Opioid use disorder
Methadone is a potent, LONG ACTING opioid agonist used in the maintenance treatment of opioid use disorder
Both street and prescription opioids have a high abuse potential. Treatment of addiction includes the use of alternative opioid agonists with fewer euphoric effects and less potential for acute withdrawal and craving, thereby allowing patients to function more productively on a daily basis. In the United States, the most commonly used agonists are methadone and buprenorphine.
Methadone is a full mu-opioid receptor agonist used for withdrawal and maintenance treatment for opioid use disorder. It has a long half-life, which allows it to effectively suppress cravings and withdrawal symptoms; it also blocks the euphoric effects of other opioids by maintaining high tolerance levels.
Adverse effects of methadone include QT interval prolongation and respiratory depression, accounting for its lethality in overdose.
Adolescence
Adolescence often involves some degree of moodiness, intense self-consciousness, and transient emotional outbursts. Assessment of severity, persistence, and degree of social and academic impairment can help differentiate normal adolescent behavior from behavioral changes requiring further evaluation.
PTSD AND SSRIs
post-traumatic stress disorder (PTSD). First-line treatment consists of trauma-focused cognitive behavioral therapy and antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) have the best evidence for efficacy, and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also commonly used.
NOTE : CBT FOR SPICIPHIC PHOPIA
drug-seeking behavior
Physicians have a responsibility to identify signs of potential drug-seeking behavior and prescription drug misuse. This involves being alert to red flags (eg, lost or stolen medication, pain inconsistent with physical examination) and attempting to clarify medication history by using prescription drug–monitoring programs or other information sources.
psychotic depression TX
First-line treatment of psychotic depression consists of either the combination of an antidepressant and antipsychotic or electroconvulsive therapy (ECT).
ECT is a safe and effective treatment that achieves a more rapid response than pharmacotherapy in severely depressed patients who are suicidal or psychotic. IMPORTANT
It is appropriate for severely depressed patients who require rapid intervention (eg, suicidal).
Antidepressants do not work as fast as ECT and may take up to 6 weeks for response.
DEATH
Transient behavioral disturbances are common in children after the death of a loved one. Hallucinations of recently deceased relatives are part of a NORMAL grief reaction and may not be indicative of major psychiatric illness.
Children under age 6 do not understand the finality of death and may believe that it is temporary or reversible. By the age of 7, children usually understand that death is permanent but may have difficulty understanding abstract concepts (eg, soul, heaven) until adolescence.
Alzheimer disease (AD)
AD is the most common type of dementia, characterized by insidious onset (typically age >65), early impairment of recent memory, executive dysfunction, and visuospatial deficits.
As AD progresses, it is commonly complicated by the development of neuropsychiatric symptoms, such as apathy, depressive symptoms, delusions, hallucinations, disinhibition, and agitation. Delusions with paranoid themes (eg, items being stolen, family members replaced by imposters [ie, Capgras delusion]) are common. Behavioral symptoms tend to become more common and problematic as the severity of AD worsens.
ADHD TX
Psychostimulants (methylphenidate and amphetamines) are first-line treatment for ADHD in school-age children and are generally safe and well tolerated.
They have a rapid onset of action, resulting in improvement in core ADHD symptoms for the expected duration of action .
They work by increasing the availability of norepinephrine and dopamine in the prefrontal cortex. IMPORTANTTT
The most common adverse effects include decreased appetite, weight loss, and insomnia.
IMPORTANT
FOOD
BIBOLAR TX
MOOD STABILIZER
Lithium is first-line treatment and has the added benefit of reducing the risk of suicide.
ANTIPHSYCOTICS
SAFTY FIRST
Depressed adolescents may display irritable rather than depressed mood, declining academic performance, and withdrawal from social activities. Initial evaluation of all children and adolescents with suspected depression should include a careful suicide risk assessment.
gender
Gender dysphoria is characterized by a strong and persistent desire to live and be treated as another gender, which causes distress or impairment. It is often accompanied by a desire to change one’s primary or secondary sexual characteristics.
Fetishistic disorder involves sexual urges, fantasies, or behaviors that are focused on a nongenital body part or inanimate object
Bisexuality is a form of sexual orientation defined as being attracted (sexually, romantically, and/or emotionally) to more than one gender.
Separation
Separation anxiety disorder consists of excessive and distressing anxiety (≥4 weeks in children, ≥6 months in adults) due to separation from attachment figures. Children with this disorder often experience physical symptoms and nightmares.
OCD
Obsessions are persistent and unwanted thoughts, urges, or images that often drive an individual to perform compulsions: ritualistic behaviors or mental acts (eg, counting) to alleviate anxiety or prevent a feared event. In this situation, the patient’s obsession with symmetry results in compulsions to cut her food into uniform pieces and groom her hair evenly to prevent a bad outcome.
time-consuming (>1 hr/day) or cause significant distress or functional impairment. OCD is typically a chronic disorder starting in childhood or adolescence.
Specific phobia
vs panic attack
Marked anxiety about a specific object or situation (the phobic stimulus) for >6 months
IMPORTANT TX
CBT with exposure (first-line)
Short-acting benzodiazepines (limited role)
Patients with specific phobia may experience anxiety that reaches the level of a panic attack when exposed to the phobic stimulus. However, panic attacks in specific phobia are always triggered by the phobic stimulus; diagnosis of panic disorder requires that patients experience recurrent, unexpected panic attacks with no trigger
TX SSRI
Narcolepsy VS OSA
NEONATAL
Neonatal abstinence syndrome is caused by infant withdrawal to opiates (eg, heroin) and usually presents in the first few days of life. It is characterized by irritability, a high-pitched cry, poor sleeping, tremors, seizures, sweating, sneezing, tachypnea, poor feeding, vomiting, and diarrhea.
BIPOLAR
VERY IMPORTANT
Patients with ≥1 manic episodes are diagnosed with bipolar I disorder; although most bipolar I patients will experience both major depressive and manic episodes, depressive episodes are not required for diagnosis of bipolar I. Manic episodes can occur with or without psychotic features (eg, delusions, hallucinations).
GABA
GABA is the primary inhibitory neurotransmitter in the brain and is the target of many drugs. Benzodiazepines and barbiturates work by binding to specific sites on GABA A receptors to facilitate inhibitory effects of GABA.
Flumazenil is a GABA A benzodiazepine receptor antagonist used to reverse benzodiazepine intoxication.
Baclofen is an agonist at the GABA B receptor that acts as a skeletal muscle relaxant.
Buprenorphine
Buprenorphine is a partial opioid agonist that has low intrinsic activity (efficacy) for opioid mu-receptors. However, it binds with high affinity (potency) and can prevent binding of other opioid medications. Therefore, buprenorphine acts as an opioid receptor antagonist in the presence of full opioid agonists and can precipitate withdrawal in opioid-tolerant patients with chronic pain.
Serotonin syndrome
Causes
Serotonergic medications, especially in combination (eg, SSRI/SNRI, TCA, tramadol)
Drug interactions: Serotonergic medication & MAOI or linezolid
Intentional overdose of serotonergic medications
Serotonergic drugs of abuse (eg, MDMA)
Clinical features
Mental status changes (eg, anxiety, agitation, delirium)
Autonomic dysregulation (eg, diaphoresis, hypertension, tachycardia, hyperthermia, vomiting, diarrhea)
Neuromuscular hyperactivity (eg, tremor, myoclonus, hyp
BENZO VS BARBITURATES
Benzodiazepines bind GABA A receptors, resulting in an increased FREQUANCY of chloride channel opening in the presence of GABA. Indications for prescribing include short-term treatment of anxiety disorders and alcohol withdrawal syndrome.
Barbiturates (eg, phenobarbital) increase the DURATION of opening of the GABA A receptor–chloride channel in the presence of GABA. Although barbiturates have anxiolytic properties, they are not indicated for the treatment of anxiety disorders because of their potential to induce fatal respiratory depression
Benzodiazepines act by binding to the benzodiazepine binding site, which ALLOSTERICALLY modulates the binding of GABA, resulting in an increased frequency of chloride ion channel opening.
Drug-induced parkinsonism
Drug-induced parkinsonism is an extrapyramidal side effect caused by medications that block D2 receptors (eg, antipsychotics). Management strategies include decreasing or discontinuing the offending medication and treatment with an anticholinergic medication (eg, benztropine).
ADULT ADHD
some symptoms prior to age 12 are required
ADHD frequently persists into adulthood and may go unrecognized or misdiagnosed as an anxiety, mood, or personality disorder.
adults with ADHD are less overtly hyperactive compared to children
