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Schizophreniatime duration and Brain histological findings
Chronic mental disorder with periods of psychosis, disturbed behavior and thought,and decline in functioning that lasts > 6 months. Associated with increase dopaminergicactivity, decrease dendritic branching.
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Schizophrenia symptoms - needed for diagnosis
Diagnosis requires 2 or more of the following(first 4 in this list are "positive symptoms"): Delusions Hallucinations—often auditory Disorganized speech (loose associations) Disorganized or catatonic behavior "Negative symptoms"—flat affect, social withdrawal, lack of motivation, lack of speech or thought
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Prevalence in society of schizophrenia
0.5-1%
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Risk of Twin for schizoprenia -
-Risk of sibling --
twin- 50%
sibling- 10%
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Positive symptoms for schizophrenia
too much dopamine in the mesolimbic tract
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Negative symptoms from where in the brain and why typical antipsych are not good
not enough dopamine in the mesocortical tract
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Dopamine systems of the brain which one controls the: EPS which one regulates prolactin
- -NS modulation of EPS
- -Tuberoinfundibular regulation of prolactin
- -Mesocortical for cognition, socialization
- -Mesolimbic for arousal, memory, behavior
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A patient has delusions hallucination and flattened affect for 3 weeks
Brief psychotic disorder ( MORE THEN ONE day AND LESS THEN A MONTH)
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A patient has delusions hallucination and flattened affect for > 1 mon and < 6 mons
schizopreniform disorder
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Typical antipsychotics help what symptoms in schizophrenia
they help the positive symptoms but have no effect on the progression
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When trying to determine the difference between schizoaffective disorder and depression with psychotic features how do you do it <
What was present first with out the other... in schizoaffective they will have had psychosis with out any depressive symptoms
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A patient has had MDD for 3 years and reports hearing voices telling him he is worthless and to kill himself.
MDD with Psychotic Features.Delusions are typically mood congruent.* Tx w/ Atypical antipsychotic + SSRI or ECT (esp in preggos)
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A patient has had persecutory delusions for the past 3 years ( has be diagnosised with schizoprenia before) . 6 months ago he started having sadness, guilt, insomnia, ↓concentration, SI
Schizoaffective Disorder.(delusions/hallucinations for >2wks in absence of mood ss)*Tx w/ Atypical antipsychotics + SSRI if depression and + Li if manic
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A man is convinced Miley Cyrus is in love with him but is otherwise functional.
Delusional Disorder. *Erotomanic* type. *Non-bizzare*.Tx w/ therapeutic relationship + meds
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DOC for acute agitation or psychosis
*IM* haloperidol.Quick onset of action Blocks ( antagonist) the d2 dopamine receptor
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Haloperidol affects on the nigrostriatal path and affects on the tubularinfundibulum
Nigrostrial - causes EPS Tubularinfundubulum - Hyperprolactinemia
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Low potency antipsycotics: (Low Color Tea)
Chlorpromazine and Thioridazine. Less EPS more anti-Ach—non-neurologicside effects (anticholinergic, antihistamine, and α1-blockade effects).
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Side effects of Chlorpromazine
Corneal deposits
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Side effects of Thioridazine
reTinal deposits
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Side effects of haloperidol
NMS, tardive dyskinesia.
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Neuroleptic malignant syndrome (NMS)—
rigidity, myoglobinuria, autonomic instability,hyperpyrexia. Treatment: dantrolene, D2agonists (e.g., bromocriptine).
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Mneumonic for Neuroleptic syndrom *FEVER *
- *Fever*
- E*ncephalopathy*
- V*itals unstable*
- E*nzymes elevated*
- R*igidity of muscles
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High potency Antiphyscotics : (Try to Fly High)—
: Trifluoperazine, Fluphenazine,Haloperidol—neurologic side effects (EPS symptoms).
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If patient has a history of medication non-adherence
need to give an injection to ensure compliance- Fluphenazine or haldol aka decanoate forms ever 2-4wks.
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Purple grey metallic rash over sun-exposed areas and jaundice?
Chlorpromazine
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Prolonged *QTc* and pigmentary retinopathy?
Thioridazine- prolonged QTC- can lead to torsades
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Pt wakes up with eyes "stuck" looking up or head "stuck" turned to the side. what TX
- *Acute Dystonia*. (<12hrs).
- Tx w/ benztropine or diphenhydramine
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Pt reports feeling like they *"always have to move".*
- Akathesia. (30-90 days).
- Tx w/ propranolol (1stline) or benzo
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Coarse resting tremor, masked facies, unsteady gait, bradykinesiawhat is it and what is the treatment
- Parkinsonism. (>6mo)Tx w/ benztropine/diphenhydramine,
- 2nd line: amantidine or bromocriptine.
- *NOT L-dopa!!*
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After 10 years on fluphenazine, tongue movements and grimacing.
Tardive Dyskinesia. (>years)Tx by stopping antipsychotic and switching to and atypical or clozapine.
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W/in hours of a haloperidol injections, pthas ↑CPK, T = 103F, rigidity, autonomic instability, and delirium
- Neuroleptic Malignant Syndrome. 1st-d/c the offending med.
- 2nd-cooling blankets and dantroline Na or bromocriptine (2ndline).
- Remember that metoclopramide, compazine and droperidol can cause.
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Weight neutral but prolongs the QTc?
Ziprazodone.
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Weight neutral but increases akathesia?
Aripiprazole.
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Weight neutral antipysch med
Ziprazodone & Aripiprazole
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Atypical agent w/ highest risk for EPS and ↑prolactin
Risperidone. But comes in depo shot
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Most assoc w/ weight gain? (but #1 S/E is sedation.)
Olazepine
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Causes orthostasis and cataracts?
Quetiapine (alpha blocking properties)
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Good for tx-refractory schizophrenia?
Clozapine
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Most Common S/E- Clozapine
Sedation, weight gain, ↑blood sugar and lipids
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Most Danagerous S/E- Clozapine
Agranulocytosis, decreased seizure threshold.
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What do you monitor and for how long with clozapine
- CBC --> ANC q week for 6mo and x2wks for next 6mo.
- D/c if WBCs<3000 or ANC<1500
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What the most important 1st question to ask the depressed patient
Sucisidal ideation - because this is the most likely to kill the patient
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RF for Suicidal ideation
#1 - prior attempt > 45 white male with a serious illness a detailed plan, no support decreased support use of ETOH and drugs
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polysomnogram for a depressed person
Early REM latency and more frequent REM
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Hormone that is high in a patient with depression
Coritsol, the dexamethsone supression test would be abnormal
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Medications that might cause Depression ?
IFN, beta-blockers, α-methyldopa, L-dopa, OCPs, ETOH, cocaine /amph withdrawal, opiates.
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Medical diseases that might cause depression?
HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Liver disease, Huntington's, MS, Lupus, *Left-MCA stroke*
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What is the number 1 class of drugs used for the txt of depression and what other disease can you treat with these drugs
SSRI-Fluoxetine, paroxetine, sertraline, citalopram.Also used in OCD, Bulemia, anxiety or premature ejaculation
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SSRI toxicity and tx
- Fewer than TCAs. GI distress, sexual dysfunction (anorgasmia and decreased libido).
- Serotonin syndrome with any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs,TCAs)—hyperthermia, confusion, myoclonus,cardiovascular collapse, flushing, diarrhea,seizures.
- Treatment: cyproheptadine (5-HT2receptor antagonist).
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With SSRI has the most Drug drug interactions
paroxetine
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What SSRI do you not need to taper when stoping
Fluoxetine bc it has short t1/2
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Which SSRi has the fewest Drug drug interactions
citalopram
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if a patient is taking an SSRI and stops it suddenly and experiences HA, N/V/D dizziness and fatigue when stopping suddenly
5HT discontinuation syndrome: more common with sertraline and fluvoxam
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Myoclonic jerks, tachycardia, High BP, hyperreflexia, n/v/d
5HT syndrom - If SSRI + MAOi
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IF you have a loss of erection/ ejaculation
Switch to buproprione (dopamine and norepinephrine inhibitor )
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Contraindications of buproprone
- Alcoholics
- Epileptics
- bulimics
- all because increased rick of seizures.
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Erections lasting longer then 3 hours
trazodone
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Anti-depressant for old skinny sad ladies
MIRTAZEPINE - Sedating increases appetite
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What Anti-depressents NOT for hypertensives OR those taking st johns wart
VENALFAXINE
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Pounding head, flushing, nausea, myoclonus after eating cheese, drinking red wine, taking decongestant or merperidine? and tx
- Hypertensive crisis w/ MAOI.
- Tx w/ 5mg IV phentolamine
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kid ate some unidentified pills out of grandma's purse. Grandma has HTN, HLP, fibromyalgia, insomnia and peptic ulcer disease. He now has dry mouth, tachycardia, vomiting, urinary retention, and seizures-- EKG SHOWS - widened QRS and prolonged QT intervals - what did he eat
tricyclic antidepressants
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Most common cause of death in a kid who ingested Tricyclic antidepressants
Arrhythmia--> torsades, v-fib and death
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What is the Treatment for tricyclic overdose
Treatment is sodium bicarbonate - helps metabolic acidosis and is cardio protective---- but if early on give acitvated charcoal
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Patient who is eating more, gaining weight, sleeping more and has leaden paralysis in the morning.
Atypical depression -these peple are hypersenstivie to rejection and can affect social functing treat with MAOi
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*1 month* After death of her child, a mother feels guilty cant sleep, concentrate, eat, or enjoy her interests.
- Uncomplicated Bereavement.No *suicidal ideation* (other than thoughts of wanting to be w/ loved one). No psychosis (other than hearing/seeing loved one)
- *Rarely tx w/ antidepressants for sxs
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*4 months* after the death of her chihuahua, a woman still feels guilty, can't sleep, concentrate, eat, or enjoy her interests.
*Adjustment Disorder*. Sxs *w/in 3mo* of stressor out of proportion. Can't persist longer than 6mo. *Best treated w/ psychotherapy-( other one is avoidant personality disorder*
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Adjustment disorder
emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (e.g., divorce, illness) Symptoms occur within 3 months of stressor and remit within 6 months of removal of stressor (> 6 months inpresence of chronic stressor).
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Prevalence of Bipolar in the populaiton
1%
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Prevalence in the identical twin broher
90%
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75 y/o man with the frist manic phase
- look for medical cause right frontal hemisphere stoke. -
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Generalized anxietydisorder
Pattern of uncontrollable anxiety *for at least 6 months* that is unrelated to a specific person, situation, or event. Associated with sleep disturbance, fatigue, GI disturbance, and difficultyconcentrating.
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right MCA stroke gives-->
Left MCA stroke gives-->
R-->mania
L-->depression
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GAD- treatment
SSRIs, SNRIs, buspirone, cognitive behavioral therapy.
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schizophrenia how many symptoms do you need to have
- If bizarre delusions or hearing voices you only need 1
- other wise you need 2 for greater then 6 months
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what is the incidence of manic in the population
1%
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Risk for diagnosis of manic in a twin
80-90%
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If these sxs of manic depression occured in a 75 year old patient for the *1st time*
Look for a medical cause *right frontal hemisphere stroke*
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What medication need to be avoided in a patient with manic depression
SSRI and TCA can trigger mania
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Medications to start in a manic depressive patient
Haloperidol or clonazepam for acute *agitation ( if you cant interview them) or delusion*. Lithium or valproic acid or carbamazepine for maintenace
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A *Manic patient* taking Advil develops n/v/d coarse tremor, ataxia, confusion, slurred speech
Lithium toxicity. *Precipatated by NSAIDs*Better pain (safe) med are aspirin or sulindac
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Lithium toxicity - EKG findings
*T wave* flattening or inversion + *U inversions*
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Treatment For lithium toxicity
- Fluid resuscitation,
- emergent dialysis if levels > 4 kidney diz
- if under 4 then then just fluids
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Side effects for lithium toxicity
Weight gain and acne, GI irritation and cramps
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MOA of lithium
- -Inhibits postsynaptic D2 receptor supersensitivity
- -Alters cation transport in nerve and muscle cells and influences reuptake of serotonin or norepinephrine
- -Inhibits phosphatidylinositol cycle second messenger systems
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What is the therapeutic window for lithium
0.6- 1.2
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What is the medical monitoring levels for lithium
- Li levels q4-q8wks
- TFT s q6mo-- ( can cause hypothyroidism)
- Cr, UA, CBC, EKG
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Lithium Contraindications to use
Severe Reanl diseas ( because no clearence ) NOT for preggers or breastfeeding
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why lithium not for preggos
Ebstein abnormality
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Preferred treatment for bipolar in preggos
Lurasidone
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Bipolar + elevated on LFT and hepatitis --also can cause n/v/d skin rash
Valproate
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Bipolar + steven johnsons syndrom
Lamotrogene ( more classic ) can be carbambazepeine
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Bipolar + agranulocytosis
if ANC < 2000
if ANC <1000
- Carbamazepine - check CBC regularly
- if ANC < 2000 - watch closesly every week
- if ANC <1000- stop and change the med
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Bipolar + increase AFP in a 20 wk preggos
Could be valproate or carbamazepine --> Neural tube defect Any one of reproductive age should take 4 g of folate daily
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most common complications of carbamezapine
Rash
Drug -drug interaction
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therapeutic levels Valproate
6-12
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theraputic levels carbamezapine
- 60-120
- ( move the decimals over)
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28 y/o female is brought in by EMS complaining of sob, palpitations and chest pain. She smokes 1 PPD and her only medication is OCPs. She had one of these attacks previously while grocery shopping. She shares with you that she is so afraid of having another one she rarely leaves her house .What is this ... whats the next step
PAIN disorder + agora-phobia * first medical work up--EKG ( check for heart disease), drugs screen, tsh/t4, cardiac enzymes*
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What is the drug regeimen for panic disorder- short term, long drugs
Alprazolam or clonazepam low dose PRN short term-- but SSRI are the preferred drug
*BUT DO NOT *give benzos to drug addicts COPDers or restrictive lung disease
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Counter-indications to benzo's
drug addicts, COPDers, or restrictive lung disease ( suppress the respertory drive)
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Panic disorder on benzo and then stopped taking the benzo now comes in *sxs of a temp 101, convulsions, confusion and hypertension*.
Acute benzo withdrawal reaction Similar to DT tx w/ diazepam or cholardiazepoxides + haloperidol *if psycotic*
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pt presents with a deathly fear of flying that inhibits her from interveiwing at the program of her dreams What is the diagnosis and what are the two best treatments
- Diagnosis : specific phobiaBest txt is CBT w/ flooding or exposure/extinction.
- Medication is benzo for situational use.
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Patient presents with a deathly fear of presenting a case at ground rounds because the surgeons will laugh at herDiagnosis treatment
Social phobia Best txt is propranolol to stop the hyperarousal and then situational benzo
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Patient keeps to herself and doesnt talk to peers b/c she is afraid they will laugh at her
Avoidant personality disorder Best txt is CBT
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A patient is having a diffculty falling asleep b/c she keeps thinking about failing biochem. IN class she cant concentrate b/c she worries her boyfriend will leave her Symtpoms have lasted 6 months
Generalized anxiety Disorder. Best txt is *BUSPIRONE* 5HT1a partial agonist-But doesnt work fast therefore begin treatment with benzos
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