Exam 3

ego-syntonic

"That's me," in other words. "Just who I am." may be difficult to treat simply because the person does not see them as a problem, or sees them as an intractable part of the self.

"normal" personality

* the ability to experience and respond to the environment in a flexible and adaptive way. * the ability to perceive self and environment in a generally constructive way. They can experience themselves as positive, or can take criticism in a generally adaptive way. They are able to function in the environment in such a way that they can pursue their own goals. *the ability to consistently show behavioral patterns that are useful and healthy for them. In other words, they are typically act in ways that are healthy for them.

"abnormal" or disordered personality

*the person interacts with the world, responsibilities, and relationships, in inflexible and maladaptive behavior. *the person's perceptions of self are typically self-defeating. They may see themselves as "broken" or fundamentally worthless *the person's overt behaviors can be interpreted as damaging to health

personality disorders

- age of onset, typically late adolescence or early adulthood -children cannot be diagnosed with personality disorders due to lifelong and stable (too early to know those) -lifelong prevalence -there is a likelihood that it will not only remit in therapy, but ultimately may remit on its own over time -considered basically hopeless by some (misguided) clinicians -can be difficult to detect -a counselor probably cannot avoid working with clients with personality disorder. -Personality disorder is no longer considered an unlikely risk for change. -Theodore Millon. Millon and Everly's classic 1985 -personality traits turn into personality disorders when: 1. they become inflexible and maladaptive and 2. significantly impair social and occupational functioning or cause substantial subjective distress -become less obvious by middle or old age -more pronounced during periods of high energy and under stressful conditions -personality traits and disorders are listed on Axis II, whereas mental disorders are indicated on Axis I -they have more troubled lives = more contact with police, increased use of medical services, and more suicide attempts

Theodore Millon. Millon and Everly's classic 1985

-According to Millon, temperament, an innate biological stratum, can be seen in babies from the time of birth, and possibly before birth -These traits persist over extended periods of time, and do not extinguish over time. -The combination of child's temperament and parental behavior help to shape the child's personality--or personality disorder -Temperament is reinforced or punished

treatment of personality disorders

-Dialectical Behavioral Therapy -Cognitive Behavioral Therapy -Acceptance and Commitment Therapy -the goal is not to reverse a constitutional defect but to help the person live more comfortably and efficiently within his or her limitations

psychotropic medication guidelines for pregnancy and lactation: antidepressants

-SSRIs and most TCAs not associated with teratogenesis, SSRIs some risks of birth defects include paroxetine and possibly fluoxetine MAOIs, escitalopram, duloxetine, vilazodone, atomoxetine, vortioxetine, levomilnacipran, venlafaxine, desvenlafaxine, and mirtazapine, not tested on humans lack of adverse effects noted in animal studies with bupropion present in breast milk effects on neonate exposed to TCAs and SNRIs can include CNS depression and urinary retention inconclusive data on miscarriage rate effect on neonate exposed to SRRIs and SNRIs can include CNS depression or serotonin syndrome. there are reports of severe effects on neonates exposed to SSRIs or SNRIs during the third trimester requiring hospitalization and respiratory support

Differential diagnosis for borderline personality disorder

-schizoid-detached, obsessional, paranoid, narcissistic, and dependent-histrionic -history of ego impairment dating back to adolescence or early adulthood - "stable instability"

etiology of borderline personality disorder

-up to 25% of clients present with BPD in clinics -the lifetime mortality rate by suicide may be as high as 10% -2/3rds of bpd experience a significant reduction in emotional instability and impulsivity after age forty0-five. thus appropriate crisis management and supportive medication treatment can play an important role in sustaining functioning and survival until patients reach their fourth decade -psychological factors: especially traumatic events and serious developmental failures n the early family of origin -biological theories: 1. inborn or constitutional factors in the CNS may leave certain children with defects in their ability to psychologically "metabolize" early interpersonal experiences adequately (some may not acquire adequate emotional nurturance and sustenance from otherwise good parents) 2. inborn or constitutional factors may lead to the development of a difficult temperamental style, such as an irritable, restless infant. children evoke ongoing negative reactions. the secondary parental-child friction likely contributes to ongoing problems with psychological growth 3. early, severely traumatic experiences (especially neglect) may later brain development, resulting in chronic neurotransmitter abnormalities and structural changes in the nervous system. lead to marked affect-regulation problems personality disorder i probably multifactorial

three general characteristics between individuals with personality disorders and individuals without

1. adaptive inflexibility -

medication use and risks in geriatric patients

30% of all prescription drugs are taken by people over 65 70% of older adults self-medicate with over the counter products without physician or pharmacist consultation 50%of accidental drug-related deaths occur in the geriatric patients adverse drug reactions occur at double the rate in geriatric patients than in other groups common adverse drug-related effects are hip fractures, cognitive impairment, and neuroleptic-induced parkinsonism

anxiety

5-18% of children often markedly interfere with academic performance, the development of peer relationships, the acquisition of social skills, and interpersonal competency early onset can indicate life long psychiatric disorders, and they are often comorbid with other psychiatric illnesses (especially common with bipolar disorder and ADHD) typically cause is situational > best treated by psychotherapeutic interventions

ADHD

5-7% of children symptoms: impulsivity, impaired attention, and lack of intrinsic motivation, short attention span, hyperactivity, endure at least 6 months, typically seen before or during early elementary school. lack of persistence in activities that require cognitive involvement, bouncing from one activity to the next without completion of any task, and poorly organized behavior, physically overactive, distracted, inattentive, impulsive, and hard to manage. they don't wait their turn; answers precede questions, zooms into a room and everyone notices. the constantly tapping foot is not driven by anxiety but rather by overactivity itself. demonstrate social immaturity, impairments in motor, math, or reading skills subtle impairments: coping age-appropriate figures; executing rapid alternating movements; making left-right discrimination; and showing reflex asymmetries, ambidexterity, and numerous soft neurological signs aka: minimal brain dysfunction, hyperactive syndrome, and minor cerebral dysfunction 1/3rd outgrow the disorder by early adulthood (due to maturation of the prefrontal lobes) sources of data: family history, careful history detailing the nature of and onset of behavioral symptoms, and a description of current symptoms diagnosis of exclusion common presentation of early onset is restlessness, unstable sleep patterns, affective lability (crying a lot and difficulty in being soother) neurobiology: impaired frontal lobe functioning, smaller cerebellar volumes, smaller volumes of frontal and temporal areas and a smaller caudate nucleus, and abnormalities in the dopamine neurotransmitter system in people with ADHD, reduction in frontal, temporal, cerebellar, and white-matter

symptomatic improvement of OCD symptoms in medication responders with treatment with SSRIs

6-10 wks = 25-30% symptom reduction 18-24 wks = 40-50% 52 wks = >50%

Special Populations: Elderly

65 & older 20% of population establish diagnosis and target symptoms: (first-gen antipsychotics and possible benzo, to control agitation and anxiety), alternative could be buspirone (BuSpar) obtain complete medication history: examples = depression secondary to cardiovascular drugs or delirium and confusion secondary to CNS meds, additive drug effects are common in the elderly, prone to anticholinergic delirium understand age-specific pharmacology: some benzos (diazepam (valium), chlordiazepoxide (Librium), and flurazepam (Dalmane)) > benzos that are thought to be safer are oxazepam (serax), lorazepam (Ativan), and temazepam (Restoril), benzos can cause over sedation in elderly, be aware of normal decrease in kidney function, CNS changes with aging (decreased cerebral blood flow, decreased cholinergic function, increased monoamine oxidase activity, and some brain atrophy) adjust dosage: begin with small doses, may be 30-50% lower than in younger patients, may demonstrate increased receptor or organ sensitivity to medications, also age associated decrease in albumin, resulting in more free (active) drug available use therapeutic monitoring: use labs to monitor capabilities recognize and respond to side effects promptly: more pronounced, sedation, anticholinergic reactions, extrapyramidal symptoms, delirium, postural hypotension, cardiotoxicity, and cognitive impairments and consitpation

diagnostic issues with bipolar in children

70% of cases of early onset bipolar illness first become manifest in major depressive episodes; 30% begin with mania/hypomania

obesity

BMI of 30 or higher treatment: phentermine (Fastin, Ionamin), sibutramine (Meridia) - a serotonin and norepinephrine reuptake inhibitor, Orlistat

diagnostic issues with depression in children

DSM-IV-TR criteria for diagnosing major depression failed to accurately diagnose 76% of young children for diagnostic precision: -depressed or irritable mood for more days than not -plus four of the following (vs five for adults) anhedonia significant weight loss/gain insomnia/hypersomnia more days than not psychomotor agitation or retardation fatigue more days than not feelings of worthlessness or excessive guilt impaired concentration recurrent thoughts of death/suicide

diagnostic signs and symptoms of major depression in children

MOST COMMON: irritability anhedonia play themes of death suicide, or self-destruction social withdrawal low self-esteem vegetative symptoms (sleep disturbance) COMMON: school failure sadness loneliness low energy ASSOCIATED SIGNS AND SYMPTOMS: vague, nonspecific physical complaints being bored reckless behavior; acting out substance abuse/use running away from home extreme sensitivity to rejection or failure difficulty with relationships

treatment of ADHD

STIMULANTS: inhibition of dopamine reuptake, immediate-release (methylphenidate, dextroamphetamine, and amphetamines), extended-release (methylphenidate, dextroamphetamine, amphetamine, and lisdexamphetamine), 70% response rate, low risk of abuse in ADHD patients, must take each day since it effects all aspects of life, not just academics, start with immediate-release, then move to extended, antidepressant can help with afternoons due to morning meds wearing off at this point, meds could be used into adolescence and even adulthood. side effects: initial insomnia (remedy: take earlier in day or clonidine/trazodone at bedtime, anorexia, stomachache (give with food), mild dysphoria (switch classes of stimulants or add antidepressant), lethargy, failure to accurately diagnose and treat CERTAIN ANTIDEPRESSANTS: 20% of ADHD children experience co-occurring depression, the antidepressant must increase the availability of dopamine or norepinephrine (SSRIs not affective in treating ADHD symptoms), bupropion (Wellbutrin SR/LA - 150 to 300 mg) or atomoxetine (Strattera - 1.2 to 1.8 mg/kg), treatment outcomes not as robust as with stimulants, one-a-day dosing, no need for triplicate prescription, no addiction potential, clinical effects typically last 24 hrs a day, effects generally seen within five to forty days after initiating treatment, can treat comorbid depression ALPHA-2 ADRENERGIC AGONISTS: clonidine (catapres, kapvay - .15 to .4mg 3-4xdaily) and guanfacine (tenex, intuniv - .25 to 1 mg 2-3xdaily or .05 to .12 mg per kg 1xdaily), most effective at reducing irritability, aggression, and impulsivity, helps with comorbid tics, common to take alph-2 with stimulant, not antidepressant

restless legs syndrome

a sensation of restlessness of the legs most with RLS also have periodic limb movements in sleep results in fatigue pramipexole (Mirapex) @ 0.125-2 mg ropinirole (Requip) @ 0.25-4 mg other meds sometimes used include tranquilizers (clonazepam), opiates, or anticonvulsants (gabapentin) some antidepressants and caffeine can worsen

the following may account for increased suicidality seen in some individuals treated with antidepressants:

activation and increased restlessness may add to general sense of emotional discomfort antidepressants can provoke dysphoric mania in some youngster who, in fact, have bipolar disorder (this may be one of the more common reasons for treatment-emergent suicidality) increased energy may occur before a decrease in dysphoric mood (the person then has the energy to carry out a suicide attempt)

stimulant use on the neuronal level

acute intoxication: increased catecholamines (DA and NE) many receptors occupied increased NE or DA release reuptake down acute intoxication treatment: block effects of DA and NE beta blockers clonidine benzo antipsychotics acute withdrawal: few receptors occupied decreased NE or DA reuptake down synthesis down acute withdrawal treatment: bupropion chronic use: hypersensitivity, but decreased occupancy decreased NE or DA reuptake down synthesis down maintenance treatment: Antabuse Acamprosate topiramate modafanil

Opiate Treatment

acute intoxication: Naloxone (injectable), naltrexone (oral) acute withdrawal: opiates, especially methadone and buprenorphine, clonidine, benzo abstinence maintenance: methadone, naltrexone or buprenorphine, LAAM (L-alpha-acetylmethadol) methadone (long half-life, offered in federally approved treatment, and less of a high) vs opiate antagonist (naloxone, naltrexone, or buprenorphine - opiate will be blocked if used)

contributing factors to adverse drug reactions in the edlerly

adverse drug reactions are proportional to the number of medications taken elderly patients often have multiple prescribers without consolidated records age-related factors increase the likelihood oaf adverse effects, such as the following: -impaired organ function, especially decreased liver metabolism, leading to increased medication levels and effects -multiple disease states -exaggerated therapeutic response to medications -increased sensitivity to side effects noncompliance in the elderly is common (usually underdosing) due to: -complicated directions -hearing and visual impairment -cognitive and memory deficits -child-resistant packaging -cost

bipolar disorder

age of onset - 18 years of age early onset bipolar is controversial, other countries have a rare childhood onset of bipolar childhood-onset bipolar may be more severe version of the disorder

medication treatment of target symptoms associated with autism spectrum disorder

aggression = second- gen antipsychotics self-injurious behaviors = second-gen antipsychotics hyperactivity = alpha-2 agonists; stimulants repetitive behaviors, rituals, compulsions = SSRIs, clomipramine pro-social behavior = oxytocin, baclofen, or arbaclofen

etiology of substance abuse

alcoholism affects 5 to 10% of the adult population alcoholism plays a major role in the following causes of death: accidental, homicide, suicide, and alcoholic cirrhosis one million Americans are reported to be addicted to cocaine, and over five million use cocaine regularly billions of dollars are spent annually on the treatment and prosecution of drug users 30-50% of those in mental health treatment have a significant substance-abuse disorder

stimulants

amphetamines CNS stimulants that act on the dopaminergic system dopamine-medicated endogenous reward system in the limbic system is activated by amphetamines and cocaine amphetamines produce increased release of dopamine and norepinephrine and decreased reuptake half-life of dextroamphetamine is about ten hours

eating disorders

anorexia DSM-5 criteria: 1. excessively low body weight due to restriction of food intake; weight less than minimally normal 2. fear of gaining weight 3. distorted perception of one's weight (thinking oneself fat when actually very thin) bulimia DSM-5 criteria: 1. both the binge eating and compensatory behaviors occur, on average, at least once a week for three months 2. self-esteem is overly influenced by weight 3. disturbance does not occur only during periods of anorexia nervosa binge-eating disorder: not a separate disorder, falls under eating disorder not otherwise specified, treated with diet, exercise, and sometimes antidepressants (SSRIs or bupropion), sibutramine (diet pill), or anticonvulsants (topiramate and zonisamide) anorexia usually requires a multimodal, if not a multidisciplinary, treatment approach one theory holds that anorexics get addicted to starving, which releases endorphins - naltrexone can help according to this theory

medications for treating eating disorders

anorexia: naltrexone, antidepressants, antipsychotics, cyproheptadine, lithium bulimia: antidepressants (SSRIs, TCAs, or MAOIs), naltrexone, ondansetron, topiramate

residual ADHD

appears in childhood, can persist into adulthood (residual) can have undiagnosed and present with depressive symptoms or problems with work or relationships report irritability, impulsivity, traffic accidents, forgetfulness, poor time management, and difficulty finishing tasks

pharmacogenomics

applies knowledge of pharmacogenetics to broader goals, such as customizing drug therapy, enhancing patient safety and guiding new drug development

differential diagnosis for schizoid personality disorder

avoidant personality disorder = avoidants want friends, SDPD does not

Cluster C

avoidant, dependent, and obsessive-compulsive personality disorders characterized by a highly anxious and fearful interpersonal style (internalizing)

disorders with evidence of progressive neurobiological impairment

bipolar illness ADHD schizophrenia some cases of recurrent, unipolar depression some cases of post-traumatic stress disorder

medications/drugs that adversely affect sleep

caffeine decongestants (pseudoephedrine, often found in cold meds) alcohol tranquilizers (Xanax, Ativan, valium) sleeping pills steroids bronchodilators (used to treat asthma) alcohol, tranquilizers, and sleep pills - they help people fall asleep, but once the drug wears off then it can disrupt the sleep

insomnia disorder

can be noted as comorbid disorder (when severe that warrants independent clinical attention) or insomnia disorder by itself comorbid conditions likely to contribute to insomnia: situational stress and worry, anxiety, depression and other emotional disorders, medications, drugs, and alcohol, medical illness

psychotropic medication guidelines for pregnancy and lactation: anticonvulsants

carbamazepine is a probable teratogen (neural tube defects) valproic acid is an established teratogen (neural tube defects lamotrigine is associated with neural tube defects carbamazepine and valproic acid both found in breast milk

schizoid personality disorder (SDPD)

central features: 1. minimal or no social relations 2. restricted expression of emotion 3. a striking lack of warmth and tenderness 4. an apparent indifference to others' praise, criticism, feelings, and concerns they do not exhibit eccentricities of speech, behavior, or thinking, often in a fog, absentminded, loners, detached from others, self-involved, not connected, few become psychotic

medical conditions that commonly cause insomnia

chronic pain conditions congestive heart failure respiratory disease, including chronic lung disease acid reflux (GERD) hot flashes associated with perimenopause or menopause hyperthyroidism

cluster A

consists of paranoid, schizoid, and schizotypal characterized by an odd or eccentric interpersonal style

self-mutilation

deliberate self-injury without the intent to die those with organic disorders (including intellectual disability), psychotic disorders, and personality disorders endorphins (endogenous opiates) are released by painful stimulation. opiate antagonists (naltrexone) have been helpful in reducing self-injurious behavior has been linked to dopamine (reducing), serotonin, opiate meds for treatment: MAOIs, SSRIs, carbamazepine, lithium, antipsychotics, and benzos

different patterns of sleep distrubance

difficulty falling asleep (initial insomnia) restless sleep: tossing and truing all night, with frequent awakenings early morning awakening: waking several hours before morning, such as 3 to 4 am and having difficulty falling back to sleep hypersomnia: sleeping excessively

differential diagnosis of childhood onset psychiatric disorders presenting with hyperactivity and inattention

diffuse brain damage (seen in fetal alcohol syndrome or traumatic brain injury) anxiety disorders (separation anxiety) agitated depression situational stress bipolar mania prepsychotic conditions impaired affect regulation associated with severe early abuse or neglect boredom (especially likely in bright children who are academically understimulated)

psychotic disorders in children

early-onset schizophrenia is rare psychotic symptoms in children and younger adolescents are much more likely to be associated with mood disorders meds should include antidepressants and/or mood stabilizers, but with younger patients the treatment should be with second-gen antipsychotics (olanzapine, aripiprazole, risperidone, quetiapine, and others), weight gain and extrapyramidal side effects (like dyskinesia) are more common in children so far best results are with risperidone and olanzapine, possibly clozaril in treating treatment-refractory cases (but does require blood level checks, so less tolerable for children)

paranoid personality disorder

essential features: 1. pervasive and unwarranted suspiciousness and mistrust of people 2. hypersensitivity 3. emotional detachment unpleasant, always blaming and suspicious of others, person doesn't abandon suspiciousness even with evidence supports it, instead they view the evidence as more reason to support theory, person is hostile, devious, and dark, sit with back against the wall people keep their distance > which validates PPD feelings of general distrust ppl with ppd are pathologically jealous, tense, rigid, unwilling to compromise, moralistic, always detecting ill intent and special messages, litigious, humorless, coldly objective, overly rational, haughty, and distant. they think in hierarchical terms, drawn to politics, history, science, and tech they seldom come for psychiatric treatment since they do not perceive weaknesses or faults in themselves

psychotropic medication guidelines for pregnancy and lactation: lithium

established teratogen. first-trimester exposure strongly associated with fetal cardiac anomaly for fetal lithium exposure in the first trimester, consider cardiac ultrasound to detect presence or absence of malformation if lithium is necessary after first trimester, dosage adjustments are necessary due to pregnancy-induced kidney function changes frequent lab monitoring is required reductions in lithium dose are required several weeks prior to delivery neonatal effects include impaired respiration, EKG and heart rate abnormalities, and renal impairment carbamazepine, clonazepam, and first-generation antipsychotics are possible alternatives to lithium significant concentrations in breast milk. can cause decreased muscle tone, cyanosis, lethargy in infant. nursing contraindicated

alcohol

ethanol water-soluble, rapidly absorbed and readily crossed the blood-brain barrier CNS depressant, metabolized by liver most studied of the substances associated with: dependence, abuse, withdrawal, intoxication, delirium, dementia, amnesia, delusions, hallucinations, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder there is much evidence that alcoholism is familial, but the exact biological mechanism remains unclear possible lower prolactin levels alcoholics more likely to show Taq 1 A1 restriction, fragment-length polymorphism of the D2 dopamine receptor gene, a genetic abnormality (and dopamine controls prolactin release) annual per capita alcohol consumption in 2010 in the US was estimated at 2.29 gallons of pure ethanol. today, alcoholism, along with nicotine dependence is America's most serious substance abuse problem illness of the normal people the typical person with alcoholism is in his/her mid-30s and has a good job, home and family; less than 5% of this population lives on skid row part of the clinician's job is to teach patients how the diagnosis is made so that they can make it for themselves

Hallucinogens

ex: LSD (lysergic acid diethylamide), mescaline, psilocybin, and PCP carious substances can produce transient psychotic states, often accompanied by visual, auditory, or olfactory hallucinations not associated with dependence or withdrawal, needs to run its course (about twelve to twenty-four hours) might need antianxiety or antipsychotic meds to treat, used to decrease agitation and stabilize blood pressure can produce a florid psychosis during acute intoxication can lead to flashbacks or even convulsions (PCP)

Pharmacogenomics

examines variation in drug response attributable to genetic factors since 2003, Human Genome Project genetic factors dynamics and kinetics of drugs in the body mediated patterns of protein structures, receptor sensitivities, and enzyme activity

social impairment

failure to fulfill major role obligations at work, home, or school continued use despite interpersonal problems related to use important social or recreational activities given up because of use

sleep deprivation leads to

fatigue reduced ability to think clearly, maintain attention, and retrieve information from memory reduced emotional control, which leads to increased irritability and reactivity paradoxically, it sometimes leads to increased insomnia

treatments for adolescents with depression study (TADS)

federally funded program, large scale addressed many of the methodological issues raised in other studies sample was 432 adolescents (12-17) four groups: placebo - 35% CBT - 43% fluoxetine (Prozac) - 61% CBT and fluoxetine - 71%

pharmacogenetics: clinical and practical implications

few real-world applications for pharmacogenetics mainly for labels on scripts, but no real guidelines or consensus decisions

pharmacogenetics: drug metabolism

first identified in 1950s poor metabolizers may be at risk for exaggerated or unexpected side effects at normal dosages extensive metabolizers may experience a less-than-expected response to standard dosages of given medication and at risk for buildup of intermediate toxic metabolites 50 cytochrome P450 (CYP) genes most widely studied genetic variations are linked to the specific enzymes CYP2D6, CYP2C19, & CYP2C9, all of which have significant drug metabolizing activity CYP2D6 metabolizes antidepressants and antipsychotics poor CYP2D6 metabolizers = 7% Swedish, 1% Chinese poor CYP2C19 metabolizers = 3% Swedes and Caucasian Americans & 15-18% Asians a genetic variation can result in multiple copies of the CYP2D6 gene, producing ultra-rapid metabolism of antidepressants

differential diagnosis between depression and bipolar in children

following history and clinical features indicate higher risk of bipolar: atypical depressive symptoms (hypersomnia, severe fatigue, increased appetite, and weight gain) seasonal (winter) depression history of separation anxiety disorder history of ADHD or ADHD-like symptoms positive family history of bipolar disorder history of hypomania -since antidepressants may provoke switching or cycle acceleration, they should be avoided as a monotherapy -mood stabilizers that have some antidepressant actions should be used first (lithium, quetiapine, lamotrigine (with adolescents), or olanzapine-fluoxetine combination -combinations of mood stabilizers (lithium and divalproex)

psychopharmacology of bipolar disorder

for severe agitation = benzos or second-gen antipsychotics (may begin to work within several hours) lithium and anticonvulsants mood stabilizers often take seven to fourteen days to begin reducing symptoms no one mood stabilizer is superior - treatment should consider side-effect profile second-gen antipsychotics (olanzapine) may also be added to mood stabilizer gabapentin is an ineffective monotherapy for mania, is useful add-on drug, especially in reducing anxiety second gen (atypical) antipsychotics have been shown to be superior to mood stabilizers in pediatric mania metabolic syndrome - weight gain, type II diabetes mellitus, and hyperlipidemia the antipsychotic quetiapine is FDA approved for treating both mania and bipolar depression in adults and has recently been shown to have efficacy in the treatment of childhood-onset bipolar disorder

psychotropic medication guidelines for pregnancy and lactation: antipsychotics

high-potency agents may be preferred over low-potency agents establish lowest effective dose possible potential short-term abnormal neonatal motor activity possible alternative to lithium in mania present in breast milk

cluster B

histrionic, narcissistic, antisocial, and borderline characterized by dramatic or emotionally reactive interpersonal style (externalizing)

mental health provider: PPD

important that clinicians be honest and comprehensive, be thoroughly informed and their consent obtained, with extensive documentation therapist's main job is to minimize the patient's distrust of the therapist and of the therapy clinicians should b respectful and business-like, avoiding intimacy and too much warmth clinicians should not sit between the patient and the door when clinicians err, they should admit the mistake, apologize, and get on with it; over apologizing fosters distrust being straightforward and professional is the most reassuring approach. when starting medications, these patients should be given detailed and accurate side-effect information

lithium

increased thirst, urination, and bedwetting weight gain aggravation of acne tremor cognitive impairment sedation frequent blood tests are required, which may be very hard for young children to tolerate

pharmacological criteria

increased use due to tolerance withdrawal symptoms upon discontinuation

differential diagnosis for anxiety in children

inhibited temperament: 10-15% of children, can lead to timidity and anxiety in novel situations, behavioral inhibition, persistent vigilance, heightened autonomic arousal, and a clinically significant anxiety disorder later in life for approximately one-third OCD: lifetime prevalence rate is 2.5% with 25% having first episodes prior to age 14 separation anxiety disorder: prevalence of 4% and 1.6% of young adolescents, can present as school avoidance and somatic complaints social phobia/social anxiety disorder: prevalence of 7% most cases beginning in mid-adolescence, social withdrawal, less developed social skills, loneliness, low self-esteem, depression, and substance use/abuse GAD: prevalence of 5%, rare prior to adolescence, 50% of those who go on to develop GAD were anxious and worried children PTSD: prevalence not well established for children and young teenagers, along with PTSD symptoms, children must have -generalized nightmares of monsters or of being threatened -tendency to represent the trauma in repetitive play -stomachaches and headaches specific phobias: most are not severe and are time limited. those with diagnosis, 70% have comorbid psychiatric disorder panic disorder: very rare in children, may first b seen in older adolescents, if isolated panic attacks seen in children or younger adolescents > consider significant psychological stressors

alcohol-related disorders and medications for treating them

intoxication: thiamine, folate, multivitamins withdrawal: benzo abstinence maintenance: Antabuse, naltrexone, topiramate Acamprosate, lithium, SSRIs delirium: benzo dementia: --- amnesia: thiamine delusional disorder: benzo, antipsychotics hallucinosis: benzo, antipsychotics mood disorder: antidepressants anxiety disorder: benzo, buspirone

symptomatic similarities: ADHD and childhood-onset mania

irritability inattention hyperactivity impulsivity high level of energy pressured speech chronic and nonepisodic symptoms common to bipolar but very rare with ADHD: -decreased need for sleep without daytime fatigue -intense, prolonged rage attacks (lasting two to four hours) -hypersexuality -flight of ideas -morbid nightmares -psychotic symptoms family history of clear-cut bipolar disorder or one or more of the following in blood relatives: -suicide -severe alcohol/drug abuse -multiple marriages -starting numerous businesses -hyperthymia (a form of chronic hypomania characterized by high every and productivity, gregariousness, impulsive behavior, and decreased need for sleep) comorbid ADHD and bipolar: -initiate treatment with mood stabilizers -once stability has been achieved, stimulants may be gradually added

aggression

irritability, hostility, or violent behavior, is usually a symptom of a psychiatric or neurological disorder ADHD, anger attacks, antisocial personality disorder, borderline personality disorder, conduct disorder, delirium, dementias, depression, explosive disorder, intellectual disability, mania, medication-induced aggression, paranoid disorder, postcoterm-45ncussion syndrome, schizophrenia, substance-use disorder, temporal lobe epilepsy anticonvulsants (carbamazepine) > labile mood, poor impulse control, organicity antipsychotics > disorganized behavior beta blockers (propranolol) > organicity (dementia) buspirone > organicity clonidine > anxiety, agitation lithium > labile mood, impulsivity SSRIs > anger "attacks"

treatment of schizoid personality disorder

little is known about the treatment most persons with this condition probably do not seek professional help or do so only when seeking help for depression, substance abuse, or other problems long-term group psychotherapy with other patients who have SDPD has also been reported to be successful

issues in diagnosing and initiating pharmacologic treatment of children and adolescents

medication metabolism in young clients: during a period of time (2-4 months) surrounding the entry into puberty, the rate of hepatic metabolism significantly slows drug research and outcome studies: some studies do not include severely ill children, other than ADHD there are not many studies fears regarding drug addiction

etiology of paranoid personality disorder

more common in men 2% of general population, 20% among those in inpatient psychiatric settings, and 5% among those in outpatient psychiatric clinics they seldom come for psychiatric treatment since they do not perceive weaknesses or faults in themselves

Tourette syndrome

motor (normally head and neck) and vocal tics coprolalia (sudden yelling of obscenities) - only seen in 25-30% of cases neurological disorder, although symptoms may be exacerbated by anxiety or tension involves dysfunction of dopaminergic pathways and is treated with dopamine D2 blockers - haloperidol or pimozide has higher incidences of OCD, ADHD, and other learning disabilities (Tourette's involves multiple areas of the brain) theories regarding the etiology of Tourette's includes genetic and autoimmune mechanisms related to strep infection

differential diagnosis for personality disorders

neurosis (nonpsychotic mood and anxiety disorders) vs. personality disorder = patients who develop a nonpsychotic mood or anxiety disorder regard their anxious behaviors as uncharacteristic of their usual self, as different for them personality trait vs. disorder = diagnosing a personality disorder depends the most on whether there is evidence for the enduring and stable maladaptive traits that impair functioning major mood disorders and schizophrenia vs personality disorders = impaired functioning is seldom as profound in personality disorders late-onset mental disorder = late-onset personality changes

angry-impulsive BPD

neurotransmitter: 5-HT Location: prefrontal cortex and orbital frontal cortex characterized by their pervasively hostile-aggressive way of interacting with others. they have a very low frustration tolerance and can be quite volatile interpersonal relations are replete either with ongoing intense friction or multiple rejections

schizotypal BPD

neurotransmitter: DA Location: Mesolimbic, frontal cortex, and reticular formation chronically display odd thinking - ideas of reference, magical thinking, vagueness, very idiosyncratic beliefs - and periodically experience marked episodes of depersonalization or derealization and transient psychoses truer sort of borderline schizophrenia

hysteroid-dysphoric BPD

neurotransmitter: NE Location: Locus Coeruleus these borderline clients present with a significant degree of emotional liability and are exquisitely sensitive to interpersonal rejection, loss, and abandonment cannot tolerate being alone and may engage in desperate attempts to maintain attachments, including clinging behavior and manipulative suicidal threats or gestures great risk for recurring depression

autism spectrum disorders (autism and Asperger's syndrome)

no current medications for treatment - hormone oxytocin has been shown to be effective in treating autistic spectrum disorders in experimental subjects fenfluramine, secretin, naltrexone, vitamin B6, and corticosteroids can help treat certain associated target symptoms = but have not been found to be effective in cross-validation studies

treatment of BPD

no medication treatment can directly treat personality disorders per se. psychotropic medications are used to ameliorate certain target symptoms cautions to note: 1. treatment with benzos is risky, at risk for abuse. chronic use can contribute to emotional dyscontrol and increased suicidality 2. some at risk for transient psychosis, the antidepressant bupropion (dopamine agonist) should be used with caution, may precipitate psychosis in pre-psychotic individuals 3. need low degree of toxicity when taken in overdoes due to suicide risk: SSRIs, trazodone, SNRIs, and bupropion.

signs and symptoms of early-onset bipolar mania

nonepisodic (more continuous) mixed mania is most typical with marked dysphoria and irritability intense rage episodes severe oppositional behavior ultra rapid cycling (extreme emotional lability)

ego-dystonic

not their normal functioning or generally speaking "not like them." Their urgency can mask the more chronic problems of the personality disorder.

differential diagnosis for paranoid personality disorder

ppd has overvalued ideas, not delusions paranoid personalities are not psychotic

pharmacotherapy in special populations

pregnancy geriatric patients

etiology of schizoid personality disorder

prevalence is unknown these individuals may be common on Skid Row

pharmacogenetics: membrane transporters

proteins that transport ions and neurotransmitters across cell membranes dopamine = related to major depression, bipolar disorder, and ADHD serotonin = related to anxiety and depressive disorders

risky use

recurrent use in situations where hazardous persistent use despite related physical or psychological problem

Borderline personality disorder

referred to as a wastebasket diagnosis - a depository for those clients who are severely impaired, hard to diagnose, or especially difficult to treat LOUD FORM OF PSYCHOPATHOLOGY, THEY SUFFER A LOT AND CAUSE GREAT SUFFING IN OTHERS core symptoms: generalized ego impairment, chronic emotional instability, chaotic interpersonal relations, feelings of emptiness, impaired sense of self, low frustration tolerance, impulsivity, privative defenses (like splitting and acting out), and irritability and anger-control problems

sleeping medications

referred to as hypnotics considerations: treat the primary condition, most sleep meds can reduce the amount of deep sleep one gets which could result in day time fatigue, can cause sedation, especially in the morning, can cause amnesia, habit-forming HYPNOTICS: flurazepam (Dalmane) @ 15-60 mg temazepam (Restoril) @ 15-30 mg triazolam (Halcion) @ .25-.5 mg etizolam (Prosom) @ 1-2 mg quazepam (Doral) @ 7.5-15 mg zolpidem (Ambien, Ambien CR) @5-12-5 mg and/or (Intermezzo) @ 1.75 mg zaleplon (Sonata) @ 5-10 mg eszopiclone (Lunesta) @ 1-3 mg ramelteon (Rozerem) @ 4-16 mg survorexant (Belsomra) @ 10-20 mg OTHER: diphenhydramine (Benadryl) @ 25-100 mg melatonin (Melatonin) @ .5 mg trazodone (Desyrel) @ 25-100 mg doxepin (Silenor) @ 3-6 mg

Special Populations: Pregnancy

risk factors associated with medications during pregnancy: -teratogenesis (malformation of fetus or fetal organs) -drug effects on the growing and developing fetus -drug effects on labor and delivery -residual drug effects on the newborn (neonatal) -behavioral teratogenesis (long-term effects on the child resulting from drug exposure in utero) -pregnancy-induced changes in drug actions -drug effects on the breast-fed infant

treatment of OCD

serotonin reuptake inhibitors are standard first-line treatment (sertraline, fluvoxamine, and clomipramine) response to medication is gradual and improvement may be expected to continue during the first twelve months, generally plateaus at twelve months treatment-resistant cases sometimes respond to SSRIs augmented with low doses of clomipramine (10-50 mg a day), lithium, or second-gen antipsychotics (risperidone)

psychotropic medication guidelines for pregnancy and lactation: Benzodiazepines

some benzo have established role in fetal abnormalities avoid use in the first trimester. may need to taper dose switch to clonazepam if benzo absolutely indicated switch to tricyclic antidepressant for panic disorder if continued medication is required neonatal CNS depression, drug accumulation, and withdrawal symptoms possible excreted in breast milk. produces drowsiness, failure to thrive in infant

opiates

specific opiate receptors and endogenous opioids (enkephalins and endorphins) examples: morphine, heroin, propoxyphene (Darvon), methadone, meperidine (Demerol), pentazocine (Talwin), hydromorphone (Dilaudid), oxycodone (Percodan, OxyContin), and hydrocodone (Vicodin, damason-p) and codeine opiate antagonist - naloxone and naltrexone opiate withdrawal: anxiety, agitation, sweating, gastrointestinal upset, tremulousness, and running nose

sleep hygiene

steps that one can take to prepare the body and mind for sleep, improves quality of sleep things to avoid before bed: -bright light -intense exercise (regular exercise during day helps improve sleep) -loud music and emotionally charged entertainment -intense discussions or arguments things that help sleep hygiene: -meditating or practicing progressive relaxation -watching a peaceful/boring TV show or reading (no news) -taking a warm bath -eating carbohydrate-rich foods (fruits, veggies, no sweets) or tryptophan-rich foods (milk) -listening to peaceful music -sleeping cool - 68

differential diagnosis for substance-related disorders

substance-use disorders and substance-induced disorders (intoxication, withdrawal, and other substance/medication-induced disorders)

impaired control

taking more than intended or for longer than intended multiple unsuccessful attempts to cut down use spending lots of time obtaining substance craving

normal sleep

the degree of restfulness derived from sleep seems to depend on the amount of time spent in dep sleep, stages 2 and 3 of NREM "normal" to wake one or two times per night - normally when we come out of REM sleep and start a new sleep cycle as we age, our sleep efficiency decreases

sleep apnea

transient periods of the cessation of breathing or apnea, during sleep only a few seconds, but can partially wake patient - disturbing sleep main symptom is day time sleepiness, associated with loud snoring or awakening gasping for breath caused by the collapse of the muscles of the throat during seep (obstructive type) or by the failure of the respiratory center in the brain to instruct the lungs to breathe during sleep (central type) treated with CPAP machine or surgery for obstructive, no real treatment for central type

psychopharmacology of depression

tricyclic antidepressants shown improvement when used in treatment, but significant side effects (very toxic, six children died of overdose) SSRIs: much better tolerated than tricyclics, significantly more effective than either placebos or tricyclics findings from studies: 1. the time to onset of positive mediation effects may be longer for children than for adults 2. a syndrome of apathy/amotivation or emotional disinhibition, sometimes seen in adults on chronic SSRI treatment, is more commonly encountered in children liver enzyme 2D6 is responsible for metabolizing a number of antidepressant drugs

depression

unipolar (35%) or bipolar (48%) > can have 2-4 depressive episodes before first manic episode

mood-stabilizing anticonvulsants

weight gain (especially in carbamazepine and divalproex) menstrual irregularities polycystic ovaries (with divalproex) tremor sedation