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71 Cards in this Set
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Autonomic symptoms of anxiety
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Inc. BP, HR, RR, muscle tension
Inc. levels of Epi, NE, GH, Cortisol, Prolactin |
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BDZs mechanism of action
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Positive allosteric modulators of GABA
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General effects of BDZs (5)
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Anti-convulsant
Muscle relaxant Sedative-hypnotic Amnestic Anxiolytic |
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Flumazenil
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BDZ-receptor antagonist
Block effects of BDZs Used to reverse anesthesia and in cases of OD |
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BZ-1 Receptor location & effect
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Cerebellum
Sedative |
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BZ-2 Receptor locations & effect
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Hippocampus, Striatum, SC
Anti-convulsant Muscle relaxant |
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Zolpidem (Ambien)
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BZ-1 selective agonist
Causes sedation NO disruption of normal REM sleep pattern |
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This is especially dangerous when mixed with BDZs
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Alcohol
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BDZs that are reliably absorbed IM (2)
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Lorazepam
Midazolam |
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BDZ w/ the shortest half-life and thus most amnestic effect
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Midazolam
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Lorazepam key points
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Given acutely to agitated pts.
Helps combat EPS from antipsychotics NOTE: when given in combos, sedative effects are synergistic |
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Flurazepam key points
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LONG half-life
Good for middle insomnia NOTE: can cause some daytime sedation |
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Triazolam key points
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SHORT half-life
Better for initial insomnia Rarely assoc. w/ amnesia or behavior changes |
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Side effect of ALL BDZs except Zolpidem
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Suppression of REM sleep and stages 3 and 4
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BDZ side effects (4)
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Sedation
Dizziness/Ataxia Mild cognitive impairment Greater rate of falls (elderly) |
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When is it good to use BDZs that don't have active metabolites?
Which BDZs don't have them? |
In liver disease
Lorazepam, Oxazepam, Temazepam |
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Risk factors for BDZ dependence (5)
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History of alcohol dependence
Potency of medication Duration of treatment Rapidity of onset of CNS effects Agents with shorter-effects |
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Most reasonable BDZs for routine use (2)
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Lorazepam
Clonazepam |
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What are beta-blockers good for treating (2)?
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Performance anxiety
Tremor NOTE: LESS effective for cognitive symptoms (ie worry, expectation) |
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What is clonidine used to treat (2)?
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Autonomic arousal in opiate withdrawal
MILDLY effective in anxiety disorders (NOT 1st choice) |
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5-HT's effects on NE and DA
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@ Locus Ceruleus - 5HT --> DECREASED NE
@ Nigrostriatum - 5HT --> DECREASED DA |
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What part of the brain do SSRIs enhance 5HT activity in?
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ALL areas of the brain
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Generalized Anxiety Disorder requires 3 or more of the following
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Restlessness (feeling "keyed up")
Being easily fatigued Difficulty concentrating ("mind going blank") Irritability Muscle tension Sleep disturbance |
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Behaviorist theory about anxiety
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Anxiety is a conditioned behavior
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Psychoanalytic theory on anxiety
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Sign of some unconscious conflict
"Signal anxiety" is a sign that repression is failing |
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Cognitive behavioral theory on anxiety
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Pt. is anxious due to characteristic cognitive distortions
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Characteristics common to BOTH depression and anxiety (5)
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Demoralization
Self-absorption Heightened automatic info. processing Maladaptive Schemas Reduced capacity for problem solving |
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Drug of choice for Generalized Anxiety Disorder
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Buspirone or SSRI
NOTE: TCAs and venlafaxine will also work NOTE: BDZs used to be DOC |
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Panic attack
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Discrete period of intense fear or discomfort
4 or more symptoms from the list Develop abruptly, reach a peak WITHIN 10 MINUTES |
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Within what time do panic attacks reach their peak?
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TEN MINUTES
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Panic Disorder
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Recurrent unexpected Panic Attacks
At least one of the attacks followed by 1 or more of: Persistent concern about additional attacks Worry about the implications Significant change in behavior |
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Most common comorbid condition w/ Panic Disorder
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Major Depressive Disorder (50-65%)
Comorbidity has poorer prognosis |
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Prevalence of other comorbid anxiety disorders
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Social phobia (15-30%)
OCD (10%) GAD (25%) |
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Most common age of onset for Panic Disorder
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Mid 20s
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Is Panic Disorder more common in men or women?
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Women (2-3x)
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% of panic disorder pts. who attempt suicide
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7%
Compared to 8% with MDD |
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Ablation of what in animals blocks the fear response?
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Locus Ceruleus
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These triggers true Panic Attacks in panic pts. but NOT in normals (2)
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Sodium lactate infusion
NOTE: does NOT cross BBB CO2 Inhalation NOTE: lactate is metabolized into CO2 |
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False Suffocation theory
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Pts. have overly sensitive chemoreceptors
Mild increase in CO2 triggers a smothering sensation |
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Treatment of Panic Attacks
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Education and support
Cognitive techniques BDZs can be used acutely (usually not monotherapy) SSRIs or TCAs can be used for prophylaxis ("Start low, go slow") |
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Treatments for Phobic Disorders (3)
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BDZs for acute anxiety or panic
Beta-blockers for specific phobias or performance anxiety SSRIs and MAO-Is for worry in Generalized Social Phobia |
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Main criteria for PTSD (4)
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Exposure to traumatic event
Persistent re-experiencing of traumatic event Avoidance of stimuli assoc. w/ event and numbing of responsiveness Persistent symptoms of increased arousal |
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In children, recollections of a traumatic event may present as this
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Repetitive play in which themes of the trauma are expressed
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% of people exposed to traumatic stressor that get Acute Stress Disorder
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50%
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% of people who get Acute Stress Disorder that develop PTSD
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50%
SO, of those who have traumatic stressor, 25% get PTSD |
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% of women who report childhood sexual abuse
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30%
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Learned Helplessness
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Similar to PTSD
Responds to TCAs |
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With chronic stress, what happens to cortisol system?
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Cortisol system responsiveness DECLINES
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Type of treatment required for PTSD
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Multimodal (psychotherapy + meds)
Meds alone are not especially helpful |
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Effects of TCAs and MAO-Is in PTSD treatment
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Treat mood and anxiety symptoms
Treat hypervigilance Treat re-experiencing phenomena MUCH LESS effect on withdrawal and numbing |
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Effects of clonidine, naltrexone, and propranolol in PTSD treatment
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Similar results to TCAs/MAO-Is
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Effects of Li and Carbamazepine in PTSD treatment
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Help only w/ anger outbursts
"anti-kindling" |
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Effects of BDZs in PTSD treatment
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May help w/ anxiety
(Use w/ caution) LITTLE EFFECT on numbing/re-experiencing |
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Effects of SSRIs in PTSD treatment
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Treat depression and anxiety
Treat re-experiencing and numbing BUT, many pts. can't tolerate SSRI side effects (esp. anxiety) |
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Link between Tourette's and OCD
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5% of OCD pts. have Tourette's
2/3 of Tourette's pts. have OCD |
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Is psychoanalysis effective for OCD?
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NO
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OCD responds preferentially to what types of drugs?
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SSRIs
BUT, up to 40% of pts. don't respond Addition of D2-blocker helps |
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Functional neuroimaging in OCD shows what?
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INCREASED activity in:
Orbitofrontal lobes Caudate nucleus Anterior cingulate gyrus Pts. w/ OCD appear to have TOO MUCH executive function |
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OCD pts. have loss of volume in what part of their brains?
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Caudate nucleus
This could be involved in feedback loop that relates to Tourette's |
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What effect do cocaine/stimulants have in OCD?
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Worsen the behaviors
Can bring out motor tics in Tourette's |
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How do atypical anti-psychotics effect OCD?
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They can make it worse
They further increase DA activity in the frontal lobe |
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PANDAS
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Pediatric
Autoimmune Neuropsychiatric Disorders Associated w/ Strep infection |
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In PANDAS, what does an initial negative swab test mean?
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NOTHING
Pt. should be retested in 72 hours |
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How is PANDAS treated?
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10 day course of antibiotics
OCD symptoms dissipate in about 14 days |
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Treatment for OCD
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SSRIs (60% response rate)
-- Higher doses/trial than with depression -- Effect is via downregulation of receptors Behavior Therapy Neurosurgery (90% response rate) |
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What happens in OCD when you stop SSRI treatment?
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Symptoms return
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The fear circuit centers on what?
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The Amygdala
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The pleasure circuit centers on what?
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The nucleus accumbens
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Tiazolam
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Shortest 1/2 life
Short duration of effect Good for INITIAL insomnia |
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Clonazepam
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Long half life
Slow onset of effects Can aid in smoothly detoxifying a pt. from BDZs |
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Alprazolam
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Rapid onset of effects
Short duration of effect Great risk of addiction |