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PTSD Re-experiencing symptoms include:
- flashbacks
- nightmares
- intrusive images
- sensory impressions
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PTSD Avoidance symptoms include:
Avoiding people, situations, or circumstances
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PTSD Emotional Numbing symptoms include:
- Lack of feelings
- Feeling detached
- Giving up on activities
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PTSD Hyperarousal symptoms include:
- startled response
- irritability
- difficulty concentrating
- sleep disturbances
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Diagnosis for PTSD requires all of the following happening for at least 1 month
- At least 1 re-experiencing symptoms
- At least 3 avoidance symptoms
- At least 2 hyperarousal symptoms
- Symptoms that make daily life activities difficult
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1st line therapy for PTSD:
SSRIs
**May also use TCAs and MAOIs**
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These are the only two SSRIs with an FDA-approved indication for PTSD:
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2nd line therapy for PTSD
- TCAs: Amitriptyline & Imipramine
- MAOI: Phenelzine
- SNRI: Venlafaxine ER
- Others: Trazadone, Bupropion, Mirtazapine
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TCAs cause muscharinic side effects which include:
dry mouth, urinary retention, decreased GI motility
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True or False: BZDs are not effective for PTSD symptoms
True!
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The acute phase of PTSD (the 1st four weeks) should be treated with:
Cognitive Behavioral Therapy (CBT)
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What is the primary stress hormone involved in PTSD?
Cortisol
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For PTSD, how many weeks after CBT should an SSRI be started?
4 weeks
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After how many weeks of trialing an SSRI for PTSD would you switch to a different agent if no response?
8 - 12 weeks
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For PTSD, how long should treatment be continued in patient's that are responding to pharmacotherapy?
at least 12 months (to 24 months)
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The two neurochemicals thought to be in disruptions in OCD include:
Serotonin & Dopamine
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For OCD, Obsessions are ________ and Compulsions are _______
Thoughts
Actions
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Initial treatment for OCD should start with:
Cognitive Behavioral Therapy (CBT)
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1st line pharmacotherapy agents for treating OCD are:
SSRIs
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2nd/3rd Line pharmacotherapy agents for treating OCD are:
TCA: clomipramine
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These are the only four antidepressants with an FDA-approved indication for OCD:
- Fluoxetine
- Fluvoxamine
- Sertraline
Clomipramine
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Sertraline Oral Concentrate Solution can only be diluted in:
- orange juice
- lemonaide
- water
- ginger ale
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What is the safest drug to use during pregnancy for OCD?
What drug should be avoided?
Fluoxetine
Clomipramine
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For OCD, what drug can be used as an augmenting agent for the elderly?
Buspirone
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For OCD, what drugs should be started at a lower dose in patients with renal disease?
- Fluoxetine
- Fluvoxamine
- Paroxetine
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The antidepressants used to treat OCD are metabolized extensively by the:
Liver
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For OCD, what is the duration of therapy for CBT?
Once weekly for at least 13-20 weeks
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For OCD, pharmacotherapy should be continued in patients for:
8-12 weeks
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What is the source of Coca?
Dried leaves of Erythroxylum coca Lam. or E. truxillense
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Benzoylmethylecgonine
A tertiary amine diester
Colorless
Low water solubility
HCl salt is the most common watersoluble derivative
Cocaine Chemistry
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Pharmacodynamics of Cocaine; 2 predominant actions
1. Local Anesthesia --- acting on the PNS
2. Stimulation --- acting on the CNS
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Cocaine's MOA for stimulation:
Cocaine blocks the uptake of the following biogenic amines, via bindingto the transporters of these amines:
Dopamine / Norepinephrine / Serotonin
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Major CNS AEs of Cocaine:
Respiratory Depression and Death
Temperature: Marked pyrexia (prominent feature of overdosage)
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Major Cardiovascular AEs of Cocaine:
- Acute increase in arterial pressure (PNS)
- Increased risk for: stroke / MI
Latter stages: BP drops --> death may occur
Large IV doses of cocaine may produce immediate death due to direct toxicity on the myocardial musculature
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Major Ophthalmic AEs of Cocaine:
- Sloughing of the corneal epithelium
- Corneal pitting
- Corneal ulceration
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Major AEs of Cocaine-derived topical anesthetics
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What is the method of administration for Coca Paste Abuse?
Smoking
"freebasing" increases the effects/potency
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What is the method of administration of Crack Cocaine?
Smoking
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What is the method of administratino of Cocaine Snorting?
Intranasal ingestion
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Chemistry of LSD:
Indoleamine -- Conversion of tryptophan to this compound
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LSD MOA:
**High Affinity for 5-HT2A receptor**
Binds to receptor - couples to G proteins - generates ITP - release of intracellular Ca++ ---- Causes Hallucinations
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What is the source/chemistry of LSD?
- Does not occur naturallyPrepared:
- --Chemically, via semi-synthesis from (+)-lysergic acid chloride + diethylamine
- --Microbially, via the growth of Claviceps paspali with the hydroxyethylamide
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The major actions of LSD are on the CNS which affects:
both pyramidal (conical portion of medulla oblongata) and extrapyramidal systems
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Signs/Symptoms of Acute LSD Intoxication
- Mydriasis
- Hypertension
- Tachycardia
- Hyperglycemia
- Hyperthermia
- Piloerection
- Hyperactive tendon reflexes
- Visual Hallucinations
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What is the most common form of LSD abuse?
Tripping - intensify the environment / have a novel experience
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Three well-established AEs of "bad tripping" with LSD include:
- Acute panic reactions
- Hallucinogen Persisting Perception Disorder (suicide is possible)
- Prolonged Psychosis (paranoia & schizophrenia)
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For the diagnosis of Panic Disorder, how many Somatic or Cognitive symptoms does one have to have?
At least 4
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Treatment for Panic Disorder includes:
- BZDs
- SSRIs: Fluoxetine, Paroxetine, Sertraline, Citalopram, Fluvoxamine
- TCAs: Clomipramine and Imipramine
- SNRI: Venlafaxine ER
- MAOI
- Mirtazapine
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Which BZDs are long-acting?
- Chlordiazepoxide
- Clonazepam
- Diazepam
- Flurazepam
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Which BZDs are short/intermediate acting?
- Alprazolam
- Lorazepam
- Oxazepam
- Temazepam
- Triazolam
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Excessive anxiety and uncontrollable worry that persists for at least 6 months is:
Generalized Anxiety Disorder (GAD)
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FDA-approved agents for GAD includes:
- Buspirone
- BZDs
- SSRIs: Paroxetine, Escitalopram
- SNRIs: Venlafaxine ER, Duloxetine
- Beta-Blockers: Propranolol
- Hydroxyzine (Vistaril)
- Diphenhydramine
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Max Buspirone Dose is?
60 mg/day
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Pharmacologic Treatment for Social Anxiety Disorder:
- 1st line: SSRI or Venlafaxine
- 2nd line: BZD (Clonazepam)
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Which BZDs are good to use in the elderly?
**Those that undergo phase 2 metabolism**
- Lorazepam
- OxazepamTemazepam
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BZD-receptor agonists MOA:
Interact with the GABAAα receptor subunit on or near BZD receptors
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Primary difference between BZD-receptor agonists and BZDs is:
BZD-receptor agonists preserve stage 3 NREM sleep whereas BZDs do not
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Ramelteon MOA:
Agonist at the MT1 and MT2 receptors
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Doxepin MOA:
H1 receptor antagonist
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What is the antidote for acetaminophen?
N-acetylcysteine
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What is the antidote for organophosphate?
atropine/pralidoxime
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What is the antidote for methanol/ethylene glycol?
Fomepizole
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What is the antidote for cyanide?
Hydroxycobalamin
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What is the antidote for opiods?
Naloxone
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What is the appropriate therapy for Jimson Weed poisoning?
Physostigmine 0.5 to 2 mg via slow IV push
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What are the risks associated with Dextromethorphan abuse?
- INCOORDINATION
- DROWSINESS
- CONFUSION
- BLURRED VISION
- SLURRED SPEECH
- HALLUCINATIONS (Visual/Auditory)
- CNS DEPRESSION
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Treatment of Dextromethorphan Abuse:
- Supportive Care
- SECONDARY TOXICITY: Acetaminophen, Diphenhydramine, & Decongestants
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