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91 Cards in this Set

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  • Back
What are the positive symptoms of schizophrenia? (2)
Hallucinations & delusions; thought disorders
What is one possible biochemical explanation for the positive sx of SZ?
Excess of dopamine -- either too much is released or too many receptors?
What are the negative symptoms of SZ? (4 A's + 1)
affective flattening; apathy; social withdrawal; anhedonia; alogia (poverty of speech)
What are 2 possible explanations for the existence of neg sx in SZ?
Neuronal damage (loss of nerve cells for variety of reasons, maybe genetically programmed); Glutamate deficit
What is the "dopamine hypothesis"?
SZ involves a functional excess of DA. BUT other NTs are involved so SZ is not just the opposite of Parkinson's.
What is the support for the DA Hypothesis? (2)
DA blockade is correated with clinical potency (i.e., block the receptors & Sxs improve); use of stimulants that increase DA can induce SZ-like psychosis
What are the neurological deficits in SZ that are associated with negative symptoms? (6)
enlarged ventricles; seasonality effect (viral insult midtrimester when limbic system develops); prefrontal cortex - thalamic - cerebellar connections are disturbed; GLU disturbance; white matter disturbance; anterior cingulate dysfx
How do you deal with neurological deficits?
Can only treat the symptoms; can't treat the underlying causes
What are the indications for administering antipsychotics? (6)
SZ, acute mania (esp if BPI, Borderline PD, Tourette's, drug induced psychosis, "preventing" SZ (conversial theory by McGlashon)
What are the indications for administering antipsychotics? (6)
SZ, acute mania (esp if BPI, Borderline PD, Tourette's, drug induced psychosis, "preventing" SZ (conversial theory by McGlashon)
What are the major dopamine pathways, and what do they affect? (4)
Mesolimbic (emotion), mesocortical (cognition), nigrostriatal (movement), tuberoinfundibular (hormones)
name 2 traditional antipsychotics
Haldol (haloperidol) and Thorazine (chlorpromazine)
What is the mesolimbic DA pathway?
From midbrain to nucleus accumbens
What is the mechanism of the traditional antipsychotics, and what do they effect?
They block the DA-2 receptors; this treats positive symptoms.
What is the mesocortical DA pathway?
From midbrain to cortex
What is the nigrostriatal DA pathway?
Form Substantia nigra to striatum
What is the tuberoinfundibular DA pathway?
From hypothalamus to pituitary
What are the possible motor side effects from the traditional antipsychotics? (3)
EPS (Parkinsonian SEs: shuffle, stooped posture, drooling, slow motor systems, hard to initiate movement); Dystonias (sustained muscle contractions); TD (Tardive Dyskinesia)
What is TD (Tardive Dyskinesia)?
abnormal involuntary movements of face, tongue, that can spread to shoulders, neck & torso
What causes motor side effects in SZ?
Imbalance of DA and ACH: need correct amount of each
What is onset of TD? Who gets it the worst?
Slow onset (usu after 2 years on meds); elderly
What often prompts TD to appear?
Reduction in dose of meds
Rate of TD?
4% in first 5 years on meds
What causes TD?
Denervation supersensitivity (excess DA, little Ach): D2 receptors used to being blocked, if less med then receptors are oversensitive to DA since not used to being exposed to so much
How treat TD?
can be irreversible; there is no fully effective treatment. Prevention is the key: should monitor for SX every 6 months.
What meds are associated with TD?
All antipsychotics, but more frequent with the typicals than the atypicals
What is Neuroleptic Malignant Syndrome (NMS)? What is rate of occurance, and onset?
NMS = fever, sweating, muscle rigidity; potentially fatal. 1 - 2% with high potency typical antipsychotics (esp if high dose). Onset is 3 - 9 days of tx w/rapid progression similar to allergy.
What is treatment for Neuroleptic Malignant Syndrome?
Early detection and treat symptoms with DA agonists and hydrate
What do 2nd generation atypical antipsychotics act on? What is the purpose of them?
They block 5HT receptors (and sometimes D2 receptors as well). They help reduce negative symptoms.
Why use 2Gen atypicals?
Have better efficacy in TX-resistant SZ; Have different Ses (weight gain, blood sugar and metabolic problems)
How do the 2nd Gen atypicals work?
Block Dx to decrease positive sxs and block 5HT to decrease negative sxs
clozapine
Clozaril - atypical
risperidone
Risperdal - atypical
olanzapine
Zyprexa - atypical
aripiprazole
Abilify - atypical
Who gets depot drug administration?
non compliant; outpatients (more in Europe than US); Not for acute tx
What is danger in depot drug administration?
patient needs must come first: can't use it as a chemical straight-jacket at board and care homes
Put the 6 atypicals in order from least weight gain to most
Abilify, Geodon, Risperal & Seroquel, Zyprexa, Clozaril
chlorpromazine
Thorazine - typical
haloperidol
Haldol - typial
What health condition is Zyprexa associated with?
diabetes
How do you monitor for adherence in clients? (5)
patient interview by clinician; interview family member/caregiver; blood levels; electonic monitoring; communication/web-based monitoring systme
What are some reasons for nonadherence to antipsychotic meds?
Medication not working; Side Fx; complex dosing; paranoia; substance abuse; impaired insight; med not valued by family/caregiver; can't refill/other access issues
How can you enhance adherence to antipsychotic meds?
simplify regimen; use alternative formulation (oral wafer, injection); involve family - caregiver; tailored interventions that directly target adherence (counseling; psychoed; peer support)
With SZ, what is relative efficacy of meds only, family tx + meds, social skills training + meds, all 3?
drugs only - least adherence; all 3 - most adherence; meds plus family tx or meds plus soc skills training are both about equal, in middle
Discuss prodromal treatment of SZ
Treat with Zyprexa based on early symptoms (for DSM need 6 months of symptoms). Considered especially if have 1st degree relatives w/SZ
What percentage of diagnosed SZ people also have substance abuse?
57%
(47% have ETOH problem)
pros and cons of using Clozaril?
For tx-resistant SZ (esp disorganized type); Txs neg sxs; fewer motor SEs; can cause agranulocytosis so need blood monitoring wkly/biwkly; highest weight gain of 2G meds
pros and cons of Risperdal?
more EPS than others; SEs are agitation, insomnia, wt gain;less effective than Clozaril on pos sxs
Pros and cons of Zyprexa?
more effective than others for cts w/mild sxs; low EPS; least orthostatic HPT; inc risk of diabetes; inc liver enzymes
pros and cons of Seroquel
low EPS; high rate of sedation; orthostatic HP; medium rate of wt gain; must take 2x/day
Which dx has highest rate in kids? what rate is it in population?
ADHD -- 5%
What is one unintended consequence of medicating kids for ADHD?
Many of the 10 million prescriptions written are "diverted" (non-medical use of stimulant).
What are prescription trends in ped population? (# of scrips, problem w/that & possible response)?
# of scrips doubled form 1987 to 1996; lack of reliable research; Congress wants meds tested in ped pop.
Pediatric vs. adult pharmacokinetics?
small size means more sensitive to meds; faster metabolism means drugs break down more quickly (so need higher dose); lack of exposure to meds means more sensitive than adults
How should MD deal with different pharmacokinetics in ped pop?
Adjust dose by body weight. Keep increased rate of metabolism in mind when dosing.
DSM diagnostic criteria for ADHD?
1. either inattention or hperactivity/impulsivity for at least 6 months that is maladaptive and not developmentally appropriate. 2) Sxs caused impairment before age 7. 3) Impairment in 2+ settings. 4) Clear evidence of clinically sig. impairment 5)Not due to other condition such as PDD, SZ, Mood D/O, etc.
Causes of ADHD?
Probably a bio basis since risk factors include low birth weight, birth trauma, TBI, in utero drug exposure, heavy metal poisoning, vitamin deficiency
Evidence for probably genetic component to ADHD?
Study shows increased incidence of abnormal repetitions in DNA of D4 receptors. Study shows higher concordance of disease in MZ vs. DZ twins.
Why treat ADHD w/stimulants?
Seems paradoxical but stimulants help pts focus. Ritalin increases DA in different areas.Inc in mesocortical path may help attn and concentration. Also increases NE which causes SEs.
What are pharmacological txs for ADHD?
Stimulants: methylphenidate (most common); dextroamphetamine; other amphetamines.
NON stimulants: atomxetine (Strattera - officially an anti-D but not usu taken for that. slightly lower efficacy than the stimulants)
Ritalin
methylphenidate
Other brands/versions for the same compound that forms Ritalin?
Concerta & Metadate(sustained release versions); Daytrana (patch)
Dexedrine
dextroamphetamine
Adderall
d- and l-amphetamine
Provigil
modafinil
Sparlon
modafinil
What is efficacy of Ritalin? What are positive effects of Ritalin?
about 70% efficacy
It improves attention span & decreases activity level. It helps with irritability, daydreaming, anxiety and nail biting.
What are neg side effects of Ritalin?
Appetite loss (usu s/t issue); insomnia (give early in day); headache (medicate & usu wear off).
What are long term effects of Ritalin on neuronal development?
We don't know.
What are contraindications for Ritalin and other stimulants?
Heart problems. BP problems. ADHD drugs have black box warnings about possibility of sudden death at normal doses for child/adoles w/heart conditions. Also even if no hx of psychosis, inc risk of psychotic/manic SXs.
Are kids over-medicated with Ritalin?
One study showed 1/2 of kids taking stims were never diagnosed with ADHD; took stims 3+ yrs; showed increased risk of muscle tics.
One study indicated that LOWER doses may be effective ttx.
What non-stim meds are prescribed for ADHD?
Strattera (atomoxetine - antiDep med)
Alpha2 NE agonists (clonidine/Catapres, guanfacine/Tenex) - BP drugs that block NE uptake & can work for hyperactivity.
Antidepressants (SSRIs and MAOIs) - not used much
What prescribe Strattera vs. Ritalin?
Similar efficacy, but lower rates of insomnia & appetite loss
Discuss preschoolers and ADHD medication.
Large increase in scrips.
Study: <20% of those w/signif behax probs received meds. Of these 50% had ADHD; rest had speech/lang d/o's, in utero drug exposure, etc. Most were male & MediCaid. Many had hx of abuse, neglect, foster placements. SO...both under and over medicated
Discuss diversion of Ritalin in HS and in college
study: HS - 2.4% report using (more are abusing than are using appropriately)
study: college - 5.3% using nonmedically for both studying and rec. More intranasal than oral use. Part of the issue is unfair competition.
Is ADHD a gateway drug?
Meta-analysis of previous studiesn shows medically appropr stim users have LOWER subsequent rate of SA
How do you medicate a child with ADHD who also has tics (since stim use can increase tics)?
Prescribe methylphenidate AND clonidine (hypertensive) for: increased attentiveness & on task behavior; decreased crying, frustraiton, restlessness, excitability & impulsiveness
What is tx for pediatric depression?
First try CBT or behavioral tx. Then add SSRI (Prozac, Paxil, Zoloft, Celexa)
Discuss adolescent depression and use of SSRIs
There is increased risk of suicidality, potentially, so there is a black box warning about it (which caused 20% decrease in # of scrips). Have to weigh this against increased risk of suicide from UNTREATED depression. If do prescribe it, need psychoed for ct and ct's family re: careful monitoring of suicidality
What is medication tx for Eating Disorders?
SSRIS not useful typically in underweight anorexics, though often used anyway. May reduce meal anxiety to help w/relapse prevention. Some support for SSRI use w/bulimics.
Discuss Tourette's and pediatric population
very rare. Have rapid physical or vocal tics that are very difficult to resist. 75% also have obsessive behaviors. Meds: clonidine, Prozac. Last resort: antipsychotics for tics (slow down motor responses). Hypothesis is too much GLU creates excesive DA
Why is it important to consider gender when prescribing psychotropics?
2/3 of scrips are for women. Women have more neg f/x than men. Women's cyclical hormonal changes effect some med's levels in blood (PMS fluid retention may effect water sol meds; drug absorbtion rates may change after menopause; have differential rate of absorption of "basic" vs acidic meds vs. men, etc.)
What are the gender differences in absorption of ETOH?
Women have less ability to metabolize ETOH vs. men so get more effect from less ETOH compared to them.
How can you treat PMDD?
Lifestyle interventions (diet & exercise, which are 25% effective) and meds (more common). Diet: freq, bal meals w/carbs; low caffeine, nicotine, ETOH, salt; inc exercise to reduce stress & renew energy, reduce fluid retention, inc endorphins. Hormonal tx (estrogen, progesterone); non-scrip agents (cohosh, vit A & E); tx sxs w/diuretics, etc.; SSRIs, anti-anxiety BZ
What is Sarafem and what is it used for?
it's essentially fluoxetine, and is marketed to women for PMDD. How can something with a half life of 7 days be effective when prescribed for s/t use (less than 7 days)? Ineffective at best, and pathologizing womenhood at worst.
discuss pregnancy and psychotropics
have to balance risk to fetus and mother vs. risks of not treating the condition.
placenta is not a barrier to psychotropics.
1st trimester-highest risk to developing organx
maternal toxicity does not = fetal toxicity
What are possible neg effects of use of meds during pregnancy? (3)
teratogenic fx - physical malform's from meds like valproate, thalidomide, etc.
toxic fx at birth - withdrawal syndrome (seizures, irritability, feeding difficulties, etc.), low birth weight
behavioral teratogenesis - longer term, possibly perm problems (IQ effects, learning diffs, ADHD, etc.)
Does taking birth control pills have any effect on incidence of depression in women?
Probably increases incidence depending on type of hormone used, age of woman, etc.
Discuss post partum mental illness.
13% of women experience PPD (with or w/out prior hx; for 1/3 this is first occurence).
Highest risk of incidence is first 5 weeks after birth
High risk of relapse of bipolar DO and MDD in post partum period (up to 50%)
Discuss mood stabilizers and pregnancy
Lithium: best choice but can cause cardiace malformations; avoid in 1st trimester
Tegretal: can cause digital malformations, neural tube defects (spina bifida)
Valproate: can cause neural tube defects, craniofacial defects, spina bifida