NR 546 Midterm Exam 2023/2024 Questions AND Answers Update A+

NR 546 Midterm Exam 2023/2024 Questions AND Answers Update A+ What should the PMHNP consider when prescribing chemical restraints? - Answer-- allergy status -prior med hx for adverse drug reactions r/t the meds ordered in the chemical restraint -state regulations regarding chemical restrains must be reviewed Are the PMHNP and other staff liable if the client has an allergic reaction or adverse side effects to the drugs used for chemical restraint? - Answer-No. The client has been court-ordered to take the prescribed medications and the standing order for chemical restraints is approved. The PMHNP and other staff are not liable if the patient has an allergic reaction or adverse side effects. How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients? - Answer--Genetic testing can assist by providing more information on how clients may respond to certain psychotropic medications -provides information on how a client may break down and metabolize medications based on the cytochrome P450 system. Tanrıkulu and Erbaş (2020) investigated identical twins to determine the presence of an inherited link for schizophrenia and why one twin may develop schizophrenia when the other does not. When two people have 100% identical DNA, why don't both persons develop the exact illnesses? Studies of identical Danish twins found that if one twin had schizophrenia, the other twin had a 50% lifetime risk of developing schizophrenia (Lemvigh et al., 2020). Why is there only half the risk? - Answer-Both environmental and psychosocial stressors can impact mental health. Although twins may have identical genes, their gene expression may be different. There may be an environmental exposure that turned a gene "on" that should have been "off" for one twin to develop schizophrenia and not the other. central sulcus - Answer-separates the frontal lobe from the parietal lobe frontal lobe - Answer-associated with movement, intelligence, abstract thinking broca's area - Answer-speech production temporal lobe - Answer-involves object identification and auditory signals cerebellum - Answer-coordination wernicke's area - Answer-speech comprehension occipital lobe - Answer-primary visual area parietal lobe - Answer-keeps us alert to what is going on around us sensory cortex - Answer-pain, heat, and other sensations motor cortex - Answer-movement hippocampus - Answer-involved in both memory and anxiety nucleus accumbens - Answer-involved in the reward process thalamus - Answer-involved in sensory organ and motor command processing striatum - Answer-involved in complex motor actions, also links cognition to motor actions limbic system - Answer-includes circuits that are associated with pleasure and reward basal ganglia - Answer-group of structures involved in voluntary motor movements amygdala - Answer-involved in emotional regulation and perception of odors corpus callosum - Answer-controls the communication between the two brain hemispheres white matter - Answer-contains nerve fibers that connect neurons from different regions into functional circuits grey matter - Answer-contains nerve cells and dendrites brain tissue - Answer-made up of grey matter and white matter dorsal striatum - Answer-involved in complex motor actions and linkage of cognition to motor actions -main input area for basal ganglia *activated when anticipating or engaging in pleasure The field of epigenetics is rapidly growing and can help explain how gene expression is: - Answer-influenced by environmental factors and how epigenetics contributes to the manifestation of mental illness How does epigenetics impact a person's mental health? - Answer-internal or external factors activate portions of the genome that result in the manifestation of mental health symptoms -activation is often a result of a stressful event, which, when combined with the genetic risk, results in the disease -genes being on or off -occurrence of symptoms may be the result of inheritance of an abnormal gene or of normal genes being "on" when they should be "off." Types of epigenetic changes: - Answer-DNA Methylation Histone modification Non-coding RNA The potential legal and ethical issues impacting mental health treatment must also be taken into account, including: - Answer--informed consent -competence to make healthcare decisions -off-label prescribing Informed consent - Answer-Clients have the right to receive enough information to make decisions about treatment. -must also be informed about potential risks associated with medications. -have the right to refuse treatment -cannot be forcibly medicated in non-emergencies. However, clients can be forcibly medicated if they are violent toward themselves or others and when less restrictive methods have failed Compliance - Answer-A court order may be issued for a client to receive treatment against their wishes if they are considered a danger to themselves or others. -Examples: clients with schizophrenia or sex offenders -Guardians can provide consent for clients who have limited cognitive capabilities or are incompetent to make decisions -PMHNPs are responsible for being knowledgeable about their state laws and abiding by them. Off-Label Prescribing - Answer-Some clients may benefit from the unapproved use of a drug for symptom management. -Example: many SSRIs used to tx anxiety and OCD but are not FDA approved for use in this disorder. -potentially raises ethical and legal concerns -PMHNP must remain up to date with the latest recommendations for off-label prescribing. Incidence of mental illness-what factors are increasing the incidence - AnswerPsychological and sociological factors Lifestyle factors such as a client's smoking status, diet, exercise, history of medication adherence, or history of addiction should be considered when prescribing psychotropic medications Adherence - Answer-Persistence -taking med over intended time period Compliance -taking med as prescribed left hemisphere - Answer--speech comprehension -word recognition -grammar -sequential processing -recognition of detail -conscious mental processing right hemisphere - Answer--prosody of speech -emotional modulation -visual-spatial skills -recognition of facial expression -music -abstract mathematical skills -holistic processing -unconscious mental processing Pharmacokinetics - Answer-the study of what happens to a drug from the time of administration until the parent drug and all metabolites leave the body CYP450 - Answer-CYP450 enzymes in the gut wall or liver convert drug substrate into a biotransformed product in the bloodstream, responsible for degradating of a large # of psychotropic drugs -Not all ind. have same genetic form of CYP450 enzymes, determined with pharmacogenetic testing *Most individuals have "normal" rates of drug metabolism from the major CYP450 enzymes and are said to be "extensive metabolizers", most drug doses are set for these individuals. *genetic variants of these enzymes can make poor metabolizers or ultra rapid metabolizers Five of the most important: CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4. ultra rapid metabolizers - Answer-elevated enzyme activity subtherapeutic drug levels poor efficacy with standard doses genotyping - Answer-the patient for pharmacogenomic use -genes for these CYP450 enzymes can now be readily measured and used to predict which patients might need to have dosage adjustments -measurement of genes for drug metabolism most common targets of psychotropic drugs - Answer-G-protein receptors -Drug actions at these receptors occur in a spectrum, from full agonist actions, to partial agonist actions, to antagonism, and even to inverse agonism. Pharmacokinetics concepts - Answer-absorption distribution metabolism excretion Flockhart Table - Answer-drug interactions that are mediated by cytochrome P450 enzymes comprehensive list of drugs and the interactions related to the cytochrome P450 system Neurotransmitters - Answer-chemicals released by neurons to send communication across synaptic clefts to other neurons -impact human emotion and behavior Neurotransmission: - Answer-the chemical transmission of information between neurons and their target cells -the chemicals, or neurotransmitters, are released from their transport vesicles to bind with receptor sites to perform their duties, which are excitatory or inhibitory -neurotransmitter then either returned and stored for future use (reuptake) or inactivated and dissolved by enzymes -Types: Classic, Retrograde, Volume Classic neurotransmission - Answer-neurons send electrical impulses from one part of the cell to another part of the same cell via their axons -one neuron hurling a chemical messenger, or neurotransmitter, at the receptors of a second neuron -electrical impulse converted chemical signal at the synapse in a process known as excitation-secretion coupling, the first stage of chemical neurotransmission, then back into electrical impulse in second neuron -chemical information from the first neuron triggering a cascade of further chemical messages within the second neuron to change that neuron's molecular and genetic functioning Retrograde neurotransmission - Answer-postsynaptic neurons "talk back" to their presynaptic neurons -second neuron to the first at the synapse between them -Chemicals produced specifically as retrograde neurotransmitters at some synapses include: endocannabinoids, gaseous neurotransmitter nitric oxide (NO), nerve growth factor (NGF). Volume neurotransmission - Answer-Neurotransmission without a synapse or nonsynaptic diffusion neurotransmission -Chemical messengers sent by one neuron to another can spill over to sites distant to the synapse by diffusion -neurotransmission can occur at any compatible receptor within the diffusion radius of the neurotransmitter -neurotransmission occurs in chemical "puffs" -sophisticated "chemical soup." -example: dopamine action in the prefrontal cortex, at the sites of autoreceptors on monoamine neurons Excitatory neurotransmitters: - Answer-increase the likelihood that the neuron will fire an action potential inhibitory neurotransmitters: - Answer-decrease the likelihood that a neuron will fire an action neurotransmitters that most impact mental health can be classified into four major categories: - Answer-cholinergics -acetylcholine monoamines -norepinephrine, dopamine, serotonin, histamine amino acids -gamma- amino-butyric acid and glutamate neuropeptides Inhibitors: VISA CKGQ - Answer-Valproate Isoniazid Sulfonamides Amiodarone Chloramphenicol Ketoconazole Grapefruit Juice Quinidine -decrease medication metabolism Inducers: CRAP GPS - Answer-Carbamazepine Rifampin Alcohol Phenytoin Griseofulvin Phenobarbital Sulfonylureas -increase medication metabolism neurotransmitters that may be responsible for a client's symptoms of depression - Answer-Imbalanced levels of acetylcholine, norepinephrine, serotonin, histamine, or glutamate can contribute to symptoms of depression client who is a poor metabolizer: - Answer-has a lower concentration of the necessary enzyme to metabolize a drug, which results in higher blood concentrations of the drug. -increase the risk of side effects and adverse reactions Why is trazodone not used as a front-line antidepressant - Answer-Its antidepressant that has a secondary effect of blocking histamine and adrenergic receptors -causes sedation and somnolence and as a result *often used as an adjunct in therapy when a depressed patient has difficulty sleeping effect on neurotransmitters and side effects: Selective Serotonin Reuptake Inhibitors (SSRIs) - Answer-Inhibits the reuptake of serotonin, which can cause nausea, agitation, headache, and sexual dysfunction effect on neurotransmitters and side effects: Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) - Answer-Inhibits the reuptake of serotonin and norepinephrine, which can cause nausea, sweating, insomnia, tremors, sexual dysfunction effect on neurotransmitters and side effects: Tricyclic Antidepressants - Answer--Inhibits the reuptake of serotonin and norepinephrine, which can cause sexual dysfunction -Blocks norepinephrine receptors, which can cause hypotension and tachycardia -Blocks histamine receptors, which can cause sedation and weight gain -Blocks acetylcholine receptors, which can cause dry mouth, constipation, blurred vision, and urinary retention effect on neurotransmitters and side effects: Monoamine Oxidase Inhibitors (MAOIs) - Answer-Increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it, which can cause sedation, dizziness, sexual dysfunction, and hypertensive crisis effect on neurotransmitters and side effects: Benzodiazepines - Answer-Increases the receptor affinity for GABA, which can cause dependence and confusion effect on neurotransmitters and side effects: Bupropion - Answer-Inhibits the reuptake of norepinephrine and dopamine, which can cause insomnia, dry mouth, tremors, and seizures antagonist - Answer-causes a conformational change that stabilizes the receptor in the baseline state and thus is "silent." -blocks the action of a neurotransmitter agonists - Answer-fully stimulate G-protein-linked receptors partial agonists - Answer-stimulate receptors to a lesser degree than an agonist or natural neurotransmitter SSRIs, SNRIs, and tricyclic antidepressants increase _ levels. _ do not impact serotonin levels. - Answer-increase serotonin levels. Benzodiazepines do not impact serotonin levels. Is nicotine an inducer or an inhibitor of the CYP 1A2 enzyme? - Answer-inducer Nicotine is an inducer of the CYP 1A2 enzyme. Does the PMHNP anticipate Joshua may need a higher or lower dose of olanzapine to achieve a therapeutic response? - Answer-Higher -Nicotine is an inducer of the CYP 1A2 enzyme, so it lowers the concentration of drugs. Therefore, a higher dose of olanzapine may be needed to control his symptoms. Ernesto, a 60-year-old, presents to the PMHNP with report of having anxiety, frequent occurrences of feeling frozen in place and like his heart is pounding out of his chest, as well as having difficulty sleeping. The PMHNP suspects the client has an elevated level of which neurotransmitter? - Answer-Norepinephrine -responsible for the regulation of fight or flight responses and can impact mood and sleep. Which of the following is the best medication class for the PMHNP to prescribe for Ernesto to address his elevated norepinephrine levels? - Answer-selective serotonin reuptake inhibitor would block the reuptake of serotonin, leaving a larger amount of serotonin available. Increasing the amount of serotonin would help regulate the feelings of fear and anxiety. Reducing the occurrence of fear would help reduce the release of norepinephrine. A serotonin and norepinephrine reuptake inhibitor would prevent the reuptake of norepinephrine, which would not reduce the level of norepinephrine as needed. Benzodiazepines increase the levels of GABA and do not impact norepinephrine. A monoamine oxidase inhibitor would increase levels of norepinephrine. During a follow up appointment after 4 weeks, the PMHNP should assess for the need to add which medication to Ernesto's treatment plan? - Answer-The nurse should assess for sexual dysfunction and anticipate the potential need for a phosphodiesterase inhibitor such as sildenafil (Viagra). -After 4 to 6 weeks, the client should be experiencing full effects of the SSRI, so the need for a short-term medication like a benzodiazepine or a beta blocker are not anticipated. St. John's Wort is contraindicated with an SSRI and can cause serotonin syndrome. Glu - Answer-Glutamate -amino acid -excitatory neurotransmitter -"workhorse" of the brain-can affect almost every neuron in the brain -affects: energy, memory, learning, neural plasticity -relay sensory info. and regulate spinal and motor reflexes -too much: schizophrenia, epilepsy, mania -receptors: NMDA, AMPA GABA - Answer-inhibitory neurotransmitter -decrease neuroexcitability across the brain -"chill", take the edge off stress, help people calm down, relax, destress, sleep -to little: may experience anxiety or schizophrenia -slows down everything, even breathing -affect executive function and motor coordination, increase risk for accidents -Increased levels of gamma-aminobutyric acid have a calming effect. 5HT - Answer-Serotonin -help regulate mood -makes relaxed, comfortable, decreases stress, regulate sleep, arousal, libido, aggression, pain perception NE - Answer-norepinephrine -monoamine neurotransmitter -focus and productivity -too much due to stress, meds, caffein, stimulants can cause: nervous, antsy, affect focus DA - Answer-dopamine -monoamine neurotransmitter -regulate mood -associated with executive function, ability to perform well, be organized, emotional intelligence -movement and coordination -to little: lose pleasure, interest, alertness, self-confidence, parkinson's disease -to much: schizophrenia and psychosis -reward center: can lead to addiction -has own pathways Ach - Answer-acetylcholine -in CNS: affects arousal, motivation, attention, learning, REM sleep, impacts sleep, pain perception, memory -in PNS: makes you sweat and salivate -link between brain and muscles -not enough: Alzheimer's, Parkinson's, Schizophrenia -too much: Depression -Role in addiction -Receptors: nicotinic & muscarinic Histamine (Neurotransmitter) - Answer-Histamine impacts alertness, pain sensation, and inflammatory responses; increased levels result in depression. Melatonin (neurotransmitter) - Answer-Act at MT1-3 G-protein coupled receptors Sleep/wake cycle insomnia: melatonin agonists Psychotropic drug metabolism may be impacted by factors such as: - Answer--age -smoking -caffeine intake -other medications -Some drugs or foods may inhibit or induce the rate of drug metabolism. The six main neurotransmitters are: - Answer-serotonin (5HT) norepinephrine (NE) dopamine (DA) acetylcholine (Ach) glutamate (Glu) gamma-aminobutyric acid (GABA) Signal transduction cascades can produce: - Answer-downstream (delayed) and/or long-lasting effects -explains why some psychopharmacological drugs do not provide an immediate response but require time to see the drug effects Signal transduction cascades - Answer-communication from the genome of the presynaptic neuron to the genome of the postsynaptic neuron, and then back from the genome of the postsynaptic neuron to the genome of the presynaptic neuron via retrograde neurotransmission -process involves long strings of chemical messages within both presynaptic and postsynaptic neurons -initial events occur in less than a second, but the long-term consequences are mediated by downstream messengers that take hours to days to activate, yet can last for many days or even for the lifetime of a synapse or neuron -somewhat akin to a molecular "pony express" One-third of psychotropic drugs bind to a _, and one-third bind to . - Answer-neurotransmitter, G-protein-linked receptors. Signal transduction cascades: Each molecular site within the cascade of transduction of chemical and electrical messages is a potential location for: - Answer-a malfunction associated with a mental illness -also a potential target for a psychotropic drug Retrograde - Answertranscription factor - Answer-A regulatory protein that binds to DNA and affects transcription of specific genes. antipsychotic meds - Answer-primarily used for schizophrenia & psychotic disorders -also used as adjunctive meds for management of tx-resistant depression & other conditions -not curative -decrease/control symptoms/improve quality of life Schizophrenia - Answer-a disturbance that must last for 6 months or longer, including at least one month of positive symptoms or negative symptoms -neurodevelopmental, brain disorder -psychological condition involving chronic or repeated episodes of psychosis cause: combination of genetics and environmental factors DX: based on clinical interview psychosis - Answer-set of symptoms in which a person's mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others is impaired Symptoms of psychosis: - Answer--delusions & hallucinations (Hallmarks) -disorganized speech -disorganized behavior -distortions of reality -inappropriate or very strong emotions or apathy -negative symptoms: diminished emotional expression and decreased motivation area of the brain thought to be responsible for the positive symptoms of schizophrenia is the . one of the neuronal pathways known to be affected here is the system, mesolimbic pathway, ventral tegmental area (VTA), nucleus accumbens schizophrenia: the dopamine theory - Answer-suggests that in the mesolimbic pathway, neurons from the VTA (ventral tegmental area) release higher than normal levels of dopamine into the synaptic cleft at the NAC (nucleus accumbens). -More dopamine binds to the D2 dopamine receptors in the NAC. This is thought to be the cause of positive symptoms _ from the and the . - Answer-limbic Schizophrenia: dopamine and mesocortical system - Answer-area of the brain thought to be responsible for negative symptoms of schizophrenia, prefrontal cortex -mesocortical pathway goes from the VTA (ventral tegmental area) to the PFC (prefrontal cortex) -dysregulation of dopamine between these two areas of the brain results in the negative and cognitive symptoms Dopamine pathway: mesolimbic - Answer-location: Ventral tegmental area (VTA) within midbreain to the nucleus accumbens (NA) in the limbic system function: regulates emotional behaviors & associated with reward, motivation, pleasure symptoms: overactivation causes (+) symptoms and may be a downstream consequence of prefrontal cortex dysfunction & glutamate activity in the hippocampus Dopamine pathway: mesocortical - Answer-location: ventral tegmental area (VTA) to the prefrontal cortex (PFC). Specifically affecting dorsolateral prefrontal cortex (DLPFC) & ventromedial prefrontal cortex (VMPFC) function: regulates cognition, executive function, emotions, affect. DLPFC-cognitive, (-) symptoms VMPFC-affective & (-) symptoms symptoms: hypoactivation of pathway may cause (-), cognitive, & affective symptoms dopamine pathway: nigrostriatal - Answer-location: projects from substantia nigra (in midbrain) to basal ganglia (striatum & globus pallidus) function: part of extrapyramidal nervous system, controls posture & voluntary motor movements symptoms: imbalance of pathways causes movement disorders. Common disordersparkinson's and tremor. Low dopamine in basal ganglia-akathisia & dystonia. Hyperactivation of pathway-tics, dyskinesias, chorea. Chronic blockade of D2 pathway-tardive dyskinesia. dopamine pathway: tuberinfundibular - Answer-location: projects from hypothalamus to anterior pituitary gland function: dopamine inhibits prolactin release from pituitary symptoms: disruption of pathway causes prolactin level to rise resulting in gynecomastia & galactorrhea. Females-amenorrhea Both may get sexual dysfunction neurobiological factors that contribute to psychosis and schizophrnia - Answer--genetics -neuroanatomy -neural networks -neural signaling neuroanatomy: symptoms associated with mesocortical and ventromedial prefrontal cortex - Answer-negative and affective symptoms neuroanatomy: symptoms associated with dorsolateral - Answer-cognitive symptoms neuroanatomy: symptoms associated with orbitofrontal and connections to amygdala - Answer-aggressive, impulsive symptoms Worst toxin for someone who has at risk genes for schizophrenia - Answer-marijuana Medications to treat psychosis are classified as either: - Answer-first generation antipsychotics (FGAs) or second- generation antipsychotics (SGAs) Antipsychotics are prescribed based on their: - Answer--pharmacological properties -side effect profiles -adverse effects according to the unique symptoms and needs of individuals across the lifespan First-generation antipsychotics (FGAs) - Answer-typical antipsychotics, non-selectively blocks dopamine D2 receptors, specifically in mesolimbic pathway -for the acute and chronic management of schizophrenia and psychosis -Desired effect: improve (+) symptoms -risk for developing hyperprolactinemia & extrapyramidal symptoms Extrapyramidal symptoms (EPSs) - Answer-group of symptoms related to motor control and coordination, caused by dopamine blockade or depletion in the basal ganglia -dystonia -akathisia -parkinsonism -bradykinesia -tremors -tardive dyskinesia dystonia - Answer-Involuntary contractions of muscles; can cause pain akathisia - Answer-Inner restlessness leading to repetitive motion (rocking, tapping fingers). parkinsonism - Answer-Combination of abnormal movements like those seen in Parkinson's Disease, including tremor, slow movement, impaired speech, or muscle stiffness -akinesia, rigidity, tremor bradykinesia - Answer-Slowness of movement tardive dyskinesia - Answer-hyperkinetic movement disorder characterized by abnormal facial and tongue movements and quick, jerky limb movements -Can occur from long-term blockade of D2 receptors in the nigrostriatal DA pathway -25% of clients will develop symptoms within 5 years of medication start -Failure to discontinue typical antipsychotics prior to symptom onset can result in this permanent condition Hyperprolactinemia - Answer-when the serum prolactin level rises due to the blockade of dopamine in the hypothalamus -may be asymptomatic -irregular menses -male gynecomastia -nipple discharge -osteoporosis -sexual dysfunction and infertility (both genders) Neurolepsis - Answer-antipsychotic medication effects on psychotic clients, with respect to cognition and behavior. -Neurolepsis syndrome has three major features (PEA acronym) Psychomotor slowing-extreme form of slowness or absence of motor movement (nigrostriatal pathway) Emotional quieting-worsening of (-) & cognitive symptoms (mesocortical pathways) Affective indifference-worsening of affective symptoms (mesocortical pathway) Additional adverse effects of excessive D2 receptor blockade (D2 antagonist actions) include: - Answer--cardiac concerns: QT prolongation, torsades de pointes, and sudden cardiac death -blood dyscrasias (neutropenia, leukopenia, and agranulocytosis) -esophageal dysmotility, aspiration -increased fall risk imbalance of dopamine (DA) and acetylcholine (ACh) can result in anticholinergic effects such as: - Answer--dry mouth -blurred vision -racing heart -constipation -drowsiness *due to muscarinic blockade effects due to histamine blockade: - Answer-weight gain and drowsiness effects due to α1-adrenergic blockade: - Answer-orthostatic hypotension, dizziness, and drowsiness Commonly prescribed antipsychotic medications for treatment of positive schizophrenic symptoms - Answer-lowest to highest potency - FGAs -chlorpromazine (low) -mesoridazine (low) -thioridazine (low) -thiothixene (med) -fluphenazine (med) -haloperidol (high) FGAs (typical antipsychotics) - Answer--Conventional -Higher risk of extrapyramidal side effects (EPS) -Treats positive symptoms -Developed first FGA meds - Answer--Haloperidol -Thioridazine -Thiothixene -Fluphenazine -Mesoridazine -Chlorpromazine Second Generation Antipsychotics (SGA) - Answer-Atypical, serotonin-dopamine antagonists, maintain D2 antagonism but also have simultaneous serotonin 5HT2A antagonism -treat both positive and negative signs of psychosis -classified by pharmacological properties related to their binding capacity, potency of binding is responsible for medication efficacy and side effects -Does not increase prolactin levels -Lower risk of EPS Due to the antagonism of serotonin, generally have fewer EPS and prolactin effects making them the first-line choice when prescribing medications for schizophrenia. - Answer-Second Generation Antipsychotics (SGA) SGA (atypical antipsychotics) categories: - Answer-Pines: -olanzapine (zyprexa) -quetiapine (seroquel) -asenapine (saphris) -clozapine (clozaril) 2 dones & a rone: -risperidone (risperidol) -paliperidone (invega) -ziprasidone (geodon) -iloperidone (fanapt) -lurasidone (latuda) 2 pips & a rip: -aripiprazole (abilify) -brexpiprazole (rexulti) -cariprazine (vraylar) Pines - Answer--bind more potently to the 5HT 2A receptor than the D2. -Sedation is common and relates to a high affinity for histamine. -least risk of EPS but a high risk for weight gain and metabolic abnormalities 2 dones and a rone - Answer--more potently to the 5HT 2A receptor than to D2 or bine equally between the 2 receptors. -less sedating and cause less weight gain, but have a higher risk for hyperprolactinemia and EPS 2 pips and a rip - Answer--pips: bind more potently to D2 receptors than to 5HT-2A, have low risk of metabolic side effects and weight gain, but they have a potential for EPS. -rips binds equally to both D2 and 5HT-2A receptors, have low risk for metabolic disorders Extreme caution should be taken when prescribing antipsychotics for clients with metabolic disorders. SGAs are associated with: - Answer-hyperglycemia and type 2 diabetes, dyslipidemia, and hypertension Neuroleptic malignant syndrome (NMS) - Answer-Medical emergency, rare, sometimes life-threatening reaction to antipsychotic medications S/S: -diaphoresis -anxiety -tachypnea -muscle stiffness -altered mental status -tachycardia -hyperthermia Tx of Neuroleptic malignant syndrome (NMS) - Answer-stop the administration of antipsychotic medications and provide supportive therapy. Treatment and pharmacologic management may include hydration, benzodiazepines, and muscle relaxants The PMHNP must monitor for adverse effects in clients who are prescribed SGAs. Which of the following physical exams and labs should be ordered or requested from another provider? - Answer-BMI -monthly x3 months then quarterly Fasting lipids -within first three months then check annually Electrocardiogram -baseline electrocardiogram should be obtained to evaluate for prolonged QT syndrome BP Fasting plasma glucose -within first three months then check annually Carbamazepine - Answer-glutamate, voltage-gated sodium and calcium channel blocker -Primary target symptoms: Seizures, unstable mood, mania, pain. -Side Effects: SEDATION, dizziness, confusion, unsteadiness, headache, nausea, vomiting, diarrhea, blurred vision, rash, benign leukopenia (up to 10%) -Before starting: blood count, liver, kidney, and thyroid function tests SUBSTRATE for CYP450 3A4 and an inducer of CYP450 3A4 thus, carbamazepine induces its own metabolism, often requiring an upward dosage adjustment Carbamazepine drug interactions - Answer--Enzyme-inducing antiepileptic drugs (carbamazepine itself as well as phenobarbital, phenytoin, and primidone) may increase the clearance of carbamazepine and LOWER its plasma levels -CYP450 3A4 inhibitors, such as nefazodone, fluvoxamine, and fluoxetine, can INCREASE plasma levels of carbamazepine Olanzapine (zyprexa) - Answer-SGA - Atypical serotonin-dopamine antagonist Indication: schizophrenia age 13 and older, acute agitation, acute mania/mixed mania, bipolar maintenance, bipolar depression, borderline personality disorder, PTSD -Starting dose: Initial 5-10 mg once daily orally Risk: High metabolic risk Highest risk for weight gain, sedation, blood dyscrasias, QT prolongation, cardiovascular disease, cerebrovascular effects, hyperglycemia, and hyperprolactinemia quetiapine (seroquel) - Answer-SGA - Atypical serotonin-dopamine antagonist Indication: schizophrenia ages 13 and older, mania, bipolar maintenance, depression, severe treatment-resistant anxiety, PTSD, behavioral disturbances in dementias, Parkinson's disease, children, and adolescents. -Starting dosing: initial 25 mg/day twice a day; increase by 25-50 mg twice a day each day until desired efficacy is reached; maximum approved dose 800 mg/day Risk: Sedation Moderate metabolic risk Low EPS risk Risk of orthostatic hypotension, blood dyscrasias (neutropenia, leukopenia, and agranulocytosis), QT prolongation, weight gain, and renal and hepatic impairment asenapine (Saphris) - Answer-SGA - Atypical dopamine, serotonin, norepinephrine receptor antagonist Indication: schizophrenia ages 10 and older, mania, bipolar, depression, impulse control, PTSD, behavior disturbances in dementia and in children and adolescents -Starting dosing: usual dosage range Schizophrenia and bipolar mania (sublingual): 10- 20 mg/day in 2 divided doses, Schizophrenia (transdermal): 3.8 mg/24 hours Risk: Low metabolic risk Tardive dyskinesia (reduced risk compared to conventional antipsychotics) clozapine (Clozaril) - Answer-SGA - Atypical serotonin-dopamine antagonist Indication: treatment-resistant schizophrenia, chronic SUICIDAL behavior in schizophrenia or schizoaffective disorder, treatment-resistant bipolar disorder, violent aggressive patients with psychosis and other brain disorders not responsive to other treatments. -Starting dosing: Initial 25 mg at night, increase 25-50 mg/day every 48-72 hours as tolerated Not indicated in acute presentation of schizophrenia Special Comments: The Absolute Neutrophil Count (ANC) must be 1500/mm3 when used and requires initial and weekly monitoring of WBC, granulocyte, and neutrophil counts. Risk: High metabolic risk Highest risk for weight gain. Sedation Low EPS risk. BLACK BOX WARNING: may cause severe neutropenia Contraindicated in liver disease and hepatic failure Not a first-choice mediation for treating schizophrenia risperidone (Risperidol) - Answer-SGA - Atypical serotonin-dopamine antagonist Indication: schizophrenia ages 13 and older, mania, autism, bipolar, depression, impulse control, PTSD -Starting dosing: usual is Oral: 2-8 mg/day for acute psychosis and bipolar disorder (0.5- 2mg for kids and elderly). In adults 1 mg/day orally in 2 divided doses, Increase each day by 1 mg/day orally until desired efficacy is reached. (16mg/day max) Risk: Moderate metabolic risk Highest risk of hyperprolactinemia Risk of blood dyscrasias, QT prolongation, cardiovascular, and cerebrovascular effects Sexual dysfunction paliperidone (Invega) - Answer-SGA - Atypical serotonin-dopamine antagonist Indication: schizophrenia ages 12 and older, mania, bipolar, depression, impulse control, PTSD, behavior disturbances in dementia and in children and adolescents. -Starting dosing: 6 mg/day taken in morning, Can increase by 3 mg/day every 5 days (max 12 mg/day) Risk: Moderate metabolic risk Tardive dyskinesia (reduced risk compared to conventional antipsychotics) ziprasidone (Geodon) - Answer-SGA - Atypical dopamine and serotonin receptor antagonist Indication: schizophrenia in ages 10 and older, acute agitation, mania, bipolar maintenance/depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -dosing: • Schizophrenia: 40-200 mg/day (in divided doses) orally • Bipolar disorder: 80-160 mg/day (in divided doses) orally • 10-20 mg intramuscularly -Special Comments: IM dosing in acute agitation associated with schizophrenia Risk: Low metabolic risk Lowest risk for weight gain Contraindicated in clients with QT, recent myocardial infarction, or uncompensated heart failure High incidence of rash/urticaria related to Stevens-Johnson syndrome and Drug Reaction with Eosinophilia and Systemic Syndrome (DRESS) iloperidone (Fanapt) - Answer-SGA - Atypical dopamine-serotonin receptor antagonist Indication: schizophrenia, mania, bipolar maintenance/depression, treatment-resistant depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -dosing: usual rangs 12-24 mg/day in 2 divided doses. Initial 2 mg in 2 divided doses on day 1; 4 mg in 2 divided doses on day 2; 8 mg in 2 divided doses on day 3..etc.. Risk: Moderate risk for weight gain, sedation Low risk for hyperlipidemia lurasidone (Latuda) - Answer-SGA - Atypical dopamine, serotonin receptor antagonist Indication: schizophrenia ages 13 and older, bipolar maintenance/depression, mania, treatment-resistant depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: 40-80 mg/day for schizophrenia, 20-60 mg/day for bipolar depression -should be taken with food, at least 350 calories, for maximum absorption. Risk: Low metabolic risk Dose-dependent hyperprolactinemia aripiprazole (Abilify) - Answer-SGA - Atypical dopamine, serotonin receptor partial agonist Indication: schizophrenia ages 13 and older, mania, autism, bipolar maintenance/depression, depression, tourette's disorder, acute agitation, obsessivecompulsive disorder, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: • 15-30 mg/day for schizophrenia & mania • 5-15 mg/day for autism • 5-20 mg/day for Tourette's disorder Risk: Low metabolic risk Low risk for weight gain Low risk for orthostatic hypotension Pearls -less sedation than most other antipsychotics brexpiprazole (Rexulti) - Answer-SGA - Atypical Dopamine partial agonist Indication: schizophrenia, treatment-resistant depression, mania, bipolar maintenance/depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: schizophrenia 2-4 mg once daily, Depression: 2 mg once daily. Special Comments: Considered procognitive Risk: Low metabolic risk Akathisia TD (reduced) cariprazine (Vraylar) - Answer-SGA - Atypical dopamine-serotonin partial agonist Indication: schizophrenia, mania, bipolar maintenance/depression, depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: • Schizophrenia: 1.5-6 mg once daily • Bipolar mania: 3-6 mg once daily • Bipolar depression: 1.5-3 mg once daily Risk: Low metabolic risk Sedation Akathisia, parkinsonism, TD (reduced) Haloperidol - Answer-Typical FGA (conventional) dopamine receptor antagonist High potency Indication: Psychotic disorders, tourette's syndrome, schizophrenia, bipolar disorder, behavior disturbances in dementia -Dosing: 1-40 mg/day orally, IR injection 2-5 mg each dose Risks: Neuroleptic-induced deficit syndrome Akathisia Parkinsonism Tardive dyskinesia Galactorrhea, amenorrhea Weight gain and sedation Thioridazine - Answer-Typical FGA (conventional) dopamine and serotonin receptor antagonist Low potency Indication: Schizophrenic patients who fail to respond to treatment with other antipsychotic drugs. -Dosing: 200-800 mg/day in divided doses Risks: Neuroleptic-induced deficit syndrome Akathisia Priapism Parkinsonims Tardive dyskinesia Galactorrhea, amenorrhea Sedation & weight gain QTc prolongation Sexual dysfuction Pigmentary retinopathy Pearls: -Generally, the benefits of thioridazine do not outweigh its risks for most patients -Because of its effects on the QTc interval, thioridazine is not intended for use unless other options (at least 2 antipsychotics) have failed -Phenotypic testing may be necessary to detect 7% of Caucasian population whom thioridazine is contraindicated due to a genetic variant leading to reduced activity of CYP450 2D6 Thiothixene - Answer-Typical FGA (conventional) -dopamine 2 antagonist -High potency Indication: Schizophrenia, bipolar disorder, other psychotic disorders. -Dosing: 15-30 mg/day, initial 5-10 (max 60mg/day) Risk: Neuroleptic-induced deficit syndrome Akathisia Parkinsonism Tardive dyskinesia Sedation Dry mouth, constipation, vision disturbance hypotension Fluphenazine - Answer-Typical FGA (conventional) Blocks dopamine 2 receptors -High potency -Indication: Psychotic disorders, bipolar disorder -Dosing: 1-20 mg/day oral, IM generally 1/3 to 1/2 the oral dose Risks: Neuroleptic-induced deficit syndrome Akathisia Priapism, sexual dysfunction Parkinsonism Tardive dyskinesia Galactorrhea, amenorrhea Dry mouth, constipation, urinary retention, blurred vision weight gain hypotension Chlorpromazine - Answer-Typical FGA (conventional) dopamine 2 antagonist -Low potency -Indication: Schizophrenia, severe agitation, ADHD, acute psychosis, nausea, vomiting, acute intermittent porphyria, tetanus, intractable hiccups, bipolar disorder, restlessness and apprehension before surgery. -Dosing: 200-800 mg/day Risks: Neuroleptic-induced deficit syndrome Akathisia Priapism, sexual dysfunction Sedation and weight gain Dry mouth, constipation, urinary retention, blurred vision hypotension Tardive dyskinesia Galactorrhea, amenorrhea medications noted for decreased risk of death by suicide - Answer-Clozapine -Reduction in risk of recurrent suicidal behavior in patients with schizophrenia Carla is a 35-year-old woman that is currently taking olanzapine for her diagnosed schizophrenia. She has gained 30 pounds in the last 6 months and her waist circumference is 37 inches. She requests a change in medications. Which of the following medications is less associated with weight gain? - Answer-aripiprazole -associated with the lowest risk weight gain. Alex is a returning client who reports leaking fluid from his nipples. Which of the following is most likely responsible for these undesirable side effects? - AnswerRisperidone -highest risk for galactorrhea, due to hyperprolactinemia. Prescribing Considerations (antipsychotics) - Answer--Start with lowest dose, eval tolerance, then titrate dose -no evidence that high antipsychotic doses are more effective than standard doses -Dose adjustments should be made after two weeks of taking medication -Establish efficacy and an effective med dose before switching to a long-acting injectable (LAI). dose of LAI will be same as the effective oral dose. -Most antipsychotic side effects and adverse effects are dose-related. When prescribing, document the _ at every visit. - Answer-targeted symptoms, response, and any adverse effects Many persons with schizophrenia are treated successfully in an _ , though some clients may require for initial treatment and subsequent treatment of psychotic episodes - Answer-outpatient setting, inpatient hospitalizations Why begin with monotherapy? (antipsychotics) - Answer-The use of multiple antipsychotics can increase the risk of QT prolongation. -Combinations considered only after single med have provided inadequate response. If antipsychotics switched too quickly - Answer-can develop agitation, activation, insomnia, and experience withdrawal -due to the binding differences in each medication subcategory *Cross titration over several days to weeks is required to prevent side effects Clients are more likely to experience side effects when changing from a medication in subcategory (ex: pine to done) special considerations: Pregnancy (antipsychotics) - Answer--Risk of withdrawal symptoms in the newborn: extrapyramidal symptoms may be present at delivery. -atypical antipsychotics appear more harmful than typical antipsychotics due to increased risk of gestational metabolic complications, increased gestational age weight, and increased birth weight. -Avoid Clozapine, Ziprasidone, olanzapine, risperidone, and quetiapine, especially in the third trimester special considerations: breast feeding (antipsychotics) - Answer-All antipsychotics are assumed to be secreted in breast milk. -recommended drug is discontinued or the infant bottle feeds. special considerations: Older Adult (antipsychotics) - Answer-2019 American Geriatric Society (AGS) Beers Criteria recommendations: Avoid the use of haloperidol, ziprasidone, and olanzapine due to an increased risk of cerebrovascular accident (CVA), cognitive decline, and death in persons with dementia and with dementia-related psychosis. special consideration: children (antipsychotics) - Answer-Black box warnings: -Aripiprazole: Increased risk of suicide in children. one _ to a medication in another _ - Answer-subcategory, -Quetiapine: Increased risk of suicidal ideation and suicidal behavior in adolescents/young adults during the initial 1-2 months of treatment special considerations: caution (antipsychotics) - Answer--Olanzapine - exercise caution in suspected alcohol withdrawal, stimulant intoxication, or anticholinergic intoxication -High and repeated doses of amphetamines or cocaine can mimic positive symptoms of paranoid schizophrenia legal issues/considerations when prescribing antipsychotics - Answer-informed consent -required due to serious side effects challenges -psychosis can be an obstacle -provide education before obtaining a signature in outpatient setting contingency planning -establish a plan with client and family for emergencies -designate a mental healthcare proxy if possible Prescribing Pearls - Answer--Use the lowest effective dose and slow dosage titration. -Avoid agents with anticholinergic properties. -Avoid combining benzodiazepines with intramuscular olanzapine due to an increased risk of sudden death. -Avoid the combination of intramuscular benzodiazepines with clozapine due to a risk of respiratory failure. Terence is a 23-year-old male who presented to the emergency department (ED) with hallucinations. He is highly agitated, and nonpharmacological treatment methods have not been able to calm his behaviors. His agitation continues to escalate which is interfering with their ability to gain an accurate history and assessment. Limited information is available regarding his past medical and psychiatric history. The attending providers are unclear whether his presentation is due to a mental health disorder with a need to intervene or an underlying non-psychiatric medical condition. The PMHNP is called to assist in calming the client. Which of the following statements is inaccurate regarding the management of Terence's agitation? - Answer-Aggressive pharmacological intervention should be done early to fully sedate this client so that a full evaluation can occur. Rationale: Aggressive pharmacological intervention (such as full sedation) interferes with the ability to perform a full evaluation, including history and physical examination. Terence requires medication that will support the completion of an evaluation and differential diagnosis without putting the patient or staff at risk. Early aggressive pharmacological treatment can result in masking underlying conditions. Terence continues to be uncooperative. He has become violent and is threatening to leave. He reports hearing voices and states that he will kill everybody in the room. As staff attempt to apply restraints, Terence swings his fists and almost injures a nurse. Which of the following medications is the most appropriate to administer to Terence? - Answer-Olanzapine (Zyprexa) 10mg IM Rationale: Terence is uncooperative and is threatening harm and requires immediate support. Oral medication will likely be rejected or refused. A more desirable medication would have a short onset to support the safety of all involved. Administering intranasal Versed may put the staff and the patient at risk. Further, midazolam and other benzodiazepines administered by themselves promote sedation; they do not treat the underlying disease, which is causing agitation or psychosis. Administering medication via intramuscular injection is the best option. Of the choices, olanzapine is the most appropriate medication because it has a rapid onset of action and potent antihistamine actions. Although ziprasidone is an option, the dose listed is excessive. Terence is now calm, and his workup has been completed. Physical differential diagnoses have been ruled out, and a diagnosis of new-onset schizophrenia is suspected based on history gained from the family and the physical examination. Terence is admitted for initial stabilization. Which of the following will you prescribe for his initial treatment? - Answer-Aripiprazole (Abilify) Rationale: Aripiprazole (Abilify) is the best choice of initial treatment for Terence. Second-generation antipsychotics (SGAs) are prescribed initially due to the effect on both D2 and 5HT2A. When initiating medication, it is important to consider metabolic risk, especially in a young patient such as Terence. Aripiprazole has low metabolic risks and low weight gain. Olanzapine has a high metabolic risk. Haloperidol is an FGA. Clozapine is not an appropriate choice for first-line treatment. Clozapine treatment has a serious risk of severe neutropenia and low absolute neutrophil count. Because of the risk of agranulocytosis, this medication is available only through a restricted program (REMS) and is prescribed for treatment-resistant schizophrenia. all forms of psychosis are linked to the neurotransmitter systems: - Answer-dopamine, serotonin, and glutamate Dopamine Theory - Answer-Hyperactive dopamine at D2 receptors in the mesolimbic pathway Glutamate theory - Answer-NMDA receptor hypofunction Serotonin theory - Answer-5HT2A receptor hyperfunction in the cortex Alogia - Answer-dysfunction of communication -poverty of speech asociality - Answer-lack of interest in social interactions anhedonia - Answer-a diminished ability to experience pleasure avolition - Answer--lack of motivation -reduced ability to complete everyday tasks match each symptom to hypothetically malfunctioning brain circuits: positive symptoms - Answer-mesolimbic match each symptom to hypothetically malfunctioning brain circuits: negative symptoms - Answer-mesocortical/prefrontal cortex nucleus accumbens reward circuit match each symptom to hypothetically malfunctioning brain circuits: cognitive symptoms - Answer-dorsolateral prefrontal cortex match each symptom to hypothetically malfunctioning brain circuits: aggressive symptoms - Answer-orbitofrontal cortex amygdala match each symptom to hypothetically malfunctioning brain circuits: affective symptoms - Answer-ventromedial prefrontal cortex polygenic risk score - Answer-add up all the abnormal genes an individual has amongst the known few hundred risk genes, suggesting how much risk there might be for developing schizophrenia. Barnes Akathisia Rating Scale (BARS) - Answer-rating scale to assess the severity of drug-induced akathisia. -includes objective and subjective items such as the level of the patient's restlessness Abnormal Involuntary Movement Scale (AIMS) - Answer-tool used to monitor involuntary movements and tardive dyskinesia in clients who take antipsychotic medication -best practice/recommendation to document the AIMS at minimum every 6 months for patients taking an antipsychotic agent/dopamine blocker Low-potency medications - Answer--require higher doses to achieve efficacy -have more anticholinergic, antihistaminic, and α1- properties, can result in more sedation Targeting mesolimbic/mesostriatal dopamine D2 receptors causes: - Answerantipsychotic actions Targeting dopamine D2 receptors in Mesolimbic/mesostriatal and mesocortical pathways causes: - Answer-secondary negative symptoms Targeting tuberoinfudibular dopamine D2 receptors causes: - Answer-elevation of prolactin -associated with gynecomastia, galactorrhea, amenorrhea Targeting nigrostriatal dopamine D2 receptors causes: - Answer-motor side effects -can cause drug induced parkinsonism overactivity of the mesolimbic dopamine system - Answer-may mediate the positive symptoms of psychosis any abnormal motor symptoms caused by D2 receptor blockers are lumped together and called collectively: - Answer-extrapyramidal symptsom (EPS) -motor side effects of D2 antagonists caused by chronic blockade of D2 receptors in the nigrostriatal dopamine pathway - Answer-tardive dyskinesia (TD) -tx: interventions that lower dopamine neurotransmission, inhibiting the vesicular monoamine transporter type 2 (VMAT2) lowers the "go" signals - deuterated tetrabenazine (deutetrabenazine), Valbenazine (most selective and potent) , the most common side effect of drugs that target D2 receptors for psychosis - AnswerDrug induced parkinsonism (DIP) -akinesia, bradykinesia, rigidity, and tremor *anticholinergics-drugs that block muscarinic cholinergic receptors adding 5HT2A antagonism: - Answer-improve side effects of D2 blockade and enhance the antipsychotic efficacy of D2 blockade Sedative-hypnotic agents - Answer-benzodiazepine & barbiturates, clinical indications for use: -sedation & anxiolysis -treatment of insomnia -general anesthesia -seizures -alcohol withdrawal states -as adjunctive management with neuromuscular blockage/muscle relaxation -to induce or maintain sleep sedative-hypnotic medications: use - Answer--1 in 8 adults -Higher incidence in older adults -Often co-prescribed with opioids sedative-hypnotic medications: misuse - Answer--Taken outside of prescriptive guidelines -Taken without prescription -polysubstance Abuse -Are common as second drugs of abuse, often taken with opioids and/or alcohol -Increased respiratory and CNS depression -Increased risk of emergency department visits sedative-hypnotic medications: Withdrawal - Answer--May be severe -Signs and symptoms include psychosis, hallucinations, delirium, seizures -Mild signs and symptoms: irritability, tremor, anxiety, palpitations, insomnia, nausea, vomiting, diaphoresis, headache Benzodiazepine intoxication - Answer-Can resemble alcohol intoxication: unsteady gait, cognitive impairment, discoordination, slurred speech -Overdose may lead to respiratory depression and stupor/coma Anxiety - Answer-response to situations that are perceived as stressful or dangerous -increases alertness, heart rate, and respirations, preparing the body to respond to perceived threatening environmental stimuli *when symptoms of anxiety persist and become intense or excessive, a diagnosis of an anxiety disorder may be warranted, and treatment is required anxiety disorder - Answer--affects more women than men -one of the most common mental health concerns in the United States -about 25% of people develop pathological anxiety during their lifetime -can be debilitating and negatively impact the quality of life Types of anxiety disorders - Answer--separation anxiety disorder -selective mutism -specific phobias (animal, natural environment, blood-injection-injury, situational, other) -social anxiety disorder -panic disorder -agoraphobia -generalized anxiety disorder -substance/medication-induced anxiety disorder -anxiety disorder due to another medical condition Other closely related disorders include: -obsessive-compulsive disorder -acute stress disorder -posttraumatic stress disorder. Neurobiological factors that contribute to anxiety - Answer-Genetics -(GAD) has genetic heritability of approximately 30% -Children of parents with GAD are twice as likely to experience anxiety as those who do not have a positive family history -stressful life events are environmental components with potential to impact genetic expression Neuroanatomy -fear has emotional and physical components -amygdala interprets stress or fear and sends a distress signal to the hypothalamus, hypothalamus initiates the fight-or-flight response by activating the sympathetic nervous system, adrenal glands send out adrenaline to prepare the body to fight or flee in the presence of a threat, hypothalamus activates the hypothalamic-pituitary-adrenal (HPA) axis-release of cortisol. A quick elevation of these stress hormones can increase survival in the case of a short-term threat; however, ongoing activation of the system in the presence of chronic fear or anxiety can increase morbidity -hippocampus, where memories are stored, is also involved in the fear response. Memories can trigger fear by activating the amygdala, causing persons to re-experience a traumatic past event as occurs in post-traumatic stress disorder (PTSD) Neural networks -brain contains a system of neural circuits referred to as cortico-striato-thalamo-cortical (CSTC) feedback loops or "worry loops." -Different types of anxiety or worry are linked to malfunctions in the circuit -panic and phobia, are thought to be regulated through the connections between the amygdala and the prefrontal cortex, fear-overactivation of the CSTC circuits Neural signaling -neurotransmitters (NT) are regulated within the CTSC feedback loops,serotonin, gamma-aminobutyric acid (GABA), dopamine, norepinephrine, and glutamate which also help regulate the amygdala. -GABA is the chief inhibitory NT. GABA is the "chill" to glutamate, which is the excitatory NT. -GABA works within the CTSC to inhibit the anxiety response. symptom(s) may occur in response to sympathetic stimulation from fear: - Answer-- hyperventilation -hypertension -hyperglycemia -chest pain Rationale: Fear can trigger an adaptive respiratory response which can exacerbate asthma or other chronic breathing disorders. This explains client reports of not being able to breathe during a panic attack. Sympathetic nervous stimulation causes increased heart rate, dry mouth, constipation, urinary retention, and increased blood sugar. When autonomic nervous system symptoms become chronic, there is an association with hypertension, cardiac ischemia, myocardial infarction, and sudden death. Anxiety: Medication management - Answer-Antidepressants -SSRIs -SNRIs Anxiolytics -azrapirones -benzodiazepines Other -alpha 2 delta ligands -beta blockers -histamine receptor agonists Selective serotonin reuptake inhibitors (SSRI) are the first-line drugs to treat which anxiety disorder(s)? - Answer--generalized anxiety disorder -panic disorder -obsessive-compulsive disorder -post-traumatic stress syndrome -social anxiety disorder Rationale: SSRIs are the first-line drugs to treat all anxiety disorders. SSRIs - Answer-Selective serotonin reuptake inhibitors (SSRIs) are used for the treatment of all anxiety disorders. They act by preventing the reuptake of 5-HT by synapses in the brain. Drugs -citalopram (Celexa) -escitalopram (Lexapro) -fluoxetine (Prozac) -fluvoxamine (Luvox, Luvox CR) -paroxetine (Paxil, Paxil CR) -sertraline (Zoloft) SSRI's: Adverse effects and monitoring - Answer--anorexia -diarrhea -headache -weight gain -sexual side effects -serotonin syndrome Monitoring: akathisia, increased anxiety, suicidal ideation SSRI's: clinical pearls - Answer--Dosage should be started at half the recommended dose for depression, increase dosage after 2-4 weeks as needed to control anxiety. -SSRIs should not be stopped abruptly because it can result in rebound anxiety. SNRI's - Answer-Serotonin-norepinephrine reuptake inhibitors (SNRIs) are used to treat all anxiety disorders except OCD. -preventing the reuptake of 5-HT and norepinephrine (NE) by synapses in the brain. Compared with venlafaxine and desvenlafaxine, which have serotonin reuptake inhibition (SRI) activity and dose-related affinity for norepinephrine reuptake inhibition (NRI) primarily, duloxetine has more balanced SRI and NRI activities. Levomilnacipran has higher activity at NRI than SRI. -desvenlafaxine (Pristiq) -duloxetine (Cymbalta) -venlafaxine (Effexor, Effexor XR) -levomilnacipran (Fetzima) SNRIs: adverse effects and monitoring - Answer--elevated blood pressure -sweating -anxiety -dizziness -insomnia -constipation -serotonin syndrome Monitoring: increased anxiety and suicidal ideations SNRIs: contraindication - Answer-liver problems hypertension SNRIs: clinical pearls - Answer--Due to the presence of norepinephrine, SNRIs can exacerbate anxiety. -Dosage should be started at half the recommended dose for depression to minimize side effects. Buspirone - Answer-Azapirones are Federal Drug Administration (FDA) approved for short-term anxiety treatment and are used alone or as an adjunct to antidepressants. -bind to serotonin and dopamine receptors in the brain and increase norepinephrine metabolism in the brain. -Buspirone (Buspar) Buspirone: adverse effects - Answer--dizziness -headache -sedation -nervousness -nausea Buspirone: contraindications - Answer--severe renal impairment -severe hepatic impairment -concurrent use of monoamine oxidase inhibitors (MAOIs) Buspirone: clinical pearls - Answer--Buspirone is not habit-forming, does not have abuse potential, causes withdrawal reactions, or potentiates alcohol and sedativehypnotic effects. -It is prescribed for two or three times a day due to the short half-life; it is not prescribed as needed (PRN). -It has a gradual onset of action of 2 weeks, but over time provides the same efficacy as a benzodiazepine. -BuSpar may decrease sexual side effects when used in combination with an SSRI. Alpha 2 Delta Ligands - Answer-used off-label for general anxiety disorder (GAD). -bind with glutamate calcium channel blockers (Glu-CB) to inhibit the release of several neurotransmitters. --Pregabalin has anxiolytic properties with selective binding to the α2-delta subunit of voltage-gated calcium channels. -pregabalin (Lyrica) -gabapentin (Neurontin) Alpha 2 Delta Ligands: adverse effects - Answer--sedation -dizziness -impaired attention -confusion -dry mouth -constipation -blurred vision -possible weight gain Alpha 2 Delta Ligands: Precautions & Contraindications - Answer-Precautions: -suicidal ideation -substance abuse -heart failure -renal impairment Contraindications: -myopathy -avoid prescribing concurrently with benzodiazepines (BZOs) Alpha 2 Delta Ligands: clinical pearls - Answer--works quickly to reduce anxiety symptoms -pregabalin reduces anxiety with a similar onset to alprazolam. Beta blockers - Answer-can be used to treat somatic anxiety effects such as tachycardia and physical tension symptoms. -block the effects of norepinephrine and epinephrine. -propranolol (Inderal) -atenolol (Tenormin) Beta Blockers: adverse effects - Answer--dizziness, vertigo -fatigue -hypotension -decreased libido and sexual dysfunction Beta Blockers: Precautions & Contraindications - Answer-Precautions: -Use with caution in clients with asthma or heart failure; beta-adrenergic blockade can reduce heart rate and cause bronchoconstriction. -can blunt signs of hypoglycemia in diabetics -can mask clinical signs of hyperthyroidism Contraindications: -first-degree heart block -bradycardia Beta blockers: clinical pearls - Answer--not FDA-approved for the treatment of anxiety but are commonly used. -often used for test anxiety, performance anxiety, and social anxiety because these drugs are nonsedating. -may be prescribed after a traumatic event to help prevent a permanent fear response. Histamine Receptor Antagonists - Answer-used for the treatment of anxiety and skeletal muscle tension associated with psychoneurosis, for anxiety symptoms associated with alcohol withdrawal, and for anxiety related to cardiac impairment. -act by blocking histamine 1 receptors. -hydroxyzine (Atarax) Histamine Receptor Antagonists: adverse effects - Answer--sedation -dry mouth -tremor Histamine Receptor Antagonists: monitoring & contraindications - Answer-Monitoring -hepatic status -potassium level -QT interval Contraindications: -severe hepatic impairment -QT prolongation Histamine Receptor Antagonists: clinical pearls - Answer--It is unclear if efficacy is due to an anxiolytic effect or a sedative effect. -Caution clients about potential sedation when prescribing. -When used concurrently with another central nervous system (CNS) depressant, the depressant dose should be reduced to half. -Elderly clients are more sensitive to the sedative and anticholinergic side effects of hydroxyzine. appropriate first-line medication treatment information for anxiety disorder's: Generalized anxiety disorder: - Answer-Generalized anxiety disorder: SSRIs SNRIs buspirone Drug Therapy at least 1 year appropriate first-line medication treatment information for anxiety disorder's: obsessivecompulsive disorder - Answer-Obsessive-compulsive disorder fluoxetine fluvoxamine sertraline paroxetine clomipramine Drug therapy for at least 1 year appropriate first-line medication treatment information for anxiety disorder's: PTSD - Answer-Post-traumatic stress disorder paroxetine sertraline Josie is a 36-year-old who was diagnosed with generalized anxiety disorder. She was prescribed paroxetine (Paxil) 12 weeks ago. She has been taking the medication as prescribed, and although she has tolerated the medication well, she has not achieved relief of anxiety symptoms with