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94 Cards in this Set
- Front
- Back
What is the lifetime prevalence of depression in the US population?
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10 %.
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What is reactive depression and when should it be treated?
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Depression related/associated with grief &/or bereavement.
Treated when: - Persistence >2 months - Marked functional impairment - satisfy criteria for Depression. |
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Diagnostic Symptoms/Signs for Major Depressive Disorder
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5 of 9 nearly every day for 2+ weeks. Must have 1+ *.
*Depressed mood. (SIG E CAPS) Sleep changes *Interest loss (anhedonia) Guilt or worthlessness, excessive. Energy loss Concentration difficulty Appetite & Weight (>5% in 1 month) changes Psychomotor retardation or aggitation. Suicidal &/or Homicidal Ideation. |
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Anhedonia
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Unable to experience interest or pleasure in previously enjoyed activities.
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What is Fluvoxamine, it's actions and what is it approved to treat?
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Fluvoxamine = SSRI.
Only approved to treat OCD No sedative or anti-muscarinic action. |
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Fluoxetine
- Action - Kinetics - Uses |
SSRI (may dec NE/DA reuptake too)
Sedative & Antimuscarinic actions. Bulimia*, anorexia, obesity. Depression, OCD, social anxiety, panic disorder |
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What is the mechanism of action of SSRI's?
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Inhibition of pre-ynaptic neural reuptake of Serotonin
Increases Serotonin concentration and duration within the synapse. |
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What is the mechanism of action of Tricyclic Antidepressants
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Inhibit neuronal reuptake of serotonin and norepinephrine.
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What is the mechanism of action of Second generation Heterocyclics?
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(Atypical antidepressants, 2nd: Bupropion)
Inhibits reuptake of serotonin, norepinephrine & dopamine. |
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What is the mechanism of action of MAOIs?
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Monoamine oxidase inhibitors.
Inhibit/reduce degradation of DA, NE & 5-HT in presynaptic neurons |
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Transference
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Patient projects feelings about another important person (formative) onto the physician/therapist.
Pt anger for Father is projected onto MD. |
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Countertransference
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Physician/therapist projects feelings of a important person (formative) onto patient.
MD projects feeling towards child onto Pt (sybil) |
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Name 5
Tertiary Amine Tricyclic Antidepressants. |
Amitryptelene, Clomipramine, Imipramine,
Doxepin, Trimipramine. |
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Side Effect profile of:
Tertiary Amine Tricyclic Antidepressants |
Highly Anti-cholinergic:
Sedation! dry mouth, blurring vision, orthostatic hypotension, constipation, urinary retention |
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Uses of Tricyclic Antidepressants in general.
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Depression, Neuropathic pain, Panic disorder, PTSD,
Eating disorder, Migraines, Enuresis, Irritable Bowel Synd, |
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Side Effect profile of Tri-cyclic Antidepressants in general.
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Anticholinergic: sedation, dry-mouth, blur vision, orthostatic hypotension, constipation, urinary retention
Anti-a1 blocker: Tachycardia, QT interval prolongation Anti-Histamine1: Weight gain |
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Amoxapine
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Tetracyclic Antidepressant
Side Effects = Extrapyramidal Syndrome, Neuroleptic Malignant Syndrome. |
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Tri-Cyclic Toxicity
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Tri-C's:
Convulsions, (Atropine-like: dec sweating, inc muscle act/seizures --> hyperpyrexia) Coma, Cardiotoxicity (fatal arrhythmias - wide QRS) |
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Secondary Amine Tricyclic antidepressants
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Nortriptyline
Desipramine Protriptyline (least side effects) |
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Treatment for Tri-cyclic Toxicity
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IV NaHCO3
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Tri-cyclic antidepressant:
Drug interactions |
Alcohol, Barbituates, Benzodiazepines, MAOIs.
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Drugs that may cause Depression
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- Anti-HTN: Reserpine, Propranolol, Methyldopa, Guanethidine sulfate, Clonidine, Hydralazine
- Corticosteroids: Prednisone, Cortisone acetate - Hormones/BCP: Estrogen, Progesterone - AntiParkinson's: Levodopa, Carbidopa, Amantadine - Anti-anxiety: SSRI, Benzodiazepine, Buspirone, Propranolol. - Alcohol |
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Vegetative Sx of Depression
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(reflect biochemical dysfunction)
Sleep disturbance, Appetite disturbance with Weight changes, Fatigue, Dec Sex drive, Restlessness, Agitation, Psychomotor retardation, Diurnal variation of mood, Impaired Concentration/ forgetfulness, Pronounced anhedonia. |
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Common Side Effects of SSRIs & SNRIs
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**GI problems: distress, diarrhea
Sexual SE: delayed ejaculation, Nonorgasmia (f) Agitation, Anxiety, Akanthisia (uncomfortable inner restlessness), Panic, Insomnia, HA Increased suicide (mobilization phenomena) Serotonin Syndrome |
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Contraindications/Interactions with SSRIs/SNRIs
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MAOI within 4-6 weeks.
Electro-convulsant therapy. |
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Clomipramine
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Tertiary Amine Tricyclic Anti-Depressant.
Most 5HT Reuptake Inhibitor specific. Treats OCD & depression, enuresis, IBS, Nerve pain, migraine, panic d/o, eating d/o, PTSD, induce sedation. |
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29 common diseases that may cause depression
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Alzheimer's, Parkinson's, Multiple Sclerosis.
Addison's, Cushing's, DM, Hyper/HypoThyroidism. CHF, Apnea, Asthma. Infectious Hep, Malnutrition, Ulcerative Colitis. Postpartum, Premenstrual, Menopause. RA, SLE, AIDS, Influenza, Syphilis, Ch Infection. Porphyria, Anemia, Uremia. Ch Pain, Ch Fatigue Synd, Malignancy. |
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Serotonin Syndrome
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*Tremor, Akathisia, Clonus (T>100)*
Hyperthermia, Hypertonicity, Rhabdomyolysis, Renal Failure, Convulsion, Coma --> Death. Triad of Cognitive, Autonomic & Somatic Sx. |
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Tx for Serotonin Syndrome
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Stop Rx.
Benzodiazepine &/or 5HT Antagonist (cyclopeptadine) |
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SNRI vs SSRI
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SNRIs (and tricyclic's MoA)
- effective in depression refractory to SSRIs - effective in relieving physical sx related to depression (neuropathic pain, etc) |
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Venlafaxine
- Mechanism of Action |
(Effexor)
SNRI. Potent 5HT RI, NE-RI at higher doses. mild Dopamine RI |
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Venlafaxine
- Side Effects |
(SNRI, Effexor)
Nausea, Dizziness, Insomnia, Sedation & Constipation. high dose: Inc BP |
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Venlafaxine
- Uses |
MDD (refractory to SSRI &/or with physical sx (neuropathic pain)),
GAD, Social anxiety, Panic d/o |
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Duloxetine
- Mechanism of Action |
SNRI (Cymbalta)
inhibits reuptake of 5HT & NEpi at all doses. |
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Duloxetine
- Contraindications - Side Effects |
(SNRI - Cymbalta)
C/I: Hepatic insufficiency & end-stage renal dx (liver metabolism & excreted) SE: GI: Nausea, drymouth, constipation > diarrhea, vomiting. Insomnia, dizzy, somnolence, sweating, sexual dysfunction. |
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SSRI
- Therapeutic Uses |
MDD
OCD GAD panic disorder premenstrual dysphoric disorder bulimia nervosa |
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Uses of Fluvoxamine
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SSRI
only indicated for OCD |
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Name SSRIs
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Fluoxetine (prozac)
Paroxetine (paxil) Fluvoxamine (luvox) Sertraline (zoloft) Escitalopram (lexapro) Citalopram (celexa) |
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Citalopram
MoA & Uses. |
SSRI (Celexa)
Only indicated for Depression useful in kids/teens. |
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Bupropion
- mechanism of action |
(Wellbutrin)
NEpi/Dopamine Reuptake Inhibitor Short T1/2 = multiple/day |
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Bupropion
- uses |
Depression
Smoking Cessation (Dec nicotine craving) Seasonal Affective D/o (ADHD & neuropathic pain) |
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Bupropion
- Side Effects |
No sexual side effects, sedation or anti-muscarinic
Dry mouth, sweating, tremor. High doses: Seizures |
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Mirtazapine
- Uses |
Refractory depression
esp in patients who need weight gain and have difficulty sleeping. |
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Mirtazapine
- Mechanism of Action |
Block 5HT2 & alpha-2 receptors.
Potent anti-Histaminic = Sedation. |
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Mirtazapine
- Side Effects |
No anti-muscarinic or sexual SE
Increased appetite & weight gain. Markedly sedating (anti-H) Dizziness, tremor, agranulocytosis. |
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Nefazodone
- Mechanism of Action - Side Effects |
5HT1 pre-synaptic autoreceptor blocker.
(weak SRI) = increased 5HT release Potent H1 blocker = SEDATING!! |
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Trazadone
- Mechanism of Action - Side Effects |
Block 5HT pre-synaptic auto-receptor.
(weak SRI) = increased 5HT release Potent H1 Blocker = SEDATING!! Associated with Priapism. |
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Nefazodone
- Uses |
refractory major depression
(with anxiety & insomnia) sedation requires qhs |
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Trazodone
- Uses |
refractory major depression
(with anxiety & insomnia) sedation requires qhs. |
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Name 5
Mono-Amine Oxidase Inhibitors |
Phenelzine
Tranylcypormine Isocarboxazid Selegiline (MAOI-B) Clorgyline (MAOI-A) |
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How do MAOI's work?
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Inhibition (often irreversible) of Mono-Amine Oxidase A &/or B.
Prevents the degradation of amines: A: 5HT, Dopamine, Tyramine B: NEpi, (Epi), Dopamine, Tyramine |
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MAOI
- Uses |
Panic Disorder
Phobic States Refractory Depression - unresponsive or allergic to TCAs (or) - w/ strong anxiety sx Atypical Depression (labile mood, rejection sensitivity, appetite d/o) |
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MAOI
- Cautions & C/Is |
- Reaches effect 2-4 wks post onset
- Enzyme regeneration = min 2 wks, recommended 4-6 wks post-termination. - NO tyramine: aged cheese, poultry liver, beer, red wine. |
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Actions of Tyramine
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Release of lg amt of stored catecholamines from nerve terminals
- HA, tachycardia, nausea, HTN, Cardiac arrhythmias, stroke Normally inactivated by MAOI in gut. |
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Management of tyramine ingestion with MAOIs?
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Phentolamine or Prazosin
help manage the induced HTN. |
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MAOI side effects
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Drowsiness, Orthostatic Hypotension, Dry mouth, blurred vision, dysuria, constipation.
with tyramine ingestion: HA, Tachycardia, Nausea, HTN, Cardiac Arrhythmia, Stroke. |
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Lithium
- Uses |
Drug of Choice:
- Acute mania - Prophylaxis for both manic & depressive episodes in bipolar disorder. |
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Valproic Acid / Valproate
- Uses |
(Depakene)
Mixed Manic Episodes, Rapid-Cycling Bipolar disorder |
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Lithium
- Adverse Effects |
Fine tremor, Ataxia, Thirst, Metallic taste, Polyuria, Edema, Wt gain, GI problems, Leukocytosis, Thyroid enlargement, Hypothyroidism, Nephrogenic Diabetes Insipidus (tx = amiloride)
NOT sedative, euphoriant, depressant. |
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Toxic & Lethal levels of Lithium
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Toxic >1.5
- AltMSt, Coarse tremor, Gait disturbance, Convulsions, Death (Tx=Dialysis) Lethal >2.0 |
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Therapeutic Index of Lithium
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0.7 - 1.2
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Factors that decrease Lithium levels
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NSAIDs
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Factors that increase Lithium levels
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Dehydration
Salt deprivation Impaired renal function Diuretics ACE-I Metronidazole Tetracycline Aspirin |
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Valproic Acid
- Adverse Effects |
Sedation, Wt gain, Alopecia, Hemorrhagic pancreatitis, Hepatotoxicity, Thrombocytopenia, Teratogenic (neural tube defects)
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Carbamazepine
- Mechanism of Action |
(teretol)
Blocks Na channel & Inhibits action potentials |
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Carbamazepine
- uses |
Mixed manic episodes
Rapid-cycling bipolar disorder Trigeminal Neuralgia mgmt |
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Carbamazepine
- Adverse Effects |
Skin Rash, Drowsiness, Slurred speech, Ataxia,
Leukopenia, Aplastic anemia, Agranulocytosis, Hyponatremia, Inc Liver enzymes, Teratogenic (neural tube defects) |
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Mood Stabilizer
- uses |
- Treat acute mania
- prevent manic relapses - potentiate antidepressants in pt refractory to monotherapy - potentiate antipsychotics in schizophrenia - enhance abstinence in tx of alcholism - Tx aggression & impulsivity (dementia, intoxication, MR, Personality d/o, Gen Med) |
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Name 3
Long-acting Benzodiazepines |
1-3 Days
- Chlordiazepoxide (librium) - Diazepam (valium) - Flurazepam (dalmane) |
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Name 4
Intermediate-acting Benzodiazepines |
10-20 Hours
- Alprazolam (xanax) - Clonazepam (klonopin) - Lorazepam (ativan) - Temazepam (restoril) |
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Name 2
Short acting Benzodiazepines |
3-8 Hours
- Oxazepam (serax) - Triazolam (halcion) |
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Benzodiazepine
- Mechanism of Action |
Potentiation of GABA
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Clonazepam
- Uses |
Intermediate acting Benzodiazepine (10-20 hrs)
Anxiolytic: Anxiety or Panic attack Chronic Anti-epileptic activity - suppress epileptogenic foci spread - absence & myoclonic seizures Tolerance develops. |
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Drug(s) of Choice for status epilepticus
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Diazepam & Lorazepam
(Long & Intermediate Acting Benzodiazepines) |
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Benzodiazepines
- Adverse Effects |
Sedation, Intellectual impairment, Reduced motor coordination/ Ataxia, Dizziness, Behavioral changes
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Benzodiazepines
- Toxicity |
Respiratory depression & Cardiac depression.
Combine with alcohol = lethal |
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Chlordiazepoxide
- Uses |
(librium)
Long-act Benzodiazepine (1-3d) - Alcohol Detoxification - Presurgery anxiety |
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Diazepam
- Uses |
(Valium)
Long-act Benzodiazepine (1-3d) with Rapid onset - Anxiety - Seizure control esp status epilepticus |
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Flurazepam
- Uses |
(Dalmane)
Long-act Benzodiazepine (1-3d) with Rapid onset - Insomnia |
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Alprazolam
- Uses |
(Xanax)
Intermediate-act Benzodiazepine (10-20h) - Panic Attacks |
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Lorazepam
- Uses |
(ativan)
Intermediate-act Benzodiazepine (10-20h) - panic attacks - Alchohol withdrawal - DOC Status epilepticus |
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Temazepam
- Uses |
(restoril)
Intermediate-act Benzodiazepine (10-20h) - insomnia |
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Oxazepam
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(Serax)
Short-act Benzodiazepine (3-8h) - anxiolytic |
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Triazolam
- Uses |
(Halcion)
Short-act Benzodiazepine (3-8h) with rapid onset - insomnia - anxiolytic |
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Zolpidem
- Use - Mechanism |
Short term tx for insomnia
Selective binding at Benzodiazepine's site potentiating GABA effects. |
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Zaleplon
- Use - Mechanism |
(Sonata)
Short term treatment of insomnia with shorter T1/2. Selective binding at Benzodiazepine's site potentiating GABA effects. |
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Compare Triazolam / Temazepam to Zolpidem / Zaleplon
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Zolpidem / Zaleplon have:
- no withdrawl effects - no anticonvulsant / muslce relaxant prop - minimal reboutnd insomnia - little-no tolerance/ dependence with prolonged use. |
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Malingering
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grossly exaggerated physical or psychological complaints often accompanied by INTENTIONAL production of false physical or psychological complaints
to obtain a form of secondary GAIN. |
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Signs of malingering
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Marked disparity between patient's disability and objective findings.
Often refusal of examination, previous history of dependence or substance abuse, etc. |
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Factitious disorder
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INTENTIONAL production of false physical or psychological complaints
to assume a SICK ROLE, no secondary gain. |
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Hypochondriasis
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Fear of disease
& pre-occupation with body Manifests as multiple somatic complaints. Persists despite medical evaluations Causes marked impairment Lasts 6 months or longer. |
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Conversion disorder
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Development of unexplained serious Neurological Symptoms
- preceded by an obvious emotional TRIGGER. - Not ARTIFICIALly produced. - unexplained by medical condition - severe enough to cause social & functional IMPAIRMENT. |
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Dependent Personality disorder
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Unable to make decisions without help.
Crave protection & guidance from others. Devastated by separation and loss. Go to great lengths to stay in dependent relationships. |
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What is the best treatment for cachectic anorexic cancer patients?
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Progestins
(megestrol acetate, medroxyprogesterone acetate) - as effective as corticosteroids for cachexia but better side-effect profile. - Main adverse effect is slight inc risk of DVT |