Headaches, Migraines, and Neurological Disorders: A Comprehensive Guide, Exams of Advanced Education

Download Headaches, Migraines, and Neurological Disorders: A Comprehensive Guide and more Exams Advanced Education in PDF only on Docsity! CMN 568 - Unit 5 Exam with complete solutions Diminution of headache in response to typical migraine therapies (e.g. seratonin receptor antagonists or ketorolac) does not rule out _________________ as underlying cause? - Answer- Subarachnoid hemorrhage or meningitis Mcphee p 39 IMMEDIATE TREATMENT: Vascular events - Answer- + Intracranial hemorrhage + Thrombosis + Cavernous sinus thrombosis + Vasculitis + Malignant hypertension + Arterial dissection + Aneurysm McPhee p 39 IMMEDIATE TREATMENT: Infections - Answer- + Abscess + Encephalitis + Meningitis Mc Phee p 39 Causes of headache that require IMMEDIATE TREATMENT - Answer- + Vascular events + Infections + Intracranial masses + Preeclampsia + Carbon monoxide poisioning McPhee p 39 "Thunderclap headache" is the classic presentation of what condition? - Answer- Subarachnoid hemorrhage! Should precipitate IMMEDIATE workup! McPhee p 39 New headache in a patient > ________________ years or with ___________________ (condition) should warrant IMMEDIATE neuroimaging. - Answer- + > 50years + HIV infection McPhee p 39 Headache patients with hx of hypertension (esp uncontrolled htn) should be examined for other features of WHAT? - Answer- Malignant hypertension McPhee p 39 Headache associated with pregnancy? - Answer- Preeclampsia McPhee p 39 Episodic headache associated with triad of hypertension, heart palpitations and sweats is suggestive of __________________. - Answer- Pheochromocytoma McPhee p 39 Symptoms for diagnosis or ruling out migraine in the absence of "classic" presentation (e.g. scintillating scotomoa, unilateral ha, photophobia and n/v)? - Answer- Symtoms: Nausea, photophobia, phonophobia and exacerbation with physical activtiy THREE OR MORE = MIGRAINE < THREE = r/o MIGRAINE McPhee p 39 Critical components of physical exam for complaint of HA? - Answer- + Vital signs + Complete neuro exam + Vision testing (with funduscopic exam) McPhee p 40 Kernig and Brudzinski signs are indicative of what? - Answer- Meningeal irritation McPhee p 40 Scalp and temporal artery tenderness should be performed on pts with HA who are > ______________ years. - Answer- > 60 McPhee p 40 Components of visual exam for pt presenting with HA? - Answer- + Visual acuity (Snellen) Symptoms of migrainous headaches - Answer- + Usually lateral, can be generalized + Usually throbbing, can be dull + Can be associated with anorexia, n/v, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision + Build up gradually and last ≥ 7 hours + Visual disturbances may precede or accompany HA + Triggered by emotional/physical stress, lack of/excess sleep, missed meals, specific foods, ETOH, bright lights, loud noise, menstruation, use of oral contraceptives McPhee 986-7 Symptoms of basilar artery migraine - Answer- + Blindness/visual disturbances throughout both visual fields + Dysarthria + Dysequilibrium + Tinnitus + Perioral/distal paresthesias + transient loss/impairment of consciousness or confusional state. McPhee 987 Symptomatic therapy for migraines - Answer- 1) Rest in darkened room + analgesic (aspirin, acetaminophen, ibuprofen, naproxen) taken right away 2) Prescription therapy Prevention of medication overuse headaches - Answer- 1) Limit simple analgesics to ≤ 15 days per month 2) Limit combination analgesics to ≤ 10 days per month McPhee p 987 Main classes of prescription medications used for migraine therapy - Answer- 1) Ergotamines 2) Triptans McPhee p 987 MIGRAINE: Cafergot - Answer- + *Generic name* -- Ergotamine tartrate (1 mg) + caffeine (100 mg) + *Class* -- Ergotamines + *Indications for use* -- Onset of migraine headache + *Contraindications* -- Avoid during pregnancy, in pts with CV risk factors, and pts taking potent CYP3a4 inhibitors + *Common side effects* + *Dosage* -- 1-2 tablets at onset of migraine or warning symptoms, followed by 1 tablet q 30 minutes if needed, up to 6 tablets per attack. NO MORE THAN 10 days per month! McPhee p 987 MIGRAINE or CLUSTER HA: Sumatriptan - Answer- + *Generic name* -- Sumpatriptan + *Class* -- Triptan + *Indications for use* -- Used to abort migraine attacks or as treatment for cluster HA + *Contraindications* --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease + *Common side effects* -- Nausea and vomiting + *Dosage for migraine* -- SQ, 4-6 mg once, repeat after 2 hours if needed; max dose 12 mg/24 hours --Nasal and PO avajilable, but less effective r/t slower absorption *Dosage for cluster HA* --SQ 6mg or IN 20 mg/spray McPhee p 987 MIGRAINE or CLUSTER HA: Zolmitriptan - Answer- + *Generic name* -- Zolmitriptan + *Class* -- Triptan + *Indications for use* -- Used to abort migraine attacks AND for immediate tx of migraine; also for tx of cluster HA + *Contraindications* --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease + *Common side effects* -- Nausea and vomiting + *Dosage for MIGRAINE* -- PO, 5 mg initially and relief usually occurs within 1 hour. May repeat ONCE after 2 hours. *Dosage for CLUSTER HA* -- IN, 5 or 10 mg/spray McPhee p 987 MIGRAINE or CLUSTER HA or TRIGEMINAL NEURALGIA: Topiramate - Answer- + *Generic name* -- Topiramate + *Class* -- Anticonvulsant + *Indications for use* -- Prophylaxis for migraine and cluster HA + *Contraindications* --CAUTION if use of CNS depressant, use of ETOH, depression, suicidal ideation, hepatic impairment + *Common side effects* -- Somnolence, nausea, dyspepsia, irreiability, dizziness, ataxia, nystagmuse, diplopia, glaucoma, renal calculi, weight loss, hypohidrosis, hyperthermia + *Dosage for MIGRAINE* -- PO, 100 mg divided twice daily *Dosage for CLUSTER HA* -- PO, 100-400 mg daily *Dosage for TRIGEMINAL NEURALGIA* -- PO, 50 mg BID McPhee p 988 Valproic acid (not FDA approved for migraine) - Answer- + *Generic name* -- Valproic acid + *Class* -- Anticonvulsant + *Indications for use* -- Prophylaxis for migraine -- Tx of mania + *Contraindications* -- CONTRAINDICATED in hepatic disease or impairment, pregnancy -- CAUTION in peds, elderly, renal impairment, head injury, hx of hepatic disease + *Common side effects* -- N/V, diarrhea, drowsiness, alopecia, weight gain, hepatotoxicity, thrombocytopenia, tremor, pancreatitis. Blood/liver/glucose tests at 2, 4, 12 weeks initially. + *Interactions* -- Aspirin will ↑ valproate levels -- Carbamezepine or phenytoin will ↓ valproate levels -- Valproate will ↑ warfarin levels! + *Dosage* -- PO, 500 - 1000 mg divided twice daily McPhee p 988, 1094 Candesartan (not FDA approved for migraine) - Answer- + *Generic name* -- Candesartan + *Class* -- Angiotensin receptor blocker Venlafaxine - Answer- + *Generic name* -- venlafaxine (Effexor) + *Class* -- Serotonin-norepinephine reuptake inhibitors (SNRI) + *Indications for use* -- Prophylaxis of migraine -- Depression + *Contraindications* -- CAUTION in concurrent CNS depressant use, ETOH use, pts < 25 years, elderly, pregnancy 3rd trimester, renal/hepatic impairment, bleeding risk, HTN, hyperthyroid, recent MI + *Common side effects* - HA, nausea, somnolence, dry mouth, dizziness, diaphoresis, sexual dysfunction, anxiety, weight loss, tinnitus, insomnia, nervousness, HTN (monitor BP) + *Dosage* -- MIGRAINE -- PO, 37.5 - 150 mg extended release once daily -- DEPRESSION -- More effective with doses > 200 mg/day PO. + *Notes* -- Few drug-drug interactions. -- No significant anticholinergic side effects -- ↑ risk of lethal arrhythmias compared to SSRIs but ↓ risk than TCAs. McPhee p 988, 1090 TRIGEMINAL NEURALGIA: Phenytoin - Answer- + *Generic name* - phenytoin + *Class* -- Antiseizure + *Indications for use* - Tx of trigeminal neuralgia + *Contraindications* CONTRAINDICATED in sinus bradycardia, SA block, AV block CAUTION in CV disease, hypotension, ETOH use, elderly, renal/hepatic impairment, DM, thyroid disease, depression + *Common side effects* - Nystagmus, ataxia, sedatino, confusion, blood dyscrasias, SLE, peripheral neuropathy + *Dosage* -- PO, 200 - 400 mg daily McPHee p 990 Carbamazepine - Answer- + *Generic name* - Carbamazepine + *Class* - Antiseizure + *Indications for use* -- Tx of trigeminal neuralgia -- Tx of bipolar in pts who cannot take lithium (doesn't work or ↑ side effects) + *Contraindications* CONTRAINDICATED in pts using MAOIs, bone marrow depression, sensitivity to TCAs CAUTION in CNS depressant use, ETOH use, elderly, asian, hepatic/renal impairment, CV disease, arrhythmia risk (MONITOR WITH serial blood counts and LFTs) + *Common side effects* -- Nystragmus, dysarthria, diplopia, ataxia, drasiness, nausea, hepatoxicity, hyponatremia + *Interactions* -- Will ↑ carbamazepine levels! -- NSAIDs (except aspirin), erythromycin, isoniazid, some CCBs (verapamil and diltiazem, but not nifedipine), fluoxetine, cimetidine (Tagamet). + *Dosage* -- Trigeminal neuralgia: 400 - 1600 mg (immediate or extended release) divided in 2 daily doses -- Bipolar: Start at 400-600 PO daily and increase to 800 - 1600 PO daily. McPhee p 990, 1096 Clomipramine - Answer- + *Generic name* - Clomipramine + *Class* - Tricyclic antidepressants (TCAs) + *Indications for use* - OCD in adults + *Contraindications* CONTRAINDICATED IN acute MI recovery CAUTION IN elderly, < 25 years, GI/GU obstruction, urinary retention, seizure disorder, thyrpid disease, DM, asthma, hepatic/renal impairment, bipolar disorder, ETOH abuse, suicide risk. + *Common side effects* - Xerostomia, drowsiness, tremor, dizziness, HA, consiptaion, fatigue, n/v, etc. + *Dosage* -- OCD: 150-250 mg PO qhs (Start at 25 mg po QD and increase gradually over weeks) NOTE for OCD: Check plasma levels 2-3 weeks after a dose of 50 mg/day is reached to keep plasma levels ↓ 500 ng/mL to avoid toxicity Fluoxetine - Answer- + *Generic name* - Fluoxetine + *Class* -- SSRI + *Indications for use* -- OCD in adults -- Depression + *Contraindications* CAUTION IN ETOH use, concurrent CNS depressant use, elderly, pts < 25 years, pregnancy 3rd trimester, hepatic impairment, QT issues, bradycardia, DM + *Common side effects* -- Insomnia, nausea, HA, diarrhea, libido ↓, dirrhea, anorexia, somnolence, anxiety, can ↑ serum concentrations of some meds. + *Dosage* -- OCD: Up to 60-80 mg day (start at 20 qd and increase after several weeks. taper to d/c) -- Depression: Starting dose of 10 mg/day for 1 week, before increasing to avg daily dose of 20 mg/day. McPhee xxx, 1089 Desvenlafaxine - Answer- + *Generic name* + *Class* + *Indications for use* + *Contraindications* + *Common side effects* + *Dosage* Lithium - Answer- + *Generic name* - Lithium + *Class* - Antipsychotic + *Indications for use* -- Tx of mania, bipolar disease + *Contraindications* -- CAUTION - Breastfeeding, elderly, renal issues, thyroid disease, ETOH use + *Common side effects* -- EARLY: Mild GI sx, fine tremors, slight weakness and sedation. Moderate polyuria and polydipsia. Thyroid and kidney issues sometimes (check function at 4 -6 month intervals) -- LONG TERM: Cogwheel rigidity and sometimes EPS. + *Interactions* -- ↑ lithium levels! AVOID thiazide diuretics (loop ok), ACEI, fluoxetine, ibuprofen, K- sparing diuretics + *Dosage* -- Bipolar/Manic disorder: start at 300 mg po bid or tid, measure trough after 5 days, 12 hours after last dose. Peak serum levels in 1 - 3 hours. McPhee p 1094-5 Lorazepam - Answer- + *Generic name* - Lorazepam (valium) What is a post-traumatic HA? - Answer- + Occurs after a closed head injury. + Usually appears within a day or so following injury, may worsen over ensuing weeks, and gradually subsides + HA which START 1-2 weeks after injury are probably not directly attributable to injury McPhee p 989 What is a primary cough HA? - Answer- + Severe head pain produced by coughing, lasting for a few minutes or less + CT and MRI scans should be done in all cases to check for lesions or tumors, and should be repeated annually for several years. + Symptoms may clear after lumbar puncture McPhee p 989 Features of HA due to intracranial mass lesions - Answer- + New or worsening HA in middle or later life (should prompt for brain imaging) + Pain may be worse upon lyind down, awaken pt at night or peak in morning after overnight recumbency. + Sx suggestive of infection or malignancy include: fever, night sweats and weightloss; immunocompromise; hx or malignancy McPHee p 989 In approximately HALF of pts with chronic dialy HA, _____________ is responsible. - Answer- + Medication overuse NOTE: Initiating migraine preventive tx EARLY permits withdrawal of analgesics and eventual relief of HA McPhee 990 When to refer pt with sx of HA? - Answer- + Thunderclap onset + Increasing HA unresponsive to simple measures + Hx of trauma, HTN, fever, visual changes + Presence of neuro signs or scalp tenderness McPhee p 990 ESSENTIALS OF DIAGNOSIS: Trigeminal neuralgia - Answer- + Brief episodes of stabbing ffacial pain + Pain in territory of 2nd and 3rd division of trigeminal nerve + Pain exacerbated by touch :McPHee p 990 Types of pts most commonly affected by trigeminal neuralgia - Answer- + Women more often than men + Middle/later life McPhee p 989 Differential dx for trigeminal neuralgia - Answer- + Multiple sclerosis -- Suspect when < 40 years of age + Other neoplasm when symptoms are BILATERAL McPhee p 990 Clinical findings in trigeminal neuralgia - Answer- + Sudden lancinating facial pain + Commonly located near one side of mouth + Pain shoots toward ear, eye or nostril on same side McPhee p 990 Atypical facial pain - Patient profile and treatment - Answer- + Common in middle-aged women, many of them depressed + Trials of simple analgesics and TCAs, carbamazepine, phenytoin; although response is often disappointing. McPhee p 991 Glossopharyngeal neuralgia - Symptoms and tx - Answer- + Symptoms: Trigeminal neuralgia-like pain occurs in throat, near tonsillar fossa and sometimes deep in ear and at back of tongue + Pain may be precipiated by yawning, swallowing, chewing, talking and is cometimes accompanied by syncope + No underlying structural issue, often. MS is sometimes responsible + Oxcarbasepine and carbamazepine are tx of choice McPHee p 991 Postherpetic neuralgia - Patient profile, symptoms and treatment - Answer- + Occurs in 15% of pts with hx of shingles (usually when rash is severe and when 1st division of trigeminal nerve is affected) + WITHIN 72 hours of rash onset, reduce post-herpetic neuralgia by ALMOST HALF with: -- Acyclovir (800 mg 5 times daily) -- Valacyclovir (1000 mg TID) + Topical application of capsacian cream and topical lidocaine may be helpful. McPHee p 991 Other causes of facial pain - Answer- + TMJ dysfunction -- Tenderness of mastication muscles and pain begins with chewing + Giant cell arteritis -- pain develops progressively with mastication + Sinusitis and ear infections -- Pt has hx of respiratory infection, fever and sometimes nasal/aural discharge + Glacuoma - Pain in periorbital region + Cardiac issues - Jaw pain may be related to MI or angina pectoris, especially when precipitated by exertaion and when radiating. McPhee p 991 Most common cause of subarachnoid hemorrage - Answer- Trauma. Prognosis depends on severity of head injury McPhee p 1007 Cause of spontaneous subarachnoid hemorrhage - Answer- Non-traumatic, frequently results from rupture of arterial sacular ("berry") aneurysm, or from an AVM. McPhee p 1007 S/S of subarachnoid hemorrhage - Answer- + Thunderclap headache of severity never before experienced + Followed by N/v and a loss or impairment of consciousness that can either be transient or progress toward coma and death + If consciousness is regained, pt is often confused and irritable and may show other signs of altered mental status. + Neuro exam reveals nuchal rigity and other signs of meningeal irritation McPhee p 1007-8 Signs of aneurysm prior to rupture - Answer- + Usually asymptomatic unless they compress adjacent structures. + Some pts have headaches with nausea and neck stiffness a few hours or days before massive hemorrhage occurs. (r/t "warning leaks") McPhee p 1008 What patients are most at risk for subarachnoid hemorrhage? - Answer- + Older age + Female + Non-white + Hypertensive + Smoker + ↑ ETOH consumption + Previous symptoms + Posterior circulation aneurysms + Other stress disorders (e.g. PTSD) + Personality disorders exacerbated by stress + Somatic disorders with psychic overlay NOTE: Adjustment disorders are *wholly situational* and usually resolve when the stressor resolves or the individual effectively adapts to the situation. McPhee p 1059 An adjustment disorder occurs within ________________________ (time period) of an identifiable stressor. - Answer- + 3 months Treatments for adjustment disorder - Answer- 1) Behavioral (e.g stress reduction techniques to mitigate symptoms when recognized to keep them from blowing up, keeping log of stress precipitators, relaxation, mindfulness, exercise 2) *Social* (clarifying problem in the patient's psychosocial context to allow pt to view it in proper fram and facilitate decision making to mitigate stressor) 3) *Psychological* (Supportive psychotherapy -- usually not long term -- to help pt develop coping mechanisms. Cognitive/behavioral therapy has also shown useful.) 4) *Medical* (Sedatives for SHORT TIME to provide relief from acute anxiety sx. Also, short-term SSRIs targeting dysphoria and anxiety might be helpful.) McPhee p 1060 ESSENTIALS OF DIAGNOSIS: PTSD - Answer- + Exposure to traumatic or life- threatening event + Flashacks, intrusive images and nightmares in which pt re-experiences event + Avoidance symptoms (e.g. social, numbing) and avoidance of triggers + Increased vigilance, such as startle response and difficulty falling asleep + Symptoms impair functioning McPhee p 1060 PTSD is more common when associated with WHAT TYPE of injury? - Answer- PHYSICAL, rather than psychological. McPhee p 1060 Confirming dx of PTSD lies in the ability to do WHAT? - Answer- Identify the hx of exposure to actual or perceived life-threatening event, serious injury or sexual violence McPhee p 1060 Useful screening instruments for PTSD - Answer- + Primary Care PTSD Screen + PTSD Checklist McPhee p 1060 In 75% of cases of PTSD, it occurs with comorbid existence of WHAT OTHER disorders? - Answer- + Depression + Panic disorder NOTE: There is considerable overlap in symptoms between the three. McPhee p 1061 Types/duration of psychotherapy as tx for PTSD - Answer- + Psychotherapy should begin as soon as possible after the event and should be brief (8 - 11 sessions) as soon as individual feels safe. + Types of psychotherapy which have proven useful: -- Cognitive processing therapy -- Prolonged exposure therapy -- Eye-movement desensitization reprocessing McPhee p 1061 What kind of medications are useful in ameliorating depresssion, panic attacks, sleep disruption and startle responses in PTSD pts? - Answer- SSRIs + They are the only class of meds approved for tx of PTSD + Examples: Sertraline (Zoloft), paroxetine (Paxil) McPhee p 1061 Other types of medications often used to treat peripheral symptoms of PTSD - Answer- + Beta blockers - Helps with anxiety (e.g. propranolol) + Noradrenergic agents - Help with hyperarousal (e.g. clonadine) + α-adrenergic blockers - Decrease nightmares (e.g. prazosin) + Antiseizure medications - Mitigate impulsivity and difficulty with anger management (e.g. carbamazepine) + Benzodiazepines - Reduce anxiety and panic attacks but CAUTION WITH DEPENDENCE (e.g. clonazepam) NOTE: 2nd generation antipsychotics have not proven useful. McPhee p 1061 ESSENTIALS OF DIAGNOSIS: Anxiety disorders - Answer- + Three primary types: Generalized anxiety disorder, panic disorders, phobic disorders + Persistent excessive anxiety or chronic fear and associated behavioral disturbances + Somatic symptoms referable to the autonomic nervous system or to a specific organ system (e.g. dyspneal, palpitations, paresthesias) + Not limited to an adjustment disorder + Not a result of physical disorders, other psychiatric conditions (e.g. schizophrenia) or drug abuse + Anxiety disorders may be long standing and difficult to treat. McPhee p 1062 Clinical Findings and treatment: Generalized Anxiety Disorder - Answer- FINDINGS + Anxiety symptoms of apprehension, worry, irritability, difficulty in concentrating, insomnia or somatic complaines are present *more days than not for at least 6 months* + Focus of anxiety can be a number of everyday activities TREATMENT + Antidepressants (includings SSRI, SNRI) are 1st line medications, but may take awhile to start working. --Venlafaxine and duloxetine (SNRIs) are approved for tx of GAD. Start low and titrate upward -- Escitalopram and paroxetine (SSRIs) are also approved for GAD. -- TCAs and MAOIs are 2nd or 3rd line tx. + Benzodiazepines can provide immediate symptom relief but can lead to dependence. --Diazepam and clorazepate are most rapidly absorbed PO. --Lorazepam is better for use in elderly and pts with liver dysfunction. -- Avoid long acting benzos (e.g. flurazepam and diazepam) in older adults r/t long half- lives. OTHER TREATMENT + Cognitive behavioral tx appears to work. McPhee p 1063-4 Clinical Findings and treatment: Panic Disorder - Answer- FINDINGS: + Recurrent, unpredicable episodes of intense surges of anxiety accompanie by marked physiologic manifestations. + Key to diagnosis is psychic pain individual expresses. + Onset usually < 25 years, female to male ratio is 2:1 + Consider MI, phyochromocytoma, hyperthyroid and drug reactions in differential dx TREATMENT - MEDICATION + Antidepressants are 1st line treatment --- Fluoxetine, paroxetine and sertraline (SSRIs) are approved for panic disorder --- Venlafaxine (SNRI) is approved for panic disorder + Benzos are best used early in tx, because dependence is possible. --- Taper meds like clonazepam and alprazolam after antidepressant starts working. --- Paradoxical reactions to short-acting benzos have been reported. --- Reversal agent is flumazenil. BEHAVIORAL + Biofeedback -- e.g. using electronic stethoscopie to amplify ↑ peristalsis so pt can recognize and learn to identify and change sounds. SOCIAL + Family members should come for appts with pt. + Ongoing communication with employer may be important. NOTE: Prognosis better if primary clinician can intervene early before situation deteriorates. McPhee p 1068-9 ESSENTIALS OF DIAGNOSIS: Chronic pain disorders - Answer- + Chronic complaints of pain + Symptoms frequently exceed signs + Minimal relief with standard tx + History of having seen many clinicians + Frequent use of several nonspecific medications NOTE: Counterproductive to speculate whether or not pain is real. IT IS REAL TO PATIENT. McPhee p 1069 Components of chronic pain syndrome - Answer- + Anatomic changes + Chronic anxiety and depression + Anger + Changed lifestyle McPhee p 1069 Chronic pain patients have a marked ____________ in pain threshhold. - Answer- + decrease McPhee p 1069 Cornerstone to a unified approach to chronic pain syndromes is __________________________________. - Answer- A comprehensive behavioral program. McPhee p 1069 In the case of chronic pain, the clinician must shift from the idea of biomedical care to ________________________. - Answer- Ongoing care of the patient. McPhee p 1069 Behavioral approaches to chronic pain - Answer- + Assign patient self-help tasks graded up to maximal activty as a means of positive reinforement. + Avoid positive reinforcers for pain such as marked sympathy and attention to pain. + Emphasize a positive response to productive activities which remove the focus from the pain. + Hypnosis tends to be more effective in patients with a high level of denial who are more responsive to suggestion. McPhee p 1070 Attitude of clinician to patient with chronic pain - Answer- Honesty, interest and hopefulness -- not for a cure but for control of pain and improved function. McPhee p 1070 Medical management of chronic pain - Answer- + SNRIs (e.g. venlafaxine, milnacipran and duloxetine) and TCAs (e.g. nortriptyline) in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes. + Fibromyalgia -- Both duloxetine and milnacipram are approved for tx. + Duloxetine is approved in chronic pain conditions. + SNRIs are safer in overdose than TCAs. + Gabapentin and pregabalin anticonvulsants have been shown to be useful in somatic symptom disorders and fibromyalgia. McPhee p 1070 ESSENTIALS OF DIAGNOSIS: Most depressions - Answer- + Mood varies from mild sadness to intesnse despondency and feelings of guilt, worthlessness and hopelessness + Difficulty in thinking, including inability to concentrate, ruminations and lack of decisiveness. + Loss of interest, with diminished involvement in work and recreation + Somatic compaints such as disrupeted, lessend or excessive sleep; loss of energy; change in appetite; decreased sex drive McPhee p 1083 ESSENTIALS OF DIAGNOSIS: Some severe depressions - Answer- + Psychomotor retardation or agitation + Deulsions of a somatic or persecutory nature. + Withdrawal from activties + Physical symptoms of major severity, e.g. anorexia, insomnia, reduced sexual drive weight loss and various somatic complaints + Suicidal ideation McPhee p 1083 ESSENTIALS OF DIAGNOSIS: Possible symptoms in mania - Answer- + Mood ranging from euphoria to irritability + Sleep disruption + Hyperactivity + Racing thoughts + Grandiosity or extreme overconfidence + Variable psychotic symptoms. McPhee p 1083 Depression may be the final expression of 3 things: - Answer- 1) Genetic factors (e.g. neurotransmitter dysfunction 2) Developmental problems (personality problems, childhood events) 3) Psychosocial stresses (divorce, unemployment) McPhee p 1083 True/false: Depression is a normal response to loss - Answer- FALSE. Sadness and grief are normal, but depression is not. Grief is usually accompanied by intact self-esteem, whereas depression is marked by a sense of guilt and worthlessness. McPhee p 1083 CLINICAL FINDINGS: Adjustment disorder with depressed mood - Answer- + Depression occuring in reaction to some identifiable stressor or adverse life situation. + Anger is often associated with the loss, and this in term often produces a feeling of guilt + Occurs within 3 months of the stressor and causes significant impairment in social or occupational functioning + The presence of a stressor is NOT the determining diagnostic! It is the resultant syndromal complex. McPhee p 1084 Subcategories of "major depressive disorder" - Answer- 1) Psychotic major depression 2) Major depression with atypical features 3) Melancholic major depression 4) Major depression with seasonal onset (SAD) 5) Major depression with peripartum onset + Corticosteroids and oral contraceptives are associated with depression and hypomania + Anti-HTN meds likemthyldopa, guanethidine and clonidine have been associated with development of depressive episodes, as have dititalis and antiparkinsonism medications. + Interferon is strongly associatd with depressed mood and fatigue as a side effect McPhee p 1085 Differential diagnoses with depression - Answer- + Personal life adjustment problems + Medication side effects + Schizophrenia, partial complex seizures, organic brain syndromes, panic disorders and anxiety disorders. + Thyroid dysfunction and other endocrine disorders + Malignancies + Strokes McPhee p 1085 SUICIDE: Differences between men and women - Answer- Men > 50 years old are more likely to COMPLETE a suicide, bc of tendency to use violent means Women make MORE ATTEMPTS but are less likely to complete. McPhee p 1085 A patient is at HIGH RISK if he thinks about suicide > _____________ hours per day - Answer- ONE McPhee 1086 Four groups of antidepressants - Answer- 1) "Newer" antidepressants - SNRIs, SSRIs, buproprion, vilazodone, vortioxetine, and mirtazapine 2) TCAs and classically similar 3) MAOIs 4) Stimulants, ECT and repetitive transcranial magneyic stimulation. McPhee p 1086 Depression medication -- If no background information is available, what two medications are good STARTING places? - Answer- FULL TRIALS can be started with either: + Sertraline (Zoloft) - 25 mg PO, increase gradually to 200 mg + Venlafaxine (Effexor) - 37.5 mg/day PO and titrated graually to maximum dose of 225 mg/day. +++Monitor for worsening mood or suicidal ideatio ecry 1-2 weeks until week 6. McPhee p 1086 In patients < ______________ years, there is an association between antidepressant use and increased suicidality. - Answer- 25 (TWENTY FIVE) What is the STAR*D trial and what does it suggest with regard to medication for depression? - Answer- If response to 1st medication is inadequate, best alternatives are: 1) Switch to a second agent from the same or different class of antidepressant 2) Try augmenting the 1st agent with buproprion (150-450 mg/day), lithium (300-900 mg/day PO), thyroid medication (liothyronine 25-50 mcg/day PO) or a 2nd generation antipsychotic (aripiprazole 5-15 mg/day or olanzapine 5 - 15 mg/day). <---- This approach is often taken when there has been at least a PARTIAL response to the initial drug. McPhee p 1088 Notes on SSRIs - Answer- Examples: Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram (Lexapro) ADVANTAGES: + Generally well tolerated + Starting dose is often therapeutic + Lower lethality in overdose DOSING + Most given in AM to not interfere with sleep --- EXCEPTION: Paroxetine and fluvoxamine have sedation and are given at bedtime. + Given ONCE daily + Usually some delay in response -- EXCEPTION: Fluoxetine requires 2-6 weeks for depression 4 - 8 weeks for panic disorder, 6 - 12 weeks for OCD. + Most have short half-life and lesser effect on hepatic enzymes, and less effect on metabolism of other meds, and more rapid clearing if side effects occur. INDICATIONS + Depression, panic disorder, bulimia, GAD, OCD and PTSD SIDE/ADVERSE EFFECTS + HA, nervousness, tinnitus, nausea, insomnia + Akathisia is common + Abnormal bleeding can occur r/t affected platelet seratonin levels -- NOTE: Sertraline and escitalopram are safest to use with warfarin. + Sexual side effects very common + High doses or combinations with MAOIs can cause *seratonin syndrome* + Safer to use than TXAs in patients with cardiac disease. Sertraline is ok for pts with AMI or unstable angina. McPhee p 1089 Symptoms of seratonin syndrome - Answer- + Rigidity + Hyperthermia + Autonomic instability + Myoclonus + Confusion + Delirium + Coma McPhee p 1089 Symptoms of withdrawal from antidepressants - Answer- Diziness, paresthesias, dysphoric mood, agitation and a flu-like state have been reported for the SSRIs and SNRIs, but may also occur with TCAs and MAOIs. Discontinue over a period of WEEKS or MONTHS to reduce risk of withdrawal phenomena McPhee p 1090 Commonly used antidepressants: SNRIs (from $ to $$$, sedation from 1 - 4) - Answer- + Duloxetine (Cymbalta): 40 mg qd (max 60 mg qd) S0 + Desvenlafaxine (Pristiq): 50 mg qd (max 100 mg qd) S1 + Milnaciprin: 100 mg qd (max 200 mg qd) S1 + Levomilnaciprin: 40 mg qd (max 120 mg qd) S1 + Venlafaxine XR (Effexor): 150-225 mg qd (max 225 qd) S1 McPhee Table 25-7 Commonly used antidepressants: SSRIs (from $ to $$$, sedation from 1 - 4) - Answer- + Citalopram (Celexa): 20 mg qd (max 40 mg qd) S0 + Escitalopram (Lexapro): 10 mg qd (max 20 mg qd) S0 + Paroxetine (Paxil): 20-30 mg qd (max 50 mg qd) S1 + Sertraline (Zoloft): 50-100 mg qd (max 200 mg qd) S0 + Fluvoxamine (Luvox): 100-300 mg qd (max 300 qd) S1 + Fluoxetine (Proxac): 5-40 mg qd (max 80 mg qd) S0 McPhee Table 25-7 because they do not require serum monitoring! - Answer- Lithiuim or valproic acid, 2nd generation antipsychotics NOTE: 2nd gen antipsychotics (eg. risperadone, olanzapine, aripiprazole) seem to be more rapidly effective. Gradually reduce dosage when lithium or valproic acid is started. McPHee p 1093 What medications are approved for maintenance of bipolar disorder, to prevent subsequent cycles of mania and depression? - Answer- Olanzapine quetiapine ziprasidone aripiprazole long acting injectable risperidone McPHee p 1094 ________________ is a 1st line tx for mania because it has a broader safety index than lithium. - Answer- Valproic acid INTERACTIONS: McPHee p 1094 Uses of lithium - Answer- + Works best in patients with Bipolar 1 disorder + Works bets in patients with low frequency of episodes. + Sometimes useful in prophylaxis of recurrent unipolar depressions. + Can be used alone long-term for dx of bipolar disease in MOST patients. McPhee p 1094 Criteria for adult-diagnosed ADHD - Answer- ≥ 5 inattention symptoms or ≥ 5 hyperactivity/impulsivity symptoms are required McPhee p 1097 Causes of insomnia - Answer- + Depression + Manic disorders + Abuse of ETOH (can be cause of or secondary to a sleep disturbance) + Heavy smoking (> pack/day) + Other medical conditions (e.g. delirum, pain, respiratory distress, uremia, asthma, thyroid disorders, nocturia r/t BPD) McPhee p 1099 Treatment of insomnia - Answer- + *Psychological* -- Start here for primary insomnia -- Good sleep hygiene + *Medical: Short 2 week course* -- BENZOS: Lorazepam (0.5 mg) or temazepam 7.5 - 15 mg) -- NON-BENZOS: Zolpidem (5 mg ♀, 5-10 mg ♂), zaleplon (5-10 mg). McPhee p 1099 Components of good sleep hygiene - Answer- + Go to bed only when sleepy + Use bedroom for sleep and sex + Get up if not asleep in 20 minutes + Get up at same time every day + No caffeine/nicotine in pm + Daily exercise + Avoid ETOH + Limit fluids in PM + Use relaxation techniques + Bedtime ritual and routine for going to sleep McPHee p 1099 What is "kindling" - Answer- + Repeated stimulation of brain that makes it more susceptible to focal bgrain activtiy with minimal stimulation. + Stimulants and depressants lead to kindling McPhee p 1102 Definition of at-risk drinking - Answer- + 4 drinks/day or 14 drinks/week for MEN + 3 drinks/day or 7 drinks/week for WOMEN McPhee p 1103 Tool for assessing ETOH withdrawal symptom severity? - Answer- CIWA-Ar: Max score = 67 points + Minimal withdrawal sx -- < 8 pts -- PO benzo with taper over 3 days -- Assess sedation and sx q 6 hours + Mild withdrawal sx -- 8 to 15 pts -- PO/IV benzo hourly for 2 hours, then q 4 hours -- Assess sedation and sx q 4 hours + Moderate withdrawal sx -- 16 to 20 pts -- PO/IV benzo hourly for 2 hours, then q 2 hours -- Assess sedation and sx 30 minutes after each PO dose and 15 minutes after each IV dose. + Severe withdrawal sx -- 21 pts McPHee p 1106 Grades of withdrawal from opioids - Answer- + Grade 0 - Craving/anxiety + Grade 1 - Yawning, lacrimation, rhinorrhea, perspiration + Grade 2 - Above + mydriasis, pilerection, anorexia, tremors, hot/cold flashes with generalized aching + Grades 3/4 - ↑ intensity of above + ↑ temp, BP, pulse, RR/D If very severed, vomiting, diarrhea, weight loss, hemoconcentration and spontaneous orgasm Treatment for withdrawal starts at Grade 2 McPHee p 1109 What are the Kleinmann questions? - Answer- A set of questions used to elicit the patient's thoughts about the cause of their depression: 1) What do you think caused your problem? 2) Why do you think it started when it did? 3) What do you think your sickness does to you? 4) How severe is illness? Short or long course? 5) What kind of tx should you receive? 6) What are the most important results for you? 7) What are the chief problems your illness has caused in YOU? 8) What do you fear most about your sickness? Medscape article 3 types of childhood depressions - Answer- 1) Major depressive disorder --Sad or depressed mood ≥ 2 weeks. Described as "irritability" and may have somatic manifestations in younger kids. Adolescents engage in risky behavior and may become withdrawn or aggressive. 2) Dysthymia or dysthymic disorder -- Chronic depression that does not meet full MDD criteria and is present on MOST days for ≥ 1 year. Sx are less life-threatening but do interfere with function 3) Bipolar affective disorder -- Sx of MDD but have manic episodes that alternate with depression. NOTE: Sx are sometimes mistaken for ADHD and medical tx for that disorder can intensify mania! USPSTF recommends screening for adolescents WHEN? - Answer- Ages 12-18 AND when adequate systems are in place to ensure accurate dx, psychotherapy and follow up! ACPM article When does Bright Futures (AAP) suggest beginning screening for depression? - Answer- At the 11 year old visit ACPM Education of adolescent patient and family on a dx of depression - Answer- 1) It's an illness, not a weakness. Very common. Genetic + environment 2) Functional impairment in various domains can be manifestations of illness 3) Can be recurrent. Recovery may take awhile 4) Stay with tx plan long term is KEY 5) Parent/child stress may be part of problem 6) Ask adolescent about future goals (if none, be wary of suicidal ideation) ACPM Horner Syndrome mnemonic - Answer- P - Ptosis A - Anhydrosis M - Miosis Model programs for treating depression in older adults - Answer- + Healthy IDEAS (Identifyin Depression, Empowering Activities for Seniors): In-home treatment + IMPACT (Improving Mood - Promoting Access to Collaborative Treatment): Clinic- based depression program + PEARLS (Program to Encourage Active, Rewarding Lifestyles for Seniors): Home- based care for minor depression and dysthymia. CDC Healthy Aging Article Potential causes of treatment-resistant depression - Answer- + Misdiagnosis + Inadequate tx, undertreatment or starting tx too late + Failure to achieve initial remission + Nonadherence + Failure to address concurrent disorders -- Occult substance abuse -- Occult general medical conditions -- Concurrent Axis I or II disorders Johns Hopkins PPT Minimum recommended trial period for initial medication treatment - Answer- MINIMUM of 6 - 12 weeks. Johns Hopkins PPT Interviewing pt about non-adherence to depression medication regimen - Answer- + Ask pt what they are taking and when + 50% of pts fail to take meds as prescribed due to lack of understanding of instructions or unnatural fears of side effects/drug dependence + Ask about troubling and intolerable side effects, including sexual dysfuntion, nausea, akathisia, etc. Johns Hopkins PPT 4 D Model for managing Treatment Resistant Depression - Answer- + FIRST D - Diagnosis -- Is this major depression? -- Has bipolar disorder been r/o? -- Has a medical cause been r/o? -- Has psychosis been r/o? -- Has substance/ETOH use been r/o? + SECOND D - Right DRUG -- Was appropriate drug (or combination of drugs) selected for pts individual needs? -- Were comorbidities considered when selecting drug? -- Were adverse events optimally managed? + THIRD D - Right DOSE -- Was pt given right dose of med? -- Was pt's age, weight, sex and ethnic background considered in dose determination? -- Was patient compliant with med? + FOURTH D - DURATION -- Did pt take medication for a MINIMUM of 6 - 8 weeks? -- Did patient skip doses or reduce dose on their own? Johns Hopkins PPT Medication approved for treatment of depression in children and adolescents? - Answer- Fluoxetine (Prozac) FDA Medication approved for tx of OCD in children and adolescents? - Answer- + Fluoxetine (Prozac) + Sertraline (Zoloft) + Fluvoxetine (Luvox) FDA Acute HA - RED FLAGS in adults - Answer- + New onset HA in pt > 50 yrs + Thunderclap HA + HA + fever + Hx head trauma + Vision changes + Hx of/current HTN + Immunosupprssion + Positive neuro exam (e.g. dilated eyes, slowed responses, etc.) + Changes in personality BBB Acute HA - RED FLAGS in children - Answer- + HA in pt < 5 yrs + New or worsening HA in previously healthy child + Worst HA of life + FUO + HA = BE CONCERNED! + Night-time HA that wakes child + Posterior HA at back of skull + HA with vomiting, esp w/o nausea + ↑ HA with straining or postural chgs + Neuro deficits + Neurocutaneous stigmata (cafe au lait spots or hypopigmentation) + Recent head trauma BBB Episodic migraine vs. chronic migraine - Answer- Episodic is < 15 days/month Chronic is > 15 days/month BBB Meds for symptomatic relief of migraine - Answer- + Cafergot: 1/100 mg (ergot/caff), start with 1-2 tabs, repeat q 30 min to max dose of 6 mg per 24 hours + Triptans -- CONTRAINDICATED in CV disease -- CAUTION in pregnancy, hemiplegic or basilar migraines, hx of stroke or TIA, hx of DM, hyperlipidemia or obesity May be combined with naproxen BBB Conditions which must be ruled out before a diagnosis of colic is made - Answer- + Gastroesophageal reflux + Cow's milk allergy + Undetected corneal abrasion + UTI + Unrecognized traumatic injuries (incl. child abuse) Hay p 82 Behavioral states in children - Answer- + Crying state + Quiet alert state + Active alert state + Transitional state + Deep sleep state -- These states are 1) maintained until NECESSARY to shift to another, 2) STABLE over several minutes, 3) SAME STIMULUS elicts a STATE-SPECIFIC response different from other states -- Behavior is more easily influenced during TRANSITIONAL state Hay p 82 In colic, the behavioral states of importance with respect to making behavior changes are.... - Answer- 1) Crying state 2) Transitional state Hay p 82 Colic is a _________________ that involves interaction between infant and caregiver. - Answer- BEHAVIORAL PHENOMENON. + Inconsiderate caregiver response to crying infant (i.e. infant is "spoiled", or caregiver is hurried) can result in infant being unable to organize or self-soothe. + Caregivers who understand temperament of colicky infant and work to decipher the rhythm cues, can anticipate crying and intervene before the behavior becomes "organized" in crying state and is more difficult to extinguish. Hay p 83 Crying patterns in US middle-class infants - Answer- + 2 hours per day at 2 weeks of age + 3 hours per day by 6 weeks of age + 1 hour per day by 3 months of age Hay p 82 Recommendations to parents for management of colic - Answer- 1) Educate them on normal crying patterns for age, and that crying will increase in month 2 and decrease some by month 3/4. 2) Reassure parents that child is not sick. Explain conditions that have been ruled out. The condition is usually self-limited. Keep diary of patterns. Ease anxiety. 3) Teach to understand infant's cues. Help to devise interventions to calm parent and infant. Quiet environment without excessive handling. -- If onset of crying can be anticipated, swinging/rocking, drives in car or walks in stroller can be helpful. -- If gastric distention appears to be contributing to problem, change feeding habits to not rush infant, allow ample opportunity to burp, feed more frequently. 4) Do not use meds with risk of adverse reactions and overdose. If GERD is making child uncomfortable, a trial of ranitidine or another PPI can be tried. 5) For colic refractory to behavioral changes, try eliminating cow's milk from infant's or mother's diet. Maybe whey formulas. (Conflicting evidence regarding usefulness of probiotics) 6) No conclusive evidence for complementary and alternative interventions for tx of colic. Hay p 83 ESSENTIALS OF DIAGNOSIS + TYPICAL FEATURES: Feeding disorders - Answer- + Inadequate or disordered intake of food due to any of the following conditions -- Poor oral/motor coordination -- Fatigue resulting from a chronic disease -- Lack of appetite -- Behavioral issues related to parent-child interaction -- Pain associated with feeding Hay p 83 Common denominator in feeding disorders? - Answer- FOOD REFUSAL Hay p 83 Early developmental stages and associated feeding behavior - Answer- 1) Homeostasis (0 - 2 months) Parent allows infant to determine timing, amount, pacing and preference of food intake 2) Attachment (2 - 6 months) Allow infant to control feeding so that parent can engage infant in a positive manner 3) Individuation (6 months - 3 years) Conflict may arise if parent seeks to dominate child by intrusive and controlling feeding behavior at the same time the child is striving to achieve autonomy. Hay p 84 ESSENTIALS OF DX + TYPICAL FEATURES: Sleep disorders in children < 12 years - Answer- + Difficulty *initiating* or *maintaining* sleep that is viewed as problem by child or caregiver + May be characterized by its severity, chronicity, frequency AND associated impairment in daytime function in child or family + May be due to primary sleep disorder OR occur in association with other sleep, medical or psychiatric disorders Hay p 85 ESSENTIALS OF DX + TYPICAL FEATURES: Sleep disorders in adolescents - Answer- + Difficulty initiating or maintaining sleep, or early morning awakening or nonrestorative sleep or a combination of these problems Hay p 85 Deepest NREM sleep occurs when? - Answer- During the first 1-3 hours after going to sleep Hay p 85 Stages of NREM sleep - Answer- 1 - Light sleep, reduced body movements, slow rolling of eyes 2 - Slowing of eye movements, respirations and heart rate and relaxation of muscles. **Most mature individuals spend most of their time in this stage.** 3 and 4 - Deepest NREM stages, during which breathing is slow and shallow and heart rate is slow. Also known as delta or slow-wave sleep. Hay p 85 Most children stop napping between ___ and ___ years of age. - Answer- 3 and 5 Hay p 85 School aged children typically sleep _________ hours per night without a nap - Answer- 10 - 11 hours Hay p 85 Adolescents need _______ hours per night but often only get ____. - Answer- NEED 9 - 9.5 hours Hay p 88 Suggestions for parents to manage tantrums - Answer- 1) Minimize need to say "no" by childproofing environment 2) Use distraction when furstration ↑; direct child to other activities and reward response 3) Present options to allow child to achieve mastery and autonomy 4) Fight only the battles that need to be won 5) Do not abandon child when tantrum occurs. Stay nearby without intruding. Threats serve no purpose 6) Do not use negative terms when tantrum is occurring. Point out that child is out of control and give praise when control is regained 7) Never let child hurt himself 8) Do not hold a grudge afterwards, but do not grant demands that led to tantrum 9) Maintain environment that provides positive reinforcement for desire behavior 10) Some tantrums are so severe that referral might be needed. Can reflect poor parenting, problems with parent/child interaction, or overpermissiveness. Hay p 88 Age during which breath-holding spells commonly occur - Answer- Age 6 months to 6 years Hay p 88 Ages of developmental screenings - Answer- 9, 18 and 24 or 30 months. Hay p 89 When should autism screening be performed - Answer- + 18 months + 24 - 30 months, to catch children whose autism was not detected at the earlier screening Hay p 89 What is the most common neurodevelopmental disorder in children? - Answer- ADHD Hay p 89 Components of the neurodevelopmental examination of pediatric patient - Answer- 1) Defining child's level of developmental abilities in a variety of domains, including: -- language -- motor -- visual-spatial -- attention -- social abilities 2) Determine etiology of any developmental delays 3) Planning a treatment program Hay p 90 ESSENTIALS OF DX + TYPICAL FEATURES: Autism spectrum disorders - Answer- TWO core deficits + Persistent deficits in social communication and social interation across multiple contexts + Restricted, repetitive patterns of behavior, interests or activities Hay p 93 Autism severity score per DSM-5 - Answer- Level I - Requiring support Level II - Requiring substantial support Level III - Requiring very substantial support Hay p 94 Most common early characteristics of an ASD in a pediatric patient, recognizable in the first 12-18 months of life. - Answer- Consistent failure to: + orient to one's name + regard people directly + use gestures + develop speech Hay p 94 Evidence of "joint attention" should be present by what age, and if it is not, may be a sign of an ASD if other, earlier sx are present? - Answer- Age 16 - 18 months + "Joint attention" occurs when two people attend to the same thing at the same time. Child should be able to point to object by this age Hay p 94 Screening tool for pediatric patients and their parents - Answer- M-CHAT Hay p 95 Worsening behavior of a child with autism may be indicative of what? - Answer- + Possible medical issues (e.g. dental abscess or esophagitis) Hay p 95 ESSENTIALS OF DIAGNOSIS + TYPICAL FEATURES: Anxiety Disorder in children - Answer- + Fear or anxiety that is excessive or persists beyond developmetnally appropriate period + Fear or anxiety is accompanied by behevioral disturbances or physical manifestations + Symptoms cause functional impairment or significant distress Hay p 187 True/False: Children with anxiety disorders often have other psychiatric disorder as well - Answer- TRUE + Important to carefully screen children with anxiety disorder to ensure that another disorder isnot missed. Hay p 187 Medications that can cause anxiety in pediatric patients - Answer- + Steroids (e.g. taken for asthma, allergies) + ACE inhibitors + Anticholinergics + Dopamine agonists + Beta-adrenergic agonists (e.g. asthma) + SSRIs (e.g.depression) + Thyroid medications + Procaine derivatives Hay p 187 Medical illnesses that can lead to symptoms suggestive of anxiety - Answer- + Hyperthyroid + Hypoglycemia + Hypoxia + Pheochromocytoma Hay p 187 Pharmaceutical interventions for anxiety in pediatric patients - Answer- + SSRIs and alpha agonists have shown some benefit, but are not FDA approved for < 8 years old + Benzos are not recommended for peds because the developing brain is at increased risk for dependency and iatrogenic substance abuse. Hay p 188 ESSENTIALS OF DX + TYPICAL FEATURES: Separation anxiety - Answer- + Presistent excessive worr yabout losing or being separate from attachmet figures, due to harm,illness or death befallign either the attachment figure of the patient How is agoraphobia in children most likely to present? - Answer- School refusal Hay p 192 When is agoraphobia most likely to occur in children? - Answer- In later adolescence Hay p 193 For a diagnosis of agoraphobia, pt must: - Answer- + Experience 2 or more specific fears related to: -- Open spaces -- Public transportaiton -- Standing in line -- Crowds -- Enclosed space -- Being outside home alone -- Similar fears + Fears must last for over 6 months and lead to impairment Hay p 193 Treatment for agoraphobia - Answer- + Challenging because often pt won't leave home + CBT with exposure is 1st line tx + Addition of SSRI for pts who do not respond to treatment or who are severely impacted Hay p 193 Differential dx for agoraphobia - Answer- + Other anxiety disorders + PTSD + Depression + Medical conditions (eg inflammatory bowel disease) Hay p 193 ESSENTIALS OF DX + TYPICAL FEATURES: Generalized anxiety disorder - Answer- + Multiple, intense, disproportionate or irratinoal worries, often about future events + Worry is accmpanied by other symptoms + Worry is difficult to control Hay p 193 When does GAD usually present? - Answer- RARELY does it present before adolescence Hay p 193 What do younger children with GAD usually worry about? - Answer- Competence or performance Hay p 193 What do older youth with GAD usually worry about? - Answer- Family finances or being on time Hay p 193 Diagnostic criteria for GAD - Answer- + At least ONE of these symptoms: - Fatigue - Restlessness or poor concentration - Irritability - Feeling on edge - Sleep disturbance + Symptoms must cause significant distress or disturbance of function AND be present for ≥ 6 (SIX) months Hay p 194 First line treatment for GAD - Answer- CBT with possible addition of SSRI if response is insufficient Hay p 194 What should be considered in adolescents who experience a sudden onset of anxiety? - Answer- Substance-induced anxiety Hay p 194 ESSENTIALS OF DX + TYPICAL FEATURES: Social anxiety disorder - Answer- + Excessive worrying in social settings + Inability to perform in front of others as expected for age + Avoidance of events or settings that are social in nature or involve large groups Hay p 194 What age of child suffers most from social anxiety disorder? - Answer- + Older children and adolescents Hay p 194 Mainstay of therapy for social anxiety disorder - Answer- + CBT with a goal to modify behavior and diminish anxiety + SSRIs have been approved for children with social anxiety disorder Hay p 194 What are some predictors of persistent social anxiety disorder over time? - Answer- 1) Early age of onset 2) More severe avoidance 3) Presence of panic symptoms Hay p 194 ESSENTIALS OF DX + TYPICAL FEATURES: Obsessive compulsive disorder - Answer- + Recurrent obsessive thoughts, impules or images that are experienced as instrusive at times + Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts + Obsessions and compulsions cause marked distress, are time-consuming and interfere with normal activities Hay p 195 Males have an earlier age of onset of OCD, usually occuring before ____ years of age - Answer- 10 (TEN) Hay p 195 Obsessions and compulsions of OCD consume more than _________ (time) per day - Answer- 1 hour Hay p 195 Sudden onset of OCD should alert pediatricians to what? - Answer- Group A strep infections, as pediatric autoimmune disorders associated with these infections have been implicated in development of OCD in some children Hay p 195 Treatment of OCD in kids - Answer- + CBT-specific for OCD + SSRIs -- specifically fluvoxamine and sertraline -- have FDA approval for treatment of pediatric OCD NOTE: Combination of CBT *plus* medicatio is the most effective tx for patients who do not respond to either treatmetn alone. Prophylactic treatment for migraine headaches includes the use of: A. amitriptyline. B. ergot derivative. C. naproxen sodium. D. clonidine. - Answer- A NPCE book Evidence supports the use of all of the following vitamins and supplements for migraine prevention except: A. butterbur. B. riboflavin. C. feverfew. D. ginkgo biloba. - Answer- D NPCE book You are examining a 65-year-old man who has a history of acute coronary syndrome and migraine. Which of the following agents represents the best choice of acute headache (abortive) therapy for this patient? A. verapamil B. ergotamine C. timolol D. sumatriptan - Answer- C NPCE book With migraine, which of the following statements is true? A. Migraine with aura is the most common form. B. Most migraineurs are in ongoing healthcare for the condition. C. The condition is equally common in men and women. D. The pain is typically described as pulsating. - Answer- D NPCE book Which of the following oral agents has the most rapid analgesic onset? A. naproxen (Naprosyn) B. liquid ibuprofen (Motrin, Advil) C. diclofenac (Voltaren) D. enteric-coated naproxen (Naproxen EC) - Answer- B NPCE The mechanism of action of triptans is as a(n): A. selective serotonin receptor agonist. B. dopamine antagonist. C. vasoconstrictor. D. inhibitor of leukotriene synthesis. - Answer- A NPCE The use of neuroleptics such as prochlorperazine (Compazine) and promethazine (Phenergan) in migraine therapy should be limited to less than three times per week because of their: A. addictive potential. B. extrapyramidal movement risk. C. ability to cause rebound headache. D. sedative effect. - Answer- B NPCE Which of the following statements about ergotamines is false? A. are effective for tension-type headaches B. act as 5-HT1A and 5-HT1D receptor agonists C. have potential vasoconstrictor effect D. should be avoided in the presence of coronary artery disease - Answer- A NPCE A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers prescribing all of the following except: A. continuous monophasic oral contraceptive. B. phasic combined oral contraceptive with a 7-day-per-month withdrawal period. C. low-dose estrogen patch use during the premenstrual week. D. triptan prophylaxis. - Answer- B NPCE A first-line prophylactic treatment option for the prevention of tension-type headache is: A. nortriptyline. B. verapamil. C. carbamazepine. D. valproate. - Answer- A NPCE A 47-year-old woman experiences occasional migraine with aura and reports partial relief with zolmitriptan. You decide to add which of the following to augment the pain control by the triptan? A. lamotrigine B. gabapentin C. naproxen sodium D. magnesium - Answer- C NPCE