Psychopharmacology Review

Exam 2 Key Points

• The best treatment for PTSD are paroxetine and sertraline, which are first-line SSRIs.
• Short-term benzos like Prazosin can be used for nightmares.
• Mood stabilizers, antipsychotics, antidepressants, hypnotics, and sedatives as well as therapies such as EMDR, CPT, and PE can be considered for PTSD.
• Symptoms of PTSD include:
  • Flashbacks
  • Nightmares
  • Insomnia
  • Hyperarousal
  • Anxiety
  • Avoidance
  • Amnesia
  • Memory blocks
  • Dissociation

Brain Regions Impacted by PTSD

• The brain regions implicated by PTSD are:
  • Amygdala
  • Prefrontal Cortex
  • Hippocampus

PTSD Medication

• SSRIs like paroxetine and sertraline are first-line medications for PTSD
• TCAs are second-line medications
• Short term benzos such as Prazosin can be implemented

Fight or Flight vs. Rest and Digest vs. Freeze

• Fight-or-flight: Adrenaline, the sympathetic nervous system, confronting a stressor and an increase in heart-rate are all factors
• Rest-and-digest: Involves acetylcholine, the parasympathetic nervous system as well as a decrease in heart-rate.
• Freeze: Numb, immobile, "shutting down" in response to a stressor/threat and an inability to respond to stress.

General Adaptation Syndrome and Polyvagal Theory

• GAS by Hans Selye: The stress response system defends, then fatigues
  • Alarm
  • Resistance
  • Exhaustion
• Polyvagal theory: Explains how the ANS regulates fear, social connection, and emotion.
  • Safety
  • Activation
  • Collapse

Depersonalization and Derealization

• Depersonalization: Feeling detached from oneself
• Derealization: Surroundings appear unreal or distant; fog/dream
• Disorder involves persistent, recurring episodes often triggered by severe stress which can occur comorbidly with anxiety, depression, and some personality disorders

Major Acronyms

• SIGECAPS: Sleep changes, Interest loss, Guilt, Lack of energy, Reduced cognition, Low appetite, Psychomotor, Suicide.
• SOLER: Sit, Open posture, Lean forward, Eye contact, Relaxed body language.
• DIGFAST: Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkative.

Alcohol and Benzo Withdrawals

• Both withdrawals can be deadly because they cause symptoms such as anxiety, insomnia, muscle tension, and seizures.
• Delirium tremens lead to respiratory failure.
• Doses should be gradually tapered.

Signs of Lithium Toxicity

• Tremors, confusion, seizures, hyperreflexia, myoclonia, ataxia.
• GI distress, slurred speech, blurred vision, ringing in the ears, kidney problems, heart rhythm disturbances.
• Dehydration, NSAIDs, antiHTN, and diuretics can increase lithium levels.

Treatment of Lithium Toxicity

• Immediately stop Lithium tx, administer IV Fluids, administer anticonvulsants, hemodialysis, bowel irrigation, dialysis.
• Prompt recognition and timely intervention, as it is 100% excreted in kidneys.

Lithium Levels

• Lithium is a mood stabilizer and the first line agent for bipolar disorder with a narrow therapeutic range.
  • Therapeutic: 0.8-1.4
  • Maintenance: 0.4-1.3
  • Toxic: >1.5

Long-Term Effects of Lithium

• Hypothyroidism, weight gain, cognitive impairment, kidney problems, tremors, GI upset, hair loss
• Monitor lithium levels, kidney, FX, BUN/Cr, and thyroid.

Lithium Level Frequency Monitoring

• 1-2 weeks initially and once stable checks are typically done every 3-6 months

Chronic Stress Impacts

• Increased inflammation.
• Weakened immune system.
• Heart disease, HTN, obesity, depression/anxiety, cognitive decline.
• Unhealthy coping, lack of sleep and exercise, smoking, binge eating.
• Chronic conditions.
• Depression is the leading cause of disability.

A's of Schizophrenia

• Alogia: limited speech output.
• Anhedonia: inability to experience pleasure.
• Anergia: lack of energy.
• Apraxia: inability to perform purposeful movements.
• Avolition: lack of motivation.

Extrapyramidal Side Effects (EPS)

• EPS are involuntary movement disorders occurring due to the blockade of dopamine receptors and can be treated with benztropine or trihexyphenidyl. They include:
  • Akathisia: (restlessness)
  • Dystonia: (contractions/posture)
  • Parkinsonism: (tremors)
  • Tardive dyskinesia: (face, tongue, extremities)
  • TD is often irreversible

Antipsychotics and Side Effects

• Second-generation antipsychotics are more likely to cause weight gain, galactorrhea, lactation, QT prolongation, and cataracts.
• Weight gain is more likely with olanzapine, risperidone, quetiapine, and clozapine.
• Galactorrhea/lactation result from increased prolactin levels due to risperidone.
• Prolonged QT interval is more likely with ziprasidone, iloperidone, and asenapine.
• Cataracts are more likely with phenothiazine antipsychotics and chlorpromazine.

Haloperidol Side Effects

• Monitor patients who received a haloperidol injection 24 hours prior, as it is a high potency, first-generation/typical antipsychotic because side effects such as:
  • Extrapyramidal sx: dystonia, akathisia, parkinsonism
  • Sedation
  • Orthostatic hypotension
  • Anticholinergic/drying effects
  • Neuroleptic malignant syndrome
  • Involuntary muscle movement
  • Prolonged QT interval

PRN Medications for Dystonic Reactions

• Benztropine (Cogentin): An anticholinergic relieving muscle spasms and rigidity.
• Diphenhydramine (Benadryl): An antihistamine relieving dystonic symptoms.

Medications for Akathisia

• Propranolol: A first-line treatment or beta blocker for akathisia.
• Benzodiazepines: Like lorazepam and clonazepam for akathisia.
• Anticholinergics: Benztropine, trihexyphenidyl, lower antipsychotic dose to treat akathisia.

Testing for Tardive Dyskinesia

• Use the AIMS scale-abnormal involuntary movement scale.
• Early detection is priority and TD is often irreversible.

Mindfulness

• Mindfulness is bringing one's attention to the present which cultivates awareness.
• Practice includes meditation and breathing exercises to turn negative thoughts into positive thoughts.
• Reduces stress, improves focus/concentration, and promotes overall well-being, encouraging to disengage patients from negative thought patterns.

Medication Classes

• Sertraline, paroxetine, escitalopram, citalopram, fluoxetine are SSRIs
• Duloxetine, venlafaxine, desvenlafaxine are SNRIs
• Haloperidol, Chlorpromazine are first gen antipsychotics
• Olanzapine, risperidone, ziprasidone, quetiapine, clozaril or clozapine are atypical antipsychotics (2nd gen)
• Alprazolam, clonazepam, lorazepam, diazepam are Benzodiazepines
• Amphetamines, methylphenidate are CNS stimulants
• Parnate, nardil are MAOI's
• Donepezil is a cholinesterase inhibitor
• Bupropion(Wellbutrin) is an atypical (NDRI)
• Mirtazapine is an antidepressant

Phases of Schizophrenia

• Prodromal: Proceeds onset of psychotic symptoms, along with withdrawal and declining functioning
• Active: Full psychotic symptoms emerge, with experiences of hallucinations and delusions; diagnosis occurs here
• Residual: Positive symptoms may reside, yet negative symptoms often remain, such as apathy, lack of motivation, and difficulty with social engagement

Positive vs Negative Symptoms

• Positive: Behaviors or experiences usually present but should not be, e.g. hallucinations, delusions, disorganized speech/behavior; that what added.
• Negative: Absence or disruption of normal functions, incl. lack of motivation, emotional expression, speech, or inability to experience pleasure and social withdrawal; that what taken away.

First vs. Second-Generation Antipsychotics

• 1st gen (typical)
  • Block Dopamine D2 receptors
  • Are most effective for treating positive symptoms
  • Carry a higher risk for extrapyramidal side effects
• 2nd gen (atypical)
  • Exhibit a broader receptor spectrum and block D2 receptors but also block/agonize serotonin receptors; 5HT2A
  • Are effective for both positive and negative symptoms
  • Carry a lower risk for EPS
  • Can cause metabolic side effects such as weight gain

Agranulocytosis

• Clozapine (Clozaril) is a second-generation antipsychotic that can cause Agranulocytosis, or a severe deficiency of WBCs.
• Patients taking this medication require weekly monitoring of WBC count as there is a risk of infection due to a suppressed immune system.

Hallucinations in Schizophrenia

• The most common hallucinogenic experiences in schizophrenia are:
  • Auditory: Voices and sounds; are the of the most distressing and potentially harmful
  • Visual: People/objects
  • Tactile, smells, and tastes are less frequent

Neuroleptic Malignant Syndrome (NMS)

• A life-threatening reaction to antipsychotics.
• Treatment includes discontinue antipsychotic, starting IV fluids, cooling measures, dantrolene, monitor for kidney failure, respiratory distress, and rhabdomyolysis
• ECT may be administered in severe cases
• Most patients recover within 2 weeks

Serotonin Syndrome

• Treatment includes discontinue medication, IV fluids, administer serotonin antagonists (cyproheptadine or chlorpromazine), benzodiazepines, paralysis, and intubation in severe cases
• Recognize symptoms early and calm body down

Bipolar I vs Bipolar II

• Bipolar I: Full-blown manic episodes that can last a week, along with an elevated mood, energy, and action.
• Bipolar II: Hypomanic episodes which alternate with major depressive episodes that last less than a week.

Mania vs Hypomania

• Mania (Bipolar I): Is more severe, longer in duration, necessitates hospitalization, shows psychotic features such as hallucinations and delusions as well as impaired functioning.
• Hypomania (Bipolar II): Less extreme, shorter in duration, where a person can still function normally and is not typically hospitalized.

Depression Origins

• Genetic/biological predisposition, stressful life events, brain chemical imbalances, negative thought patterns, low self-esteem, childhood trauma, and environment.
• ACE (adverse childhood events scale).

Bipolar Disorder Origins

• Genetic factors, neurotransmitter imbalances, environmental stressors, and adverse life events.
• Brain structure and function abnormalities contribute.

Over the Counter Substances for Depression

• St. John's Wort, omega-3 fatty acids, exercise, and SAM-e are all common substances
• Contraindicated with some medications
• Do not take in addition to anti-depressants due to the risk of serotonin syndrome

First gen antipsychotics

• They function as a dopamine 2 receptor blocker
• Excess dopamine leads to schizophrenia

Dissociative Disorders

• Dissociative identity disorder: two or more personality states linked to childhood trauma.
• Dissociative amnesia: the inability to recall important info tied to stress and/or trauma.
• Depersonalization/Derealization: feeling detached from self and/or environment
• Dissociative Fugue: reversible amnesia, unplanned traveling and wandering

Treatment for Dissociative Disorders

• Phase 1: Safety, coping skills, psychoeducation, and crisis intervention
• Phase 2: Trauma processing, EMDR, and medication
• Phase 3: Increase self-awareness, improve relationships; work on life goals

Ethical principles

Non-maleficence: wrong side operation

• Autonomy: helping a patient with advanced directives Beneficence: to do good
• Justice: to treat everyone fairly
• Fidelity: keep commitments/loyalty
• Veracity: to be truthful Confidentiality: protect patient information.

Tarasoff Laws

• Require mental health professionals to warn or protect individuals who may be in danger due to a patient's threats of harm.

Timing of Restraints

• 5-7-year-old adolescents: 1 hour
• Adults: 4 hours
• Orders can be renewed for a max of 24 consecutive hours.

Conducting a Mental Status Exam

• Observe and question.
• "ASEPTIC M2" (Appearance and behavior, speech, mood, thought, process, thought content, perception, cognition, insight and judgment, orientation, emotional expressions Subjective-patient, objective-HCP)

Screening Tools

• PHQ-9: screening for depression.
• GAD-7: screening for anxiety.
• MMSE (mini-mental state examination): screening for cognitive impairments (delirium, dementia).
• Max score of 30 with a lower score indication cognitive deficits due to dementia and amnesia.
• AIMS scale abnormal involuntary movement scale for tardive dyskinesia, for patients on antipsychotics with extrapyramidal symptoms.

Electroconvulsive Therapy (ECT)

• ECT induces a brief, controlled, general anesthesia with a seizure and is used for treatment resistant depression, mania, catatonia, schizophrenia and other mental illnesses like bipolar disorder. ECT is a fast an effective treatment for severe depression

Electroconvulsive Therapy (ECT) Side effects

• Memory loss or amnesia, headaches, N/V, muscle aches, confusion.
• ECT is generally considered to be safe.

Electroconvulsive Therapy (ECT) Candidates

• Someone with treatment-resistant mental illness such as severe depression, severe mania, catatonia, schizophrenia, older adults who cannot tolerate medication and are actively suicidal, and patients who cannot have food or fluids.

Preparation for Electroconvulsive Therapy (ECT)

• Obtain informed consent, educate, discuss risks vs. benefits, conduct medical evaluation and lab tests, NPO, administer anticholinergic medication, anesthesia, VS, seizure activity and fluids and provide comfort, support, reassurance

Transcranial Magnetic Stimulation (TMS)

• TMS is a non-invasive procedure that produces magnetic pulses that induce electrical currents in the prefrontal cortex as well as involving it in mood regulation and improving neurotransmitter levels.
• TMS occurs often in a series of daily sessions over several weeks and is an outpatient procedure

Transcranial Magnetic Stimulation (TMS) vs Electroconvulsive Therapy (ECT)

• TMS is primarily used to treat non-responsive depression.
• ECT: Anesthesia, produces a seizure and hospitalization.
• TMS: Non-invasive, carries less side effects and risk, is an outpatient procedure, may be less effective and is newer and more targeted.

Primary Safety Issues

• Primary safety issues surrounding depression are suicide risk and self-harm.
• Bipolar safety issues include impulsive, reckless, and aggressive behavior and mania.
• Schizophrenia safety issues consist of delusions and hallucinations leading to self-harm and violence, as well as an inability to care for themselves.

Capacity vs Competence

 - Capability: The skill to perform a task or function.

Skills to do the task may not be developed yet. - Competence: Actual ability with demonstrated skills, fully realized and practiced.

Cymbalta

• If a patient taking cymbalta, duloxetine SNRI for depression/anxiety has a blood pressure of 180/100 this would cause a hypertensive crisis, and would lead to holding the medication. Cymbalta can increase BP

Speech Types

• Not answering a simple question is evasive speech.
• Talking in circles and including more detail than you asked for is known as circumstantial speech.

Review of key concepts in psychopharmacology. Topics include antipsychotics, antidepressants, PTSD, and the sympathetic nervous system. Also covers derealization, dopamine activity, and the D4 receptor.