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Psychiatry Highlights .......... - rithishsham - ArchivalUser - 05-10-2009 USMLE Step 2 ” Lesson 1:Child Psychiatry Psychiatry Highlights for USMLE Step 2 Alina Gonzalez-Mayo, MD ________________________________________ Child Psychiatry ________________________________________ Mental Retardation ¢ Present before age 18 ¢ Consisting of below-average intellectual functioning with an impairment in social adaptive functioning ________________________________________ Characteristics: Mental Retardation Degree IQ Range Characteristics Mild 55 - 69 6th gr level, can handle own affairs & live on his own Moderate 35 - 54 2nd gr. level, benefit from vocational trainng, sheltered workshop Severe 20 - 34 Can communicate, training not help- ful, can be taught basic health habits. Profound 6 months, < 7 years ¢ Increased incidence among school age ¢ Boys have a greater incidence than girls ________________________________________ Clinical features: ADHD ¢ Symptoms must be present in at least 2 situations e.g., home, school or work ¢ Symptoms may persist into adult life ¢ Increased incidence of conduct disorders ¢ Antisocial personality & substance-related disorders ________________________________________ Management ADHD ¢ Psychostimulants o - methylphenidate o - dextroamphetamine o - pemoline ¢ Methylphenidate side effect - GH suppression ¢ Consider drug holiday ________________________________________ Case Study Johnny is an 8-year-old child being evaluated for various behaviors, such as staying to himself, as well as self-abusive and aggressive behaviors. He does not play with the other children and tends to act out aggressively when things are changed around at home. He has been in foster care since an early age and has not attended regular classes due to his behavior. At the time of admission into foster care, he had an abnormal EEG but no seizures. When last given IQ tests, he scored 55, with comparable deficits in adaptive behavior. During the evaluation, Johnny spends most of his time reading a book he found in the waiting room. When asked about the book, he becomes angry and begins to rock back and forth. When called, he does not respond and does not make any eye contact. ________________________________________ Characteristics: Tourette's Disorder ¢ Multiple motor and vocal tics present for over 1 year, must occur before age 18 ¢ Three times more common in boys than in girls ¢ Association between ADHD (50%) & OCD (40%) ¢ Abnormalities in the dopaminergic and adrenergic systems ________________________________________ Clinical features: Tourette's Disorder ¢ Initial tics are in the face & neck, progress down ¢ Coprolalia o - begins in early adolescence o - occurs in 1/3 of all cases ¢ Chronic, with remissions and exacerbations ________________________________________ Management Tourette's Disorder ¢ Antipsychotic drugs - haloperidol & pimozide ¢ Noradrenergic antagonist such as clonidine ________________________________________ USMLE Step 2 ” Lesson 2: Eating Disorders Eating Disorders ________________________________________ Characteristics: Anorexia Nervosa ¢ Disturbance of body image, losing more than 15% body weight and amenorrhea ¢ Girls > boys, early teenage years ¢ All socioeconomic status ________________________________________ Clinical Features: Anorexia Nervosa ¢ Refuse to eat with others, disposes of food ¢ Constant thoughts of food - collect recipes & prepare meals ¢ Binge eating when alone, leads to self-induced vomiting ¢ Abuse laxatives, diuretics, exercising ¢ Medical complications ¢ Mortality rates are 5% to 18% ________________________________________ Management: Anorexia Nervosa ¢ Hospitalization ¢ Psychotherapy ¢ Pharmacotherapy (cyproheptadine) ________________________________________ Characteristics: Bulimia Nervosa ¢ More common than anorexia, girls > boys ¢ Binging and purging ¢ Recurrent behaviors - fasting, laxatives, diuretics ¢ Usually maintain a normal body weight ________________________________________ Clinical Features: Bulimia Nervosa ¢ Later onset, obesity predisposing factor ¢ Usually eat food high in calories during binge ¢ Food eaten secretly & rapidly, & at times not chewed ¢ Medical complications ________________________________________ Management: Bulimia Nervosa ¢ Psychotherapy ¢ Behavioral modification ¢ Pharmacotherapy ( SSRI™s) ________________________________________ Case Study A 23-year-old female (5™6™™, 90 lbs.) was seen in a clinic for œabdominal problems. The problem began as an adolescent when she started using laxatives to lose weight and would mostly drink water and eat some food during the day. At times, she would not eat for days and when overcome by hunger, would eat large quantities of food followed by vomiting. Despite this, she continued to lose weight. œThe more I lost, the more I was concerned that I would be getting fat, she said. ________________________________________ USMLE Step 2 ” Lesson 3: Anxiety Disorders Anxiety Disorders ________________________________________ Anxiety Disorders Disorders characterized by a diffuse, unpleasant, and often vague sense of apprehension, accompanied by one or more bodily sensations (autonomic hyperactivity), such as palpitations, diaphoresis, shortness of breath, stomach discomfort, etc.. ________________________________________ Characteristics: Panic Disorder (with or without agoraphibia) ¢ Women > men, 2-3:1 ¢ Most commonly develops in young adulthood (mean age is 25) ¢ Has a genetic component ¢ Associated with depressive symptoms ¢ Suicide is a risk ________________________________________ Clinical Features: Panic Disorder (with or without agoraphibia) ¢ Unexpected panic attacks (a panic attack is a short lived period of massive anxiety which may be accompanied by fear of impending doom or dread as well as symptoms of autonomic hyperactivity) ¢ Must have at least one attack followed by a one-month long period of concern about a recurrent panic attack ________________________________________ Panicogens: Panic Disorder (with or without agoraphibia) ¢ Induce panic attacks: e.g., CO2, sodium lactate, yohimbine, caffeine, flumazenil ________________________________________ Management: Panic Disorder (with or without agoraphibia) ¢ Pharmacotherapy (SSRI™s, TCA™s, MAOI™s, benzodiazapines) ¢ Behavior therapy ¢ Psychotherapy ________________________________________ Characteristics: Phobias Definition o Irrational fear of an object and the need to avoid it ________________________________________ Clinical Features: Phobias Types of Phobias o Specific phobias:  involve fear of any object o Social phobias:  involve excessive fear of humiliation or embarrassment in social settings  more common among women ________________________________________ Management: Phobias ¢ Psychotherapy ¢ Behavioral therapy (systematic desensitization) ¢ Pharmacotherapy (if stage fright - beta blockers) ________________________________________ Characteristics: Obsessive-Compulsive Disorder (OCD) ¢ Ego-dystonic, men = women, mean age = 20 ¢ Obsessions are recurring & intrusive thoughts that the patient realizes are a part of his own mind ¢ Compulsion is a recurring & time-consuming act performed to reduce the distress ¢ Suicide is a risk ¢ Genetic, serotonergic system ________________________________________ Clinical Features: Obsessive-Compulsive Disorder ¢ Most common symptom patterns o Obsession of contamination followed by washing or compulsive avoidance of contaminated object o Obsession of doubt followed by a compulsion of checking ________________________________________ Management: Obsessive-Compulsive Disorder ¢ Pharmacotherapy (TCA™s or SSRI™s) ¢ Behavior therapy ¢ Psychotherapy ________________________________________ Characteristics: Post-Traumatic Stress Disorder (PTSD) ¢ Emotional stressor that would be stressful to anyone ¢ Stressor involved actual or threatened death or serious injury ¢ Women > men, young adults, genetic predisposition ¢ Trauma for men is usually combat experience ¢ Trauma for women is usually assault or rape ________________________________________ Clinical Features: Post-Traumatic Stress Disorder ¢ Patient™s response to stressor involved fear, helplessness, or horror ¢ After stressor event, there is phobic avoidance and persistent hyperarousal ¢ The event will usually be re-experienced in many ways, including nightmares, flashbacks, etc. ________________________________________ Management Post-Traumatic Stress Disorder ¢ Pharmacotherapy (TCA™s, MAOI™s, SSRI™s, benzodiazapines) ¢ Psychotherapy ¢ Behavioral therapy ________________________________________ Case Study Marty is a 30-year-old male who lives with his mother. He works as a night-time cleaner in a large store since he dropped out of college many years ago. He complains of being œnervous all of the time and would like to œget his life back. He stated that he would like to change jobs but prefers his current job because he does not have any contact with other employees. He did not have many friends in high school or in college, mostly due to his feeling œself-conscious. When among strangers, he would feel nervous and would œbreak out in a sweat. He had what he described as œnervous attacks, which came on suddenly and lasted for a few seconds to minutes. These attacks only came on when in the presence of strangers. Since these episodes increased in intensity and frequency, he dropped out of college. ________________________________________ USMLE Step 2 ” Lesson 4: Psychotic Disorders Psychotic Disorders ________________________________________ Schizophrenia ¢ Thought disorder that impairs judgment, behavior, and ability to interpret reality ________________________________________ Characteristics: Schizophrenia ¢ Lifetime prevalence of 1 to 1.5 % ¢ Equal incidence in men and women ¢ Peak age of onset: men 15-25, women 25-35 ________________________________________ Brain Imaging Findings: Schizophrenia ¢ CT: lateral and third ventricular enlargement, reduction in cortical volume ¢ MRI: increased cerebral ventricles ¢ PET: hypoactivity of the frontal lobes ________________________________________ Types: Schizophrenia ¢ Paranoid: presence of delusions of grandeur or persecution, best prognosis, late onset ¢ Disorganized: marked regression to primitive, disinherited, and disorganized behavior, worst prognosis, early onset ¢ Catatonic: psychomotor disturbance involving rigidity, stupor, posturing, negativism, good prognosis, œwaxy flexibility ________________________________________ Types: Schizophrenia ¢ Undifferentiated: those who do not meet other criteria ¢ Residual: continuing evidence of schizophrenia without overt psychotic symptoms ________________________________________ Other Types: Schizophrenia ¢ Type I (positive symptoms): loose associations, hallucinations, bizarre behavior, and increased speech ¢ Type II (negative symptoms): changes in affect, poverty of speech, poor grooming, anhedonia, social withdrawal, cognitive defects, attention deficits ________________________________________ Clinical Features: Schizophrenia ¢ Symptoms > 6 months ¢ Prodromal signs and symptoms ¢ Perceptual disturbances ________________________________________ Management: Schizophrenia ¢ Dopamine receptor antagonists ¢ Clozapine ¢ Other atypicals (risperidone, olanzapine, quetiapine ________________________________________ Other Psychotic Disorders ¢ Schizophreniform disorder o Symptoms less than 6 months ¢ Delusional disorder o Non-bizarre delusions ¢ Brief psychotic disorder o Associated with stressor o Symptoms > one day and < one month ________________________________________ Case Study A 45-year-old male is brought to the emergency room by his mother because she is afraid of him. He is wearing a wool coat, several sweaters, a wool cap, and mittens on the hottest day of the year. His affect ranges from anger to laughter. His speech and behavior are childlike and when asked what is wrong, he replied, œThe medicine is badtomorrow is mad. His mother also reports she has heard him talking to himself in his bedroom. When she questioned him, he denied that he was speaking, but then continued to speak when she left the room. His mother stated that his problems have escalated since he stopped taking his medication several months ago. His first hospitalization occurred at the age of 18 and he has been hospitalized more than 20 times since then. ________________________________________ USMLE Step 2 ” Lesson 5: Sleep Disorders Sleep Disorders ________________________________________ Characteristics: Narcolepsy ¢ Excessive daytime sleepiness and abnormalities of REM sleep for a period of greater than 3 months ¢ REM sleep occurs in less than 10 minutes ¢ Patients will feel refreshed upon awakening ________________________________________ Clinical Features: Narcolepsy ¢ Sleep attacks ¢ Cataplexy ¢ Hypnagogic and hypnopompic hallucinations ¢ Sleep paralysis ________________________________________ Management: Narcolepsy ¢ Pharmacotherapy (psychostimulants for sleep attacks and imipramine for cataplexy) ________________________________________ Characteristics: Sleep Apnea ¢ Cessation of air flow at the nose or mouth during sleep ¢ Apneic episodes usually last greater than 10 seconds each ¢ Loud snore followed by a heavy pause ¢ Usually seen in obese, middle aged males, who complain of being tired during the day ________________________________________ Clinical Features: Sleep Apnea ¢ Types o obstructive o central o mixed ¢ Complications o arrhythmias o pulmonary hypertension ________________________________________ Management: Sleep Apnea ¢ Nasal continuous positive airway pressure ¢ Weight loss ¢ Surgery ¢ Treat the underlying condition ________________________________________ Case Study Case #1 A 45-year-old housewife is being seen at a sleep clinic for the first time. She claims that she has been unable to sleep for the last few years. According to the patient, her obese, middle-aged husband™s œsnoring keeps her up all night and interferes with her sleep. ________________________________________ Case Study Case #2 A 50-year-old businessman is seeking help to overcome his being œtired during the day. He has taken vitamins during the last few months since he thought they œmight help. He is 54 and weighs 200 pounds. ________________________________________ USMLE Step 2 ” Lesson 6: Mood Disorders Mood Disorders ________________________________________ Characteristics: Major Depression ¢ Women > men 2:1 ¢ Biological factors o Norepinephrine, serotonin, 5-HIAA ¢ Sleep o Shortened REM latency, etc. ________________________________________ Clinical Features: Major Depression ¢ Symptoms > 2 weeks ¢ Vegetative changes, anxiety ¢ Psychomotor disturbances, somatic complaints ¢ Decreased concentration, guilt, suicidal ¢ Decreased libido ¢ With psychotic features: worse prognosis ¢ With atypical features: increased weight, appetite, and sleep ________________________________________ Management: Major Depression Pharmacotherapy ¢ Tricyclic antidepressants (TCA™s) ¢ Serotonin selective reuptake inhibitors (SSRI's) ¢ Monoamine oxidase inhibitors (MAOI's) ¢ Electroconvulsive therapy (ECT) ________________________________________ Characteristics: Bipolar I Disorder ¢ Lifetime prevalence of 1% ¢ Equal prevalence in men and women ¢ Mean age of onset is 30 ¢ More prevalent among high socioeconomic status and those that did not finish college ¢ Sleep o Perceived decrease need for sleep o Decrease in total sleep time ________________________________________ Clinical Features: Bipolar I Disorder ¢ Symptoms > 1 week ¢ Increased self-esteem or grandiosity ¢ Distractibility, flight of ideas ¢ Excessive involvement in activities ¢ More talkative than usual ¢ Psychomotor agitation ¢ Increased sexual activity ¢ Increase in goal-directed activity ________________________________________ Course and Prognosis: Bipolar I Disorder ¢ Most often starts with depression ¢ Most experience both manic and depressive symptoms ¢ Untreated manic episode lasts 3 months ¢ Worse prognosis than major depressive disorder ¢ If depression and hypomania: called bipolar II disorder ________________________________________ Management: Bipolar I Disorder ¢ Pharmacotherapy: mood stabilizers, benzodiazepines, neuroleptics ¢ Psychotherapy ________________________________________ Dysthymic Disorder ¢ Chronic disorder characterized by a depressed mood that lasts most of the time during the day and is present on most days for at least 2 years ¢ Treatment: SSRI™s, TCA™s, or MAOI™s ________________________________________ Cyclothymic Disorder ¢ Chronic disorder characterized by many periods of depressed mood and many periods of hypomanic mood for at least 2 years; a milder form of bipolar II disorder ¢ Treatment: antimanic drugs such as lithium, carbamazepine, and valproic acid ________________________________________ Seasonal Affective Disorder ¢ Disorder characterized by depressive symptoms found during winter months and absent during summer months; believed to be caused by abnormal melatonin metabolism (decreased MSH) ¢ Treatment: phototherapy or sleep deprivation ________________________________________ Adjustment Disorder ¢ Disorder characterized by the development of symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor ¢ Treatment: usually require supportive psychotherapy ________________________________________ Differences: Grief ¢ Normal identification with deceased ¢ Crying, decreased libido, weight changes ¢ Self-limited, lasts 6 months - 1 year ¢ Antidepressants not helpful ________________________________________ Differences: Depression ¢ Abnormal identification with deceased ¢ Sleep disturbance, depressed mood, appetite disturbance ¢ Suicidal ideation rare ¢ Suicidal ideation common ¢ Symptoms persist greater than 1 year ¢ Antidepressants helpful ________________________________________ Case Study Case #1 A 30-year-old female was fired from her job about 1 month ago. Since then, she has complained of depressed mood and sleep problems. She denies any appetite or weight problems. She denies any suicidal ideation or plan. Her concentration is good and her memory is intact. ________________________________________ Case Study Case #2 A 28-year-old female has had a 9-year history of periods of œfeeling great and feeling lousy. During the œfeeling great periods, she reported increased libido and decreased sleep. During her œfeeling lousy periods, she reported decreased concentration and tearfulness. ________________________________________ USMLE Step 2 ” Lesson 7: Substance Disorders Substance Disorders ________________________________________ Buzz Words. ¢ Paranoia - cocaine/amphetamine intoxication ¢ Arrhythmia - cocaine intoxication ¢ Depression - cocaine withdrawal ¢ Flashback - LSD ¢ Severe violence - PCP ¢ Pin-point pupils - opiate overdose ________________________________________ Buzz Words.. ¢ Flu-like symptoms - opiate withdrawal ¢ Lack of motivation - marijuana ¢ Tremors - alcohol ¢ Seizures - benzodiazepines ¢ Death - barbiturates ________________________________________ USMLE Step 2 ” Lesson 8: Somatoform Disorders Somatoform Disorders ________________________________________ Somatoform Disorders A group of disorders characterized by the presentation of physical symptoms without any medical explanation. The symptoms will be severe enough to interfere with the patient™s ability to function in social or occupational activities. Typically, patients are females of low socioeconomic status. ________________________________________ Clinical Features: Somatization Disorder ¢ Presentation of many physical symptoms affecting many organ systems without any medical explanation ¢ Need at least 8+ symptoms in order to make a diagnosis: o 2 gastrointestinal symptoms o 1 sexual symptom o 1 pseudo-neurological symptom o 4 pain symptoms ________________________________________ Management: Somatization Disorder ¢ Must have a single identified physician as the primary caretaker ¢ Regularly scheduled brief monthly visits ¢ Increase the patient™s awareness of the possibility that the symptoms are psychological in nature ¢ Psychotherapy ________________________________________ Characteristics: Conversion Disorder ¢ One or two neurological symptoms affecting voluntary or sensory function that cannot be explained by any known neurological disorder ¢ Must have psychological factors associated with the onset or exacerbation of the symptoms ________________________________________ Clinical Features: Conversion Disorder ¢ Primary gain ¢ Secondary gain ¢ La belle indifference ¢ Identification ________________________________________ Management Conversion Disorder ¢ Psycotherapy ________________________________________ Hypochondriasis ¢ Patient believes that he or she has some specific disease ¢ Despite constant reassurance, the patient™s belief remains the same ¢ Treatment o Psychotherapy o Frequent, regular visits to their MDs ________________________________________ Body Dysmorphic Disorder ¢ Patients believes a body part is abnormal, defective, or misshapen ¢ May involve serotonergic systems ¢ Treatment: o Psychotherapy o Pharmacotherapy (SSRI™s, TCA™s, MAOI™s) ________________________________________ Factitious Disorder ¢ Conscious production of signs and symptoms of both medical and mental disorders ¢ Assume sick role and hospitalization ¢ Usually diagnosed with physical or psychological symptoms or both ¢ Men > women ¢ Hospital and health care workers ¢ Treatment: usually involves management rather than cure ________________________________________ Malingering Conscious production of signs and symptoms for an obvious gain (money, avoid work, free bed and board, etc.). It is not a mental disorder. ________________________________________ Case Study A 50-year-old woman was referred by her husband™s psychiatrist because of œattacks of dizziness that have been occurring for more than 10 years. Every day, at about 3pm, the attacks occur. They leave her helpless and, when her husband arrives, she is unable to attend to him. She remains in bed until 8pm when the attacks subsided, and she would watch TV and fall asleep. When questioned, she described her husband as abusive and not caring about her well-being. He has repeatedly abused her and their children, which resulted in their leaving home at an early age, and moving in with their grandmother. She stated that she hated when he came home and would make comments about the house, dinner, etc. Many times, these verbal comments were followed by actual episodes of violence, several of which have resulted in her hospitalization. ________________________________________ USMLE Step 2 ” Lesson 9: Personality Disorders Personality Disorders ________________________________________ Personality Disorders ¢ Ego-syntonic maladaptive patterns of behavior ¢ These individuals rarely seek treatment by themselves and are regarded as unmotivated for treatment ________________________________________ Personality Disorders ¢ Odd, eccentric type (Cluster A): paranoid, schizoid, schizotypal ¢ Dramatic, emotional type (Cluster B): histrionic, borderline, antisocial, narcissistic ¢ Anxious, fearful type (Cluster C): avoidant, obsessive-compulsive, dependent ________________________________________ Paranoid Personality Disorders ¢ Pervasive distrust & suspiciousness of others ¢ Reluctance to confide in others ¢ Recurrent suspicions ¢ Persistently bears grudges ¢ Questions the loyalty of others ¢ Reads demeaning meaning into benign remarks ¢ Main defense mechanism is projection ________________________________________ Schizoid Personality Disorder ¢ Lifelong pattern of social withdrawal ¢ No desire for close interpersonal relationships ¢ No interest in sexual activities ¢ Appears indifferent to criticism ¢ Emotional coldness ¢ Lacks close friends ¢ Almost always chooses solitary activities ________________________________________ Schizotypal Personality Disorder ¢ Magical thinking ¢ Ideas of reference ¢ Illusions ¢ Inappropriate affect ¢ Paranoid ideation ¢ Odd appearance ¢ Excessive social anxiety ¢ If stress, may become psychotic ________________________________________ Histrionic Personality Disorder ¢ Usually characterized by colorful, exaggerated behavior ¢ Excitable, shallow expression of emotions ¢ Uses physical appearance to draw attention to self ¢ Sexually seductive ¢ Uncomfortable in situations where they are not the center of attention ________________________________________ Borderline Personality Disorder ¢ Unstable affect, mood swings, marked impulsivity ¢ Unstable relationships, identity disturbance ¢ Recurrent suicidal behaviors ¢ Chronic feelings of emptiness or boredom ¢ Inappropriate anger ¢ If stressed, may become psychotic ¢ Main defense mechanism is splitting ________________________________________ Antisocial Personality Disorder ¢ Continuous antisocial or criminal acts ¢ Inability to conform to social rules ¢ Impulsivity ¢ Disregard for the rights of others ¢ Aggressiveness ¢ Lack of remorse and deceitfulness ¢ Symptoms before 15 and patient > 18 ________________________________________ Narcissistic Personality Disorder ¢ Sense of self-importance and grandiosity ¢ Preoccupied with fantasies of success ¢ Believe they are special ¢ Require excessive admiration ¢ React with rage when criticized ¢ Lack empathy, envious of others ¢ Interpersonally exploitative ________________________________________ Avoidant Personality Disorder ¢ Extreme sensitivity to rejection ¢ Shy, social inhibition, few friends ¢ Feelings of inadequacy ¢ Reluctant to take personal risks ¢ Hypersensitive to criticism ¢ Shows restraint within intimate relationships ¢ High incidence of social phobias ________________________________________ Dependant Personality Disorder ¢ Lacking self-confidence ¢ Subordinate their needs for those of others ¢ Difficulty making decision ¢ Unable to assume responsibilities ¢ Feeling uncomfortable or helpless when alone ¢ Need support from others and urgently seek relationships as a source of care and support ________________________________________ Obsessive-Compulsive Personality Disorder ¢ Orderliness, stubbornness, inefficiency, perfectionistic ¢ Preoccupied with details, rules, lists ¢ Excessively devoted to work ¢ Unable to discard worn out objects ¢ Rigid, cheap, and over conscientious ¢ Described as being fixated at the anal stage of development ________________________________________ USMLE Step 2 ” Lesson 10: Psychopharmacology Psychopharmacology ________________________________________ Mechanism of Action Dopamine Receptor Antagonists (Antipsychotics) ¢ Act primarily by dopamine blockade, D2 ¢ Produce alpha-blockade (hypotension) ¢ Block muscarinic receptors (anticholinergic side effects) ¢ Block NE reuptake and block serotonin and histamine receptors ________________________________________ Dopamine Tracts: Dopamine Receptor Antagonists (Antipsychotics) ¢ Mesolimbic and mesocortical (psychosis) ¢ Nigrostriatal (movement disorders) ¢ Tuberoinfundibular (prolactin) ________________________________________ Acute Dystonia Dopamine Receptor Antagonists (Antipsychotics) ¢ Usually within a few hours to few days of initiating treatment ¢ Greater incidence among young males ¢ Muscular rigidity and cramping ¢ Treat with anticholinergic medication ________________________________________ Drug-Induced Parkinsonism Dopamine Receptor Antagonists (Antipsychotics) ¢ Onset within several weeks of therapy ¢ Greater incidence among the elderly ¢ Characterized by bradykinesia, rigidity, cogwheel tremor, masked facies, etc. ¢ Treatment consists of anti-parkinsonism medication and decreased antipsychotic medications ________________________________________ Akathisia Dopamine Receptor Antagonists (Antipsychotics) ¢ Onset after many weeks of therapy ¢ Characterized by restlessness and symptoms of anxiety ¢ Treatment consists of decreasing the antipsychotic medication, Beta-blockers, or benzodiazepines ________________________________________ Neuroleptic Malignant Syndrome Dopamine Receptor Antagonists (Antipsychotics) ¢ Fever, rigidity, and autonomic instability ¢ Greater incidence with high-potency neuroleptics and lithium ¢ Medical emergency ¢ Treatment consists of dantrolene or bromocriptine ¢ Obtain CPK ________________________________________ Tardive Dyskinesia Dopamine Receptor Antagonists (Antipsychotics) ¢ Onset after long term use > 3-6 months ¢ Greater incidence among elderly females ¢ Characterized by involuntary movements of the tongue, face, neck, and upper extremities ¢ Treatment consists of prevention, risks vs. benefits, vitamin E?, consider clozapine ________________________________________ Differences Between Typical and Atypical Antipsychotics Typical Atypical Dopamine receptors Dopamine & serotonin receptors Treat (+) symptoms Treat (+) and (-) symptoms Many side effects Less side effects ________________________________________ Clozapine ¢ Weak D2 receptor antagonist ¢ Blocks the mesolimbic and mesocortical dopamine tracts ¢ Adverse effects include agranulocytosis (1-2%), seizures, and drooling ¢ Weekly WBC™s ¢ Never use as first line ________________________________________ Risperidone/Olanzapine/Quetiapine ¢ Sedation ¢ Less side effects ¢ May use as first line ________________________________________ Antidepressants ¢ Mechanism of action o Block the reuptake of the neurotransmitters o Down-regulation of receptors o Increase endogenous opiates & pain threshold ________________________________________ Antidepressants ¢ Adverse effects o Sedation, weight gain, orthostatic hypotension o Dry mouth, blurry vision, urinary retention o Increased heart rate and EKG changes o Sexual dysfunctions ________________________________________ SSRI's & SSRI-Like Drugs ¢ Fluoxetine ¢ Sertraline ¢ Paroxetine ¢ Fluvoxamine (for the treatment of OCD) ¢ Nefazodone ¢ Citalopram ________________________________________ SSRI's & SSRI-Like Drugs ¢ Most common adverse effects include GI (N/V) ¢ Headache, sedation, or restlessness ¢ Anorgasmia, retarded ejaculation ________________________________________ MAOI's ¢ Phenelzine ¢ Tranylcypromine ¢ Selegiline ¢ Must have strict dietary restrictions due to tyramine reaction ________________________________________ Mood Stabilizing Agents: Lithium ¢ Mechanism of action - blocks inositol-1-phosphatase ¢ Adverse effects o N/V, anorexia, diarrhea, abdominal pain o Polyuria and polydypsia o Tremors o Hypothyroidism o Teratogenic - Ebstein™s anomaly ¢ Others - carbamazepine, valproic acid, gabapentin ________________________________________ Antianxiety Agents (Benzodiazepines) ¢ Mechanism of action o Facilitate GABA-ergic synaptic transmission o Alter membrane permeability to chloride ions (facilitate GABA effects) o All undergo hepatic microsomal oxidation except lorazepam, oxazepam, and temazepam, which undergo glucoronidation ________________________________________ Antianxiety Agents (Benzodiazepines) ¢ Adverse effects o Sedation and impairment of performance o Memory impairments ¢ Disinhibition ¢ Depression ¢ Addiction ________________________________________ |