV- severity of pshyco social factors (environmental stressors)

V- GAF - global assessment function (1-90) lower worse, admitted round 40ish
Sum points about clinical interview of mental pt
quiet atmosphere

open and closed ended questions

ok ask about suicidal thoughts
Hallucination vs delusions
hallucinations - 5 senses, most common auditory

delusion- percieved thought, dont mistake for cultural belief
clincial mental pt interview

what lookin for
dress

motor activity

speech and language

mood-sustained feeling

affect- emotional state sharing mood (flat, blunted, inappropriate)

neuropsy eval

insight judgment
for neuropsyh eval on orientation how many is usual for reg person
usually 3

time
place
person
situation
MMSE test for cognition how many to prove not impaired
want at least 24
How check movement disorders

what are the movement disorders
EPS- use simpson angus EPS scale

Dystonia- simpson scale- prolonged contraction

Akathisia- BARS, barnes akathisia rating scale - inner restlessness

Tardive dyskinesia - late onset, from extended use
Scales /inventories

Depression
note inventory is pt rated, scale is physician

hamilton depression scale (HAM-D)- gold standard

montgomery asberg scale (MADRS)- higher more depressed

Beck depression inventory BDI
Scales/ inventory

Anxiety
HAM-A scale- hamilton gold standard

beck anxiety inventory (BAI)

State trait anxiety inventory (STIA)

member inventory is pt rated
scale inventory

schizo
positive and negative symptom scale (PANSS) - GOLD STAND.

Brief psychiatric rating scale (BPRS)

Clinical global impression scale (CGI)
Inventories / scales

Bipolar disorder
mood disorder questionairre (still scale?)

bipolar spectrum disorder scale (BSDS)

goldberg mania questionaire
ADHD

epidemiology
males more than females

males- hyperactive, easier to see
females- quiet type
ADHD patho
possible prefrontal cortex abnorm (response inhibition)

decreased size cerebral volume

Dopamine and NE dysregulation in mesocortical and prefrontal areas respectively
ADHD

symptoms types
both innattentive and hyperactive types

inattentive
-fail close attention details
-not seem listen
-difficulty organize tasks
-forgetful daily activities

Hyperactive
-diff. await turn
-take excessively
-diff. standing still
-interupts
ADHD

symptom factors for diagnosis
must be present before age 7

at least 6 present for 6 months

at least 2 environments

significant impairment

not associated with another issue
Guidelines for ADHD

steps
Step 1 -stimulant (ampetamine or methylphenidate)

Step 2- opposite stim

Step 3- atomoxetine

Step 4- Bupriopion or TCA

Step 5- one you didnt use in 4

Step 6- alpha 2 ags
Stims

methylphenidate

list em
Ritalin
Methylin

Ritalin SR
Methylphenidate SR
Methylin ER
Metadate ER

Concerta
Metadate CD
Ritalin LA
Stims -methylphendates

short acting and their info
Ritalin
Methylin

3-5 h

5mg - 20mg BID or TID
Stims - methylphendates

intermed acting and info
Ritalin SR
Methylphendate SR
Methylin ER
Metadate ER

3-8 h

20mg - 40 mg QD - BID
Stims- methylphendates

long acting and info
Concerta- ghost tab - 18mg- 72mg

Ritalin LA 20 - 40 mg

Metadate CD 20 mg

8 - 12 h
+ves and -ves for methylphendates

vs amphetamines
generics

less likely supress appetite

less likely tics or insomnia

-ves
erratic conc. w/ IR/SRs

concerta GI obstruction possiblility

generic diff. reported
Daytrana

what is it, what used for, info...
methylphendate patch- ADHD

10, 15, 20 ,30 QD
on hip 2 h before needed

NnV

20mg ~ oral 20mg TID

9h wear time covers 12 h
Dexmethylphendate product...
Focalin, Focalin XR

12h

less headache
greater GI

<25kg 2.5-7.5 QD
>25kg 2.5-10 BID
max 20
Amphatemines

list em
Dextroamphetamine

Dexedrine spansule
Mixed salts (Adderal)

Adderal XR
Short acting amphetamine

what is it, dose info blah blah blah
Dextroamphetamine
(Dexedrin, Dextrostat)

3-5 h

<25kg = 2.5- 10mg
>25kg= 5- 10 BID- TID
Intermediate amphetamine
5-8 h

dexedrine spansules 5- 15 BID

Mixed salts (addderall) 0.5 mg/ kg / day`
Amphetamine long acting
8-12 h

Adderal XR 10 - 30 QD

****if taken with high fat meal can lower conc 50%....aka dont fuckin do that

can sprinkle in apple sauce
amphetamines

+ves and -ves

vs methylphenadtaes
-generics

spansules can be opened and sprinkled

predictable kietics


-ves
***worsen tics

greater growth issues
lisdexamfetamine

what is it
why is that fucked up
info
Vyvanse

amphetamine is not spelled like that ever

prodrug of reg amphetamine

30 - 70 mg

10- 12 h

openable and DISSOLVABLE in water

not generic
General AE with stims

how solve
Appetite supression -
nausea-
----for these take a high fat meal at night and should calm everything down

dizzy
insomnia
headache
whats the BBW on stims

how much is it worriable
sudden death....

its actually less than stratera sooo durrrr
Strattera is

used for

general
atomoxetine
2nd liner

selective NE reuptake (presynaptic)

1st nonstim noncontrolled
food no matter

2-4 wks for effect

no tapering
Strattera dosing stuff
best efficacy 1.2 mg/kg/day start .5
but from chart maybe better...

basically said know ranges so whatever their weight is in pounds half of that proxy starting dose kinda...

40-62 ------18 -------25
63-93-------25--------40
94-126-----40-------60
127 and up----40-----80
strattera SE
down appetitie

up BP, naseau, headache, mood change, liver tox

BBW suicide

2d6----antifungals....

not if less than 61

80% response rate
TCAs and ADHD
up NE

most common
-nortriptyline- DOC if has to be one of these bastards
-imipramine
-desipramine- avoid---then dont write it on damn slide....

10 BID or 25 QD

70% response

good w/ comorrbidities
-OCD, depression, anxiety, tics, euresis

1-2 wks to work

taper monitor vitals, ECG, behavior scale............
Wellbutrin and ADHD
up DA and NE

70% response rate

no controlled trials,,,

less abuse

Disadvantages- less effective at distractability, excasterbate tics

range 50- 300 QD
Alpha Agonists and ADHD
Clonidine and guanfacine
inhib NE (g more selective)

less effective inattention

2-4 wks respond

can combo with extended release stuff?

patch only good 5 days in children!!!! need oral first
-PATCH NOT W/ STIMS!!

SE brady, hypotension, Depression (CI), taper
other ADHD drugs that are random

and when use
Carbamazepine - use w/ bipolar, intermittant explosive disorder

Antipsychos
-very low dose, only w/ severe agression

Herbals- Zinc and blah others
ADHD drug selections
1st stims

special considerations
-atomoxetine- refuse stim, tic/anxiety

-Bupropion - depression

- TCAs- depression or anxiety

Poss. Adjunct
-Carbamzepine- mood stabilize
-alpha 2 if on stim and tics (not patch!!)
-antipsychos- severe agression
Who are a high % of ppl that suffer from insomnia
depressed ppl
50%
how do we measure sleep stages
latency to persistant sleep (LPS)

Total Sleep Time

Quality of sleep- feel good when wake?

Polysomnogprahy- electrical

Objective- awakenings / night etc
what causes these sleep issues
decrease serotonin --sleep reduction

up dompamine -- up wakefulness

melatonin - sleep promoter
Primary sleep disorder...
due to endogenous abnormal of sleep wake cycle or circadian rhythm

dysomnia- primary
parasomnia- nightmare, sleep walking
different symptoms of sleep disorder

and lengths
diff fall asleep

diff stay asleep

non restorative sleep

transient 1-3 nights
short term less 30 days
long term 30 days or more (comorbidity?)
Etiology of sleep issues
situational

psychiatric

medical

drug induced - bronchodilators, diuretics, steroids, levodopa, SSRI, thyroid, stims
Tx of sleep issue
Cognitive behavioral therapy (CBT)
-Stim control
-Sleep Restrictions
-Sleep Hygiene education
(works for LPS and TST)

Pharm tx
-Benzos
-Non Benzos (broad)
-Ramelteon
Benzos
Short
Med
Long acting
Short
-Triazolam - for onset

Med- maintence
-Temazepam
-Estazolam

Long- maintence and early awaken
-Flurazepam
Quazapam
Benzos sleep overview
nonselective GABAa aplha 1-3, 5

AE- daytime sleepiness
memory impair
psycomotor dysfunc

addition potential

CAREFUL elderly and abusers

tolerance
NON benzos and sleep

doses
Zolpidem - 5-10

Zolpidem CR 6.25- 12.5

Zolpimist--- 5-10 spray

Zaleplon (sonata)-- 5- 20 mg (short t1/2)

Eszopiclone (lunesta) 2-3mg
Non benzos general and where each used
bind alpha 1 GABAa subunit

Zaleplon- LPS

Zolpidem- LPS, TST....withdrawl

Eszopiclone- LPS, TST, long term... shit taste!!!
non benzos caution with
3A4 inhib - antifungals

zaleplon- hepatic impairment
special considerations sleep meds
diphenydramine
valerium root

Seroquel- if psychotic 200-800

Mirtazapine (remeron)- antidepressant

Trazadone (deseryl)- antichol SE, but antidepress
Ramelteon and sleep
sleep onset!!!!!!

melatonin receptor agonist

8mg w/i 30 mins of sleep

noncontrolled