Neurobiology of Mental Disorders: Exploring the Brain's Role, Exams of Nursing

Download Neurobiology of Mental Disorders: Exploring the Brain's Role and more Exams Nursing in PDF only on Docsity! NR 546 MIDTERM EXAM 2024-2025 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES GRADED A+ What should the PMHNP consider when prescribing chemical restraints? - ANSWER -allergy status -prior med hx for adverse drug reactions r/t the meds ordered in the chemical restraint -state regulations regarding chemical restrains must be reviewed Are the PMHNP and other staff liable if the client has an allergic reaction or adverse side effects to the drugs used for chemical restraint? - ANSWER No. The client has been court-ordered to take the prescribed medications and the standing order for chemical restraints is approved. The PMHNP and other staff are not liable if the patient has an allergic reaction or adverse side effects. How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients? - ANSWER -Genetic testing can assist by providing more information on how clients may respond to certain psychotropic medications -provides information on how a client may break down and metabolize medications based on the cytochrome P450 system. Tanrıkulu and Erbaş (2020) investigated identical twins to determine the presence of an inherited link for schizophrenia and why one twin may develop schizophrenia when the other does not. When two people have 100% identical DNA, why don't both persons develop the exact illnesses? Studies of identical Danish twins found that if one twin had schizophrenia, the other twin had a 50% lifetime risk of developing schizophrenia (Lemvigh et al., 2020). Why is there only half the risk? - ANSWER Both environmental and psychosocial stressors can impact mental health. Although twins may have identical genes, their gene expression may be different. There may be an environmental exposure that turned a gene "on" that should have been "off" for one twin to develop schizophrenia and not the other. central sulcus - ANSWER separates the frontal lobe from the parietal lobe frontal lobe - ANSWER associated with movement, intelligence, abstract thinking broca's area - ANSWER speech production temporal lobe - ANSWER involves object identification and auditory signals cerebellum - ANSWER coordination wernicke's area - ANSWER speech comprehension occipital lobe - ANSWER primary visual area parietal lobe - ANSWER keeps us alert to what is going on around us sensory cortex - ANSWER pain, heat, and other sensations motor cortex - ANSWER movement hippocampus - ANSWER involved in both memory and anxiety nucleus accumbens - ANSWER involved in the reward process thalamus - ANSWER involved in sensory organ and motor command processing striatum - ANSWER involved in complex motor actions, also links cognition to motor actions limbic system - ANSWER includes circuits that are associated with pleasure and reward basal ganglia - ANSWER group of structures involved in voluntary motor movements amygdala - ANSWER involved in emotional regulation and perception of odors corpus callosum - ANSWER controls the communication between the two brain hemispheres -grammar -sequential processing -recognition of detail -conscious mental processing right hemisphere - ANSWER -prosody of speech -emotional modulation -visual-spatial skills -recognition of facial expression -music -abstract mathematical skills -holistic processing -unconscious mental processing Pharmacokinetics - ANSWER the study of what happens to a drug from the time of administration until the parent drug and all metabolites leave the body CYP450 - ANSWER CYP450 enzymes in the gut wall or liver convert drug substrate into a biotransformed product in the bloodstream, responsible for degradating of a large # of psychotropic drugs -Not all ind. have same genetic form of CYP450 enzymes, determined with pharmacogenetic testing *Most individuals have "normal" rates of drug metabolism from the major CYP450 enzymes and are said to be "extensive metabolizers", most drug doses are set for these individuals. *genetic variants of these enzymes can make poor metabolizers or ultra rapid metabolizers Five of the most important: CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4. ultra rapid metabolizers - ANSWER elevated enzyme activity subtherapeutic drug levels poor efficacy with standard doses genotyping - ANSWER the patient for pharmacogenomic use -genes for these CYP450 enzymes can now be readily measured and used to predict which patients might need to have dosage adjustments -measurement of genes for drug metabolism most common targets of psychotropic drugs - ANSWER G-protein receptors -Drug actions at these receptors occur in a spectrum, from full agonist actions, to partial agonist actions, to antagonism, and even to inverse agonism. Pharmacokinetics concepts - ANSWER absorption distribution metabolism excretion Flockhart Table - ANSWER drug interactions that are mediated by cytochrome P450 enzymes comprehensive list of drugs and the interactions related to the cytochrome P450 system Neurotransmitters - ANSWER chemicals released by neurons to send communication across synaptic clefts to other neurons -impact human emotion and behavior Neurotransmission: - ANSWER the chemical transmission of information between neurons and their target cells -the chemicals, or neurotransmitters, are released from their transport vesicles to bind with receptor sites to perform their duties, which are excitatory or inhibitory -neurotransmitter then either returned and stored for future use (reuptake) or inactivated and dissolved by enzymes -Types: Classic, Retrograde, Volume Classic neurotransmission - ANSWER neurons send electrical impulses from one part of the cell to another part of the same cell via their axons -one neuron hurling a chemical messenger, or neurotransmitter, at the receptors of a second neuron -electrical impulse converted chemical signal at the synapse in a process known as excitation- secretion coupling, the first stage of chemical neurotransmission, then back into electrical impulse in second neuron -chemical information from the first neuron triggering a cascade of further chemical messages within the second neuron to change that neuron's molecular and genetic functioning Retrograde neurotransmission - ANSWER postsynaptic neurons "talk back" to their presynaptic neurons -second neuron to the first at the synapse between them -Chemicals produced specifically as retrograde neurotransmitters at some synapses include: endocannabinoids, gaseous neurotransmitter nitric oxide (NO), nerve growth factor (NGF). Volume neurotransmission - ANSWER Neurotransmission without a synapse or nonsynaptic diffusion neurotransmission -Chemical messengers sent by one neuron to another can spill over to sites distant to the synapse by diffusion -neurotransmission can occur at any compatible receptor within the diffusion radius of the neurotransmitter -neurotransmission occurs in chemical "puffs" -sophisticated "chemical soup." -example: dopamine action in the prefrontal cortex, at the sites of autoreceptors on monoamine neurons Excitatory neurotransmitters: - ANSWER increase the likelihood that the neuron will fire an action potential inhibitory neurotransmitters: - ANSWER decrease the likelihood that a neuron will fire an action neurotransmitters that most impact mental health can be classified into four major categories: - ANSWER cholinergics -acetylcholine monoamines -norepinephrine, dopamine, serotonin, histamine agonists - ANSWER fully stimulate G-protein-linked receptors partial agonists - ANSWER stimulate receptors to a lesser degree than an agonist or natural neurotransmitter SSRIs, SNRIs, and tricyclic antidepressants increase ________ levels. ___________ do not impact serotonin levels. - ANSWER increase serotonin levels. Benzodiazepines do not impact serotonin levels. Is nicotine an inducer or an inhibitor of the CYP 1A2 enzyme? - ANSWER inducer Nicotine is an inducer of the CYP 1A2 enzyme. Does the PMHNP anticipate Joshua may need a higher or lower dose of olanzapine to achieve a therapeutic response? - ANSWER Higher -Nicotine is an inducer of the CYP 1A2 enzyme, so it lowers the concentration of drugs. Therefore, a higher dose of olanzapine may be needed to control his symptoms. Ernesto, a 60-year-old, presents to the PMHNP with report of having anxiety, frequent occurrences of feeling frozen in place and like his heart is pounding out of his chest, as well as having difficulty sleeping. The PMHNP suspects the client has an elevated level of which neurotransmitter? - ANSWER Norepinephrine -responsible for the regulation of fight or flight responses and can impact mood and sleep. Which of the following is the best medication class for the PMHNP to prescribe for Ernesto to address his elevated norepinephrine levels? - ANSWER selective serotonin reuptake inhibitor would block the reuptake of serotonin, leaving a larger amount of serotonin available. Increasing the amount of serotonin would help regulate the feelings of fear and anxiety. Reducing the occurrence of fear would help reduce the release of norepinephrine. A serotonin and norepinephrine reuptake inhibitor would prevent the reuptake of norepinephrine, which would not reduce the level of norepinephrine as needed. Benzodiazepines increase the levels of GABA and do not impact norepinephrine. A monoamine oxidase inhibitor would increase levels of norepinephrine. During a follow up appointment after 4 weeks, the PMHNP should assess for the need to add which medication to Ernesto's treatment plan? - ANSWER The nurse should assess for sexual dysfunction and anticipate the potential need for a phosphodiesterase inhibitor such as sildenafil (Viagra). -After 4 to 6 weeks, the client should be experiencing full effects of the SSRI, so the need for a short- term medication like a benzodiazepine or a beta blocker are not anticipated. St. John's Wort is contraindicated with an SSRI and can cause serotonin syndrome. Glu - ANSWER Glutamate -amino acid -excitatory neurotransmitter -"workhorse" of the brain-can affect almost every neuron in the brain -affects: energy, memory, learning, neural plasticity -relay sensory info. and regulate spinal and motor reflexes -too much: schizophrenia, epilepsy, mania -receptors: NMDA, AMPA GABA - ANSWER inhibitory neurotransmitter -decrease neuroexcitability across the brain -"chill", take the edge off stress, help people calm down, relax, destress, sleep -to little: may experience anxiety or schizophrenia -slows down everything, even breathing -affect executive function and motor coordination, increase risk for accidents -Increased levels of gamma-aminobutyric acid have a calming effect. 5HT - ANSWER Serotonin -help regulate mood -makes relaxed, comfortable, decreases stress, regulate sleep, arousal, libido, aggression, pain perception NE - ANSWER norepinephrine -monoamine neurotransmitter -focus and productivity -too much due to stress, meds, caffein, stimulants can cause: nervous, antsy, affect focus DA - ANSWER dopamine -monoamine neurotransmitter -regulate mood -associated with executive function, ability to perform well, be organized, emotional intelligence -movement and coordination -to little: lose pleasure, interest, alertness, self-confidence, parkinson's disease -to much: schizophrenia and psychosis -reward center: can lead to addiction -has own pathways Ach - ANSWER acetylcholine -in CNS: affects arousal, motivation, attention, learning, REM sleep, impacts sleep, pain perception, memory -in PNS: makes you sweat and salivate -link between brain and muscles -not enough: Alzheimer's, Parkinson's, Schizophrenia -too much: Depression -Role in addiction -Receptors: nicotinic & muscarinic Histamine (Neurotransmitter) - ANSWER Histamine impacts alertness, pain sensation, and inflammatory responses; increased levels result in depression. Melatonin (neurotransmitter) - ANSWER Act at MT1-3 G-protein coupled receptors Sleep/wake cycle insomnia: melatonin agonists Psychotropic drug metabolism may be impacted by factors such as: - ANSWER -age -smoking -caffeine intake -More dopamine binds to the D2 dopamine receptors in the NAC. This is thought to be the cause of positive symptoms Schizophrenia: dopamine and mesocortical system - ANSWER area of the brain thought to be responsible for negative symptoms of schizophrenia, prefrontal cortex -mesocortical pathway goes from the VTA (ventral tegmental area) to the PFC (prefrontal cortex) -dysregulation of dopamine between these two areas of the brain results in the negative and cognitive symptoms Dopamine pathway: mesolimbic - ANSWER location: Ventral tegmental area (VTA) within midbreain to the nucleus accumbens (NA) in the limbic system function: regulates emotional behaviors & associated with reward, motivation, pleasure symptoms: overactivation causes (+) symptoms and may be a downstream consequence of prefrontal cortex dysfunction & glutamate activity in the hippocampus Dopamine pathway: mesocortical - ANSWER location: ventral tegmental area (VTA) to the prefrontal cortex (PFC). Specifically affecting dorsolateral prefrontal cortex (DLPFC) & ventromedial prefrontal cortex (VMPFC) function: regulates cognition, executive function, emotions, affect. DLPFC-cognitive, (-) symptoms VMPFC-affective & (-) symptoms symptoms: hypoactivation of pathway may cause (-), cognitive, & affective symptoms dopamine pathway: nigrostriatal - ANSWER location: projects from substantia nigra (in midbrain) to basal ganglia (striatum & globus pallidus) function: part of extrapyramidal nervous system, controls posture & voluntary motor movements symptoms: imbalance of pathways causes movement disorders. Common disorders-parkinson's and tremor. Low dopamine in basal ganglia-akathisia & dystonia. Hyperactivation of pathway-tics, dyskinesias, chorea. Chronic blockade of D2 pathway-tardive dyskinesia. dopamine pathway: tuberinfundibular - ANSWER location: projects from hypothalamus to anterior pituitary gland function: dopamine inhibits prolactin release from pituitary symptoms: disruption of pathway causes prolactin level to rise resulting in gynecomastia & galactorrhea. Females-amenorrhea Both may get sexual dysfunction neurobiological factors that contribute to psychosis and schizophrnia - ANSWER -genetics -neuroanatomy -neural networks -neural signaling neuroanatomy: symptoms associated with mesocortical and ventromedial prefrontal cortex - ANSWER negative and affective symptoms neuroanatomy: symptoms associated with dorsolateral - ANSWER cognitive symptoms neuroanatomy: symptoms associated with orbitofrontal and connections to amygdala - ANSWER aggressive, impulsive symptoms Worst toxin for someone who has at risk genes for schizophrenia - ANSWER marijuana Medications to treat psychosis are classified as either: - ANSWER first generation antipsychotics (FGAs) or second- generation antipsychotics (SGAs) Antipsychotics are prescribed based on their: - ANSWER -pharmacological properties -side effect profiles -adverse effects according to the unique symptoms and needs of individuals across the lifespan First-generation antipsychotics (FGAs) - ANSWER typical antipsychotics, non-selectively blocks dopamine D2 receptors, specifically in mesolimbic pathway -for the acute and chronic management of schizophrenia and psychosis -Desired effect: improve (+) symptoms -risk for developing hyperprolactinemia & extrapyramidal symptoms Extrapyramidal symptoms (EPSs) - ANSWER group of symptoms related to motor control and coordination, caused by dopamine blockade or depletion in the basal ganglia -dystonia -akathisia -parkinsonism -bradykinesia -tremors -tardive dyskinesia dystonia - ANSWER Involuntary contractions of muscles; can cause pain akathisia - ANSWER Inner restlessness leading to repetitive motion (rocking, tapping fingers). parkinsonism - ANSWER Combination of abnormal movements like those seen in Parkinson's Disease, including tremor, slow movement, impaired speech, or muscle stiffness -akinesia, rigidity, tremor bradykinesia - ANSWER Slowness of movement tardive dyskinesia - ANSWER hyperkinetic movement disorder characterized by abnormal facial and tongue movements and quick, jerky limb movements -Can occur from long-term blockade of D2 receptors in the nigrostriatal DA pathway -25% of clients will develop symptoms within 5 years of medication start -Lower risk of EPS Due to the antagonism of serotonin, ______ generally have fewer EPS and prolactin effects making them the first-line choice when prescribing medications for schizophrenia. - ANSWER Second Generation Antipsychotics (SGA) SGA (atypical antipsychotics) categories: - ANSWER Pines: -olanzapine (zyprexa) -quetiapine (seroquel) -asenapine (saphris) -clozapine (clozaril) 2 dones & a rone: -risperidone (risperidol) -paliperidone (invega) -ziprasidone (geodon) -iloperidone (fanapt) -lurasidone (latuda) 2 pips & a rip: -aripiprazole (abilify) -brexpiprazole (rexulti) -cariprazine (vraylar) Pines - ANSWER -bind more potently to the 5HT 2A receptor than the D2. -Sedation is common and relates to a high affinity for histamine. -least risk of EPS but a high risk for weight gain and metabolic abnormalities 2 dones and a rone - ANSWER -more potently to the 5HT 2A receptor than to D2 or bine equally between the 2 receptors. -less sedating and cause less weight gain, but have a higher risk for hyperprolactinemia and EPS 2 pips and a rip - ANSWER -pips: bind more potently to D2 receptors than to 5HT-2A, have low risk of metabolic side effects and weight gain, but they have a potential for EPS. -rips binds equally to both D2 and 5HT-2A receptors, have low risk for metabolic disorders Extreme caution should be taken when prescribing antipsychotics for clients with metabolic disorders. SGAs are associated with: - ANSWER hyperglycemia and type 2 diabetes, dyslipidemia, and hypertension Neuroleptic malignant syndrome (NMS) - ANSWER Medical emergency, rare, sometimes life- threatening reaction to antipsychotic medications S/S: -diaphoresis -anxiety -tachypnea -muscle stiffness -altered mental status -tachycardia -hyperthermia Tx of Neuroleptic malignant syndrome (NMS) - ANSWER stop the administration of antipsychotic medications and provide supportive therapy. Treatment and pharmacologic management may include hydration, benzodiazepines, and muscle relaxants The PMHNP must monitor for adverse effects in clients who are prescribed SGAs. Which of the following physical exams and labs should be ordered or requested from another provider? - ANSWER BMI -monthly x3 months then quarterly Fasting lipids -within first three months then check annually Electrocardiogram -baseline electrocardiogram should be obtained to evaluate for prolonged QT syndrome BP Fasting plasma glucose -within first three months then check annually Carbamazepine - ANSWER glutamate, voltage-gated sodium and calcium channel blocker -Primary target symptoms: Seizures, unstable mood, mania, pain. -Side Effects: SEDATION, dizziness, confusion, unsteadiness, headache, nausea, vomiting, diarrhea, blurred vision, rash, benign leukopenia (up to 10%) -Before starting: blood count, liver, kidney, and thyroid function tests ✽SUBSTRATE for CYP450 3A4 and an inducer of CYP450 3A4 thus, carbamazepine induces its own metabolism, often requiring an upward dosage adjustment Carbamazepine drug interactions - ANSWER -Enzyme-inducing antiepileptic drugs (carbamazepine itself as well as phenobarbital, phenytoin, and primidone) may increase the clearance of carbamazepine and LOWER its plasma levels -CYP450 3A4 inhibitors, such as nefazodone, fluvoxamine, and fluoxetine, can INCREASE plasma levels of carbamazepine Olanzapine (zyprexa) - ANSWER SGA - Atypical serotonin-dopamine antagonist Indication: schizophrenia age 13 and older, acute agitation, acute mania/mixed mania, bipolar maintenance, bipolar depression, borderline personality disorder, PTSD -Starting dose: Initial 5-10 mg once daily orally Risk: High metabolic risk Highest risk for weight gain, sedation, blood dyscrasias, QT prolongation, cardiovascular disease, cerebrovascular effects, hyperglycemia, and hyperprolactinemia quetiapine (seroquel) - ANSWER SGA - Atypical serotonin-dopamine antagonist Risk: Moderate metabolic risk Tardive dyskinesia (reduced risk compared to conventional antipsychotics) ziprasidone (Geodon) - ANSWER SGA - Atypical dopamine and serotonin receptor antagonist Indication: schizophrenia in ages 10 and older, acute agitation, mania, bipolar maintenance/depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -dosing: • Schizophrenia: 40-200 mg/day (in divided doses) orally • Bipolar disorder: 80-160 mg/day (in divided doses) orally • 10-20 mg intramuscularly -Special Comments: IM dosing in acute agitation associated with schizophrenia Risk: Low metabolic risk Lowest risk for weight gain Contraindicated in clients with QT, recent myocardial infarction, or uncompensated heart failure High incidence of rash/urticaria related to Stevens-Johnson syndrome and Drug Reaction with Eosinophilia and Systemic Syndrome (DRESS) iloperidone (Fanapt) - ANSWER SGA - Atypical dopamine-serotonin receptor antagonist Indication: schizophrenia, mania, bipolar maintenance/depression, treatment-resistant depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -dosing: usual rangs 12-24 mg/day in 2 divided doses. Initial 2 mg in 2 divided doses on day 1; 4 mg in 2 divided doses on day 2; 8 mg in 2 divided doses on day 3..etc.. Risk: Moderate risk for weight gain, sedation Low risk for hyperlipidemia lurasidone (Latuda) - ANSWER SGA - Atypical dopamine, serotonin receptor antagonist Indication: schizophrenia ages 13 and older, bipolar maintenance/depression, mania, treatment- resistant depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: 40-80 mg/day for schizophrenia, 20-60 mg/day for bipolar depression -should be taken with food, at least 350 calories, for maximum absorption. Risk: Low metabolic risk Dose-dependent hyperprolactinemia aripiprazole (Abilify) - ANSWER SGA - Atypical dopamine, serotonin receptor partial agonist Indication: schizophrenia ages 13 and older, mania, autism, bipolar maintenance/depression, depression, tourette's disorder, acute agitation, obsessive-compulsive disorder, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: • 15-30 mg/day for schizophrenia & mania • 5-15 mg/day for autism • 5-20 mg/day for Tourette's disorder Risk: Low metabolic risk Low risk for weight gain Low risk for orthostatic hypotension Pearls -less sedation than most other antipsychotics brexpiprazole (Rexulti) - ANSWER SGA - Atypical Dopamine partial agonist Indication: schizophrenia, treatment-resistant depression, mania, bipolar maintenance/depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: schizophrenia 2-4 mg once daily, Depression: 2 mg once daily. Special Comments: Considered procognitive Risk: Low metabolic risk Akathisia TD (reduced) cariprazine (Vraylar) - ANSWER SGA - Atypical dopamine-serotonin partial agonist Indication: schizophrenia, mania, bipolar maintenance/depression, depression, impulse control, PTSD, behavioral disturbances in dementias and in children and adolescents -Dosing: • Schizophrenia: 1.5-6 mg once daily • Bipolar mania: 3-6 mg once daily • Bipolar depression: 1.5-3 mg once daily Risk: Low metabolic risk Sedation Akathisia, parkinsonism, TD (reduced) Haloperidol - ANSWER Typical FGA (conventional) dopamine receptor antagonist High potency Indication: Psychotic disorders, tourette's syndrome, schizophrenia, bipolar disorder, behavior disturbances in dementia -Dosing: 1-40 mg/day orally, IR injection 2-5 mg each dose hypotension Chlorpromazine - ANSWER Typical FGA (conventional) dopamine 2 antagonist -Low potency -Indication: Schizophrenia, severe agitation, ADHD, acute psychosis, nausea, vomiting, acute intermittent porphyria, tetanus, intractable hiccups, bipolar disorder, restlessness and apprehension before surgery. -Dosing: 200-800 mg/day Risks: Neuroleptic-induced deficit syndrome Akathisia Priapism, sexual dysfunction Sedation and weight gain Dry mouth, constipation, urinary retention, blurred vision hypotension Tardive dyskinesia Galactorrhea, amenorrhea medications noted for decreased risk of death by suicide - ANSWER Clozapine -Reduction in risk of recurrent suicidal behavior in patients with schizophrenia Carla is a 35-year-old woman that is currently taking olanzapine for her diagnosed schizophrenia. She has gained 30 pounds in the last 6 months and her waist circumference is 37 inches. She requests a change in medications. Which of the following medications is less associated with weight gain? - ANSWER aripiprazole -associated with the lowest risk weight gain. Alex is a returning client who reports leaking fluid from his nipples. Which of the following is most likely responsible for these undesirable side effects? - ANSWER Risperidone -highest risk for galactorrhea, due to hyperprolactinemia. Prescribing Considerations (antipsychotics) - ANSWER -Start with lowest dose, eval tolerance, then titrate dose -no evidence that high antipsychotic doses are more effective than standard doses -Dose adjustments should be made after two weeks of taking medication -Establish efficacy and an effective med dose before switching to a long-acting injectable (LAI). dose of LAI will be same as the effective oral dose. -Most antipsychotic side effects and adverse effects are dose-related. When prescribing, document the _____________ at every visit. - ANSWER targeted symptoms, response, and any adverse effects Many persons with schizophrenia are treated successfully in an ______________, though some clients may require ________________ for initial treatment and subsequent treatment of psychotic episodes - ANSWER outpatient setting, inpatient hospitalizations Why begin with monotherapy? (antipsychotics) - ANSWER The use of multiple antipsychotics can increase the risk of QT prolongation. -Combinations considered only after single med have provided inadequate response. If antipsychotics switched too quickly - ANSWER can develop agitation, activation, insomnia, and experience withdrawal -due to the binding differences in each medication subcategory *Cross titration over several days to weeks is required to prevent side effects Clients are more likely to experience side effects when changing from a medication in one ___________ to a medication in another ____________ - ANSWER subcategory, subcategory (ex: pine to done) special considerations: Pregnancy (antipsychotics) - ANSWER -Risk of withdrawal symptoms in the newborn: extrapyramidal symptoms may be present at delivery. -atypical antipsychotics appear more harmful than typical antipsychotics due to increased risk of gestational metabolic complications, increased gestational age weight, and increased birth weight. -Avoid Clozapine, Ziprasidone, olanzapine, risperidone, and quetiapine, especially in the third trimester special considerations: breast feeding (antipsychotics) - ANSWER All antipsychotics are assumed to be secreted in breast milk. -recommended drug is discontinued or the infant bottle feeds. special considerations: Older Adult (antipsychotics) - ANSWER 2019 American Geriatric Society (AGS) Beers Criteria recommendations: Avoid the use of haloperidol, ziprasidone, and olanzapine due to an increased risk of cerebrovascular accident (CVA), cognitive decline, and death in persons with dementia and with dementia-related psychosis. special consideration: children (antipsychotics) - ANSWER Black box warnings: -Aripiprazole: Increased risk of suicide in children. -Quetiapine: Increased risk of suicidal ideation and suicidal behavior in adolescents/young adults during the initial 1-2 months of treatment special considerations: caution (antipsychotics) - ANSWER -Olanzapine - exercise caution in suspected alcohol withdrawal, stimulant intoxication, or anticholinergic intoxication -High and repeated doses of amphetamines or cocaine can mimic positive symptoms of paranoid schizophrenia legal issues/considerations when prescribing antipsychotics - ANSWER informed consent -required due to serious side effects challenges -psychosis can be an obstacle -provide education before obtaining a signature in outpatient setting contingency planning -establish a plan with client and family for emergencies -designate a mental healthcare proxy if possible Prescribing Pearls - ANSWER -Use the lowest effective dose and slow dosage titration. match each symptom to hypothetically malfunctioning brain circuits: negative symptoms - ANSWER mesocortical/prefrontal cortex nucleus accumbens reward circuit match each symptom to hypothetically malfunctioning brain circuits: cognitive symptoms - ANSWER dorsolateral prefrontal cortex match each symptom to hypothetically malfunctioning brain circuits: aggressive symptoms - ANSWER orbitofrontal cortex amygdala match each symptom to hypothetically malfunctioning brain circuits: affective symptoms - ANSWER ventromedial prefrontal cortex polygenic risk score - ANSWER add up all the abnormal genes an individual has amongst the known few hundred risk genes, suggesting how much risk there might be for developing schizophrenia. Barnes Akathisia Rating Scale (BARS) - ANSWER rating scale to assess the severity of drug-induced akathisia. -includes objective and subjective items such as the level of the patient's restlessness Abnormal Involuntary Movement Scale (AIMS) - ANSWER tool used to monitor involuntary movements and tardive dyskinesia in clients who take antipsychotic medication -best practice/recommendation to document the AIMS at minimum every 6 months for patients taking an antipsychotic agent/dopamine blocker Low-potency medications - ANSWER -require higher doses to achieve efficacy -have more anticholinergic, antihistaminic, and α1- properties, can result in more sedation Targeting mesolimbic/mesostriatal dopamine D2 receptors causes: - ANSWER antipsychotic actions Targeting dopamine D2 receptors in Mesolimbic/mesostriatal and mesocortical pathways causes: - ANSWER secondary negative symptoms Targeting tuberoinfudibular dopamine D2 receptors causes: - ANSWER elevation of prolactin -associated with gynecomastia, galactorrhea, amenorrhea Targeting nigrostriatal dopamine D2 receptors causes: - ANSWER motor side effects -can cause drug induced parkinsonism overactivity of the mesolimbic dopamine system - ANSWER may mediate the positive symptoms of psychosis any abnormal motor symptoms caused by D2 receptor blockers are lumped together and called collectively: - ANSWER extrapyramidal symptsom (EPS) -motor side effects of D2 antagonists caused by chronic blockade of D2 receptors in the nigrostriatal dopamine pathway - ANSWER tardive dyskinesia (TD) -tx: interventions that lower dopamine neurotransmission, inhibiting the vesicular monoamine transporter type 2 (VMAT2) lowers the "go" signals - deuterated tetrabenazine (deutetrabenazine), Valbenazine (most selective and potent) , the most common side effect of drugs that target D2 receptors for psychosis - ANSWER Drug induced parkinsonism (DIP) -akinesia, bradykinesia, rigidity, and tremor *anticholinergics-drugs that block muscarinic cholinergic receptors adding 5HT2A antagonism: - ANSWER improve side effects of D2 blockade and enhance the antipsychotic efficacy of D2 blockade Sedative-hypnotic agents - ANSWER benzodiazepine & barbiturates, clinical indications for use: -sedation & anxiolysis -treatment of insomnia -general anesthesia -seizures -alcohol withdrawal states -as adjunctive management with neuromuscular blockage/muscle relaxation -to induce or maintain sleep sedative-hypnotic medications: use - ANSWER -1 in 8 adults -Higher incidence in older adults -Often co-prescribed with opioids sedative-hypnotic medications: misuse - ANSWER -Taken outside of prescriptive guidelines -Taken without prescription -polysubstance Abuse -Are common as second drugs of abuse, often taken with opioids and/or alcohol -Increased respiratory and CNS depression -Increased risk of emergency department visits sedative-hypnotic medications: Withdrawal - ANSWER -May be severe -Signs and symptoms include psychosis, hallucinations, delirium, seizures -Mild signs and symptoms: irritability, tremor, anxiety, palpitations, insomnia, nausea, vomiting, diaphoresis, headache Benzodiazepine intoxication - ANSWER Can resemble alcohol intoxication: unsteady gait, cognitive impairment, discoordination, slurred speech -Overdose may lead to respiratory depression and stupor/coma Anxiety - ANSWER response to situations that are perceived as stressful or dangerous -increases alertness, heart rate, and respirations, preparing the body to respond to perceived threatening environmental stimuli *when symptoms of anxiety persist and become intense or excessive, a diagnosis of an anxiety disorder may be warranted, and treatment is required anxiety disorder - ANSWER -affects more women than men -benzodiazepines Other -alpha 2 delta ligands -beta blockers -histamine receptor agonists Selective serotonin reuptake inhibitors (SSRI) are the first-line drugs to treat which anxiety disorder(s)? - ANSWER -generalized anxiety disorder -panic disorder -obsessive-compulsive disorder -post-traumatic stress syndrome -social anxiety disorder Rationale: SSRIs are the first-line drugs to treat all anxiety disorders. SSRIs - ANSWER Selective serotonin reuptake inhibitors (SSRIs) are used for the treatment of all anxiety disorders. They act by preventing the reuptake of 5-HT by synapses in the brain. Drugs -citalopram (Celexa) -escitalopram (Lexapro) -fluoxetine (Prozac) -fluvoxamine (Luvox, Luvox CR) -paroxetine (Paxil, Paxil CR) -sertraline (Zoloft) SSRI's: Adverse effects and monitoring - ANSWER -anorexia -diarrhea -headache -weight gain -sexual side effects -serotonin syndrome Monitoring: akathisia, increased anxiety, suicidal ideation SSRI's: clinical pearls - ANSWER -Dosage should be started at half the recommended dose for depression, increase dosage after 2-4 weeks as needed to control anxiety. -SSRIs should not be stopped abruptly because it can result in rebound anxiety. SNRI's - ANSWER Serotonin-norepinephrine reuptake inhibitors (SNRIs) are used to treat all anxiety disorders except OCD. -preventing the reuptake of 5-HT and norepinephrine (NE) by synapses in the brain. Compared with venlafaxine and desvenlafaxine, which have serotonin reuptake inhibition (SRI) activity and dose- related affinity for norepinephrine reuptake inhibition (NRI) primarily, duloxetine has more balanced SRI and NRI activities. Levomilnacipran has higher activity at NRI than SRI. -desvenlafaxine (Pristiq) -duloxetine (Cymbalta) -venlafaxine (Effexor, Effexor XR) -levomilnacipran (Fetzima) SNRIs: adverse effects and monitoring - ANSWER -elevated blood pressure -sweating -anxiety -dizziness -insomnia -constipation -serotonin syndrome Monitoring: increased anxiety and suicidal ideations SNRIs: contraindication - ANSWER liver problems hypertension SNRIs: clinical pearls - ANSWER -Due to the presence of norepinephrine, SNRIs can exacerbate anxiety. -Dosage should be started at half the recommended dose for depression to minimize side effects. Buspirone - ANSWER Azapirones are Federal Drug Administration (FDA) approved for short-term anxiety treatment and are used alone or as an adjunct to antidepressants. -bind to serotonin and dopamine receptors in the brain and increase norepinephrine metabolism in the brain. -Buspirone (Buspar) Buspirone: adverse effects - ANSWER -dizziness -headache -sedation -nervousness -nausea Buspirone: contraindications - ANSWER -severe renal impairment -severe hepatic impairment -concurrent use of monoamine oxidase inhibitors (MAOIs) Buspirone: clinical pearls - ANSWER -Buspirone is not habit-forming, does not have abuse potential, causes withdrawal reactions, or potentiates alcohol and sedative-hypnotic effects. -It is prescribed for two or three times a day due to the short half-life; it is not prescribed as needed (PRN). -It has a gradual onset of action of 2 weeks, but over time provides the same efficacy as a benzodiazepine. -BuSpar may decrease sexual side effects when used in combination with an SSRI. Alpha 2 Delta Ligands - ANSWER used off-label for general anxiety disorder (GAD). -bind with glutamate calcium channel blockers (Glu-CB) to inhibit the release of several neurotransmitters. --Pregabalin has anxiolytic properties with selective binding to the α-2-delta subunit of voltage-gated calcium channels. -pregabalin (Lyrica) -gabapentin (Neurontin) Alpha 2 Delta Ligands: adverse effects - ANSWER -sedation -dizziness -QT prolongation Histamine Receptor Antagonists: clinical pearls - ANSWER -It is unclear if efficacy is due to an anxiolytic effect or a sedative effect. -Caution clients about potential sedation when prescribing. -When used concurrently with another central nervous system (CNS) depressant, the depressant dose should be reduced to half. -Elderly clients are more sensitive to the sedative and anticholinergic side effects of hydroxyzine. appropriate first-line medication treatment information for anxiety disorder's: Generalized anxiety disorder: - ANSWER Generalized anxiety disorder: SSRIs SNRIs buspirone Drug Therapy at least 1 year appropriate first-line medication treatment information for anxiety disorder's: obsessive-compulsive disorder - ANSWER Obsessive-compulsive disorder fluoxetine fluvoxamine sertraline paroxetine clomipramine Drug therapy for at least 1 year appropriate first-line medication treatment information for anxiety disorder's: PTSD - ANSWER Post- traumatic stress disorder paroxetine sertraline Josie is a 36-year-old who was diagnosed with generalized anxiety disorder. She was prescribed paroxetine (Paxil) 12 weeks ago. She has been taking the medication as prescribed, and although she has tolerated the medication well, she has not achieved relief of anxiety symptoms with increases in dosing at each follow-up visit. Place the following medications in order of what would be prescribed next for Josie. - ANSWER The correct order of prescription is: escitalopram (Lexapro) duloxetine (Cymbalta) buspirone (BuSpar) pregabalin (Lyrica) hydroxyzine (Atarax) alprazolam (Xanax) Rationale: Use a stepwise plan to change drug treatment if the initial medication was either ineffective or poorly tolerated. Paroxetine requires a taper while you start the new medication. Do not stop abruptly due to discontinuation syndrome. Switching Rx can be helpful in switching medications. Switch medications.Switch from one SSRI to another.Switch from SSRI to SNRI.Augment with buspirone.Augment with pregabalin. If standard drugs are not effective, nonstandard drugs approved for other anxiety disorders may be used.hydroxyzinebenzodiazepine (if clinically justified) are for short-term use only Benzodiazepines (BZOs) - ANSWER Controlled substance enhance gamma-aminobutyric acid's (GABA's) inhibitory effects in the brain by acting on GABA receptors outside of the receiving neuron to open a channel that allows negatively charged chloride ions to pass into the neuron -negative ions "supercharge" the neuron making it less responsive to neurotransmitters that would normally excite it. -also react at specific benzodiazepine receptors on the GABA neuron. Benzodiazepine receptor subtypes have slightly different actions: *Alpha one is responsible for sedative effects. *Alpha two is responsible for anti-anxiety effects. *Alpha one, alpha two, and alpha five are responsible for anticonvulsant effects. Benzodiazepines use - ANSWER short-term relief of acute anxiety -do not treat underlying cause not intended for long-term -risk of tolerance, dependence, uncomfortable withdrawal Benzodiazepines (BZO): adverse effects - ANSWER oversedation -drowsiness, poor concentration, incoordination, muscle weakness, dizziness and mental confusion -increased risk of accidents, falls, and injury. memory impairment -cause "blackouts" -lack of concentration and attention, impair learning depression -inability to feel pleasure or pain. -increase suicide risk tolerance and dependence -can occur in as little as 2 weeks -psychologically and physically addictive Paradoxical Effects -increased anxiety, irritability, hyperactivity, aggression, insomnia, nightmares, hallucinations at the onset of sleep, cases of assault and homicide have been reported Benzodiazepines (BZO): Patient education - ANSWER -rationale for benzodiazepine prescription -expected length of treatment (short term only) -avoiding alcohol -adverse effects -risks of tolerance and dependence -avoiding driving while taking this medication Benzodiazepines Safety and Prescribing Guidelines - ANSWER Set ground rules: -Client uses only one pharmacy. -BZO should be prescribed by only one provider. -Check the state prescription monitoring program (PMP) controlled substance database. -can cause sedation and fatigue (anterograde anesthesia) -safe with liver disease; use lower dosage with liver and renal impairment -increased risk of drug hangover due to longer half-life -increased depressive effects with opioids- do not prescribe together -caution with sleep apnea -contraindicated in angle-closure glaucoma, breastfeeding, and pregnancy -tapered dosing when discontinuing clonazepam (Klonopin) - ANSWER Long-acting Use: panic disorder Half-life: 30-40 hours Equivalence: 0.5 mg Dosage: 0.5-2 mg/day in divided doses or at bedtime starts at 0.25 mg and increases slowly -rapid onset and less sedating, but does cause some sedation and fatigue -longer duration of action -only Category C benzodiazepine; not recommended with breastfeeding -increases salivation -contraindicated with liver disease -easier to taper dosing than other BZOs due to the long half-life diazepam (Valium) - ANSWER Long-acting Use: acute myocardial infarction-related anxiety, night terrors, alcohol withdrawal Half-life: 20-50 hours Equivalence: 10 mg Dosage: 2-10 mg two times to four times daily -rapid onset -available in rectal gel -can cause sedation, fatigue, forgetfulness, and confusion -contraindicated in angle closure glaucoma -risk of dependence after 12 weeks -risk for seizures with rapid discontinuation; taper 2 mg every 3 days The PMHNP is prescribing alprazolam for a client with panic disorder. The PMHNP should be concerned if the client is also prescribed which medication? - ANSWER zolpidem Rationale: Alprazolam presents a risk for respiratory depression, especially when taken concurrently with another central nervous system depressant like zolpidem. SSRIs, SNRIs, and buspirone may be taken with alprazolam. BZO Tapering and Deprescribing - ANSWER Withdrawal symptoms tend to occur faster with shorter- acting agents (within 2 to 3 days) than with longer-acting agents (within 5 to 10 days). The Ashton Model (UK plan)Links to an external site. recommends reducing daily dosing by 10-20% every 1-2 weeks. lifespan and lifestyle factors that are foundational to safe prescribing: Pregnancy - ANSWER - Paroxetine is contraindicated, risk of atrial septal defects -Hydroxyzine is contraindicated in the 1st trimester. -Benzodiazepines cross the placenta, increased risk of neonatal complications even with therapeutic doses, use during pregnancy can cause: *intrauterine growth restriction *oversedation at birth can cause floppiness, difficulty breathing, and difficulty feeding *potential for learning disabilities, autism, and attention-deficit/hyperactivity disorder (ADHD) *neonatal withdrawal syndrome which benzodiazepine is safe in lactation - ANSWER lifespan and lifestyle factors that are foundational to safe prescribing: Breast feeding - ANSWER Contraindicated when breastfeeding: -gabapentine -benzodiazepines -histamine receptor agents -alpha 2 ligands lifespan and lifestyle factors that are foundational to safe prescribing: Older adult - ANSWER decline in renal and liver function may contribute to the prolonged elimination of medications leading to increased sedative effects and fall risk -Consider decreasing the dosage of sedative-hypnotics -taper whenever possible 2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations: -avoid barbiturates (increased dependence, tolerance, risk of overdose) -avoid benzodiazepines (increased sensitivity, decreased metabolism) -avoid gabapentin and pregabalin (falls due to sedation) -avoid hydroxyzine (clients with dementia, cognitive impairment, delirium, lower urinary symptoms, or benign prostatic hyperplasia [BPH]) lifespan and lifestyle factors that are foundational to safe prescribing: Children - ANSWER -Anxiety disorders often begin in childhood and are often comorbid with depression or bipolar disorder. -For children and adolescents, psychotherapy is the first choice of treatment. SSRIs may be used for severe symptoms or when psychotherapy is not effective. *There is an increased risk of suicide in clients less than 30 years using SSRIs. -Gabapentin is not approved for anxiety in children, it may only be used for seizures. Sofia presents to the PMHNP with a report of being overwhelmed with stress and worry. Sofia reports she has always dealt with these feelings, but it has been worse since she has taken a more advanced role in her work with significant responsibility. She has difficulty relaxing and is often fatigued. The PMHNP diagnoses Sofia with generalized anxiety disorder. - ANSWER sertraline 25 mg po once daily. Rationale: Anxiety can often be treated with antidepressants. The best choice for Sofia is the SSRI, sertraline because it is half the recommended dose for depression. The duloxetine dosage listed is an appropriate dose for depression. When treating anxiety, the dosage should start at 30 mg and be titrated up. Buspirone is not the first drug of choice and it is typically used short-term. A benzodiazepine should not be the first drug of choice. autonomic and cardiovascular responses are mediated by: - ANSWER connections between the amygdala and the locus coeruleus, home of the noradrenergic cell bodies -When autonomic responses are repetitive, inappropriately or chronically triggered as part of an anxiety disorder, this can lead to increases in atherosclerosis, cardiac ischemia, hypertension, myocardial infarction, and even sudden death The known neurobiological regulators of the amygdala: - ANSWER neurotransmitters GABA, serotonin, norepinephrine, and the voltage-gated calcium channels -known anxiolytics act upon these same neurotransmitters hypothetically in order to mediate their therapeutic actions neurotransmitters and regulators that modulate CSTC circuit - ANSWER -serotonin -GABA -dopamine -norepinephrine -glutamate -voltage-gated ion channels Excessive amygdala activity is theoretically reduced by: - ANSWER benzodiazepines -enhance phasic inhibition of GABA (γ-aminobutyric acid) by positive allosteric modulation of postsynaptic GABA receptors -blunt fear-associated outputs modulate excessive output from worry loops - ANSWER benzodiazepines -enhancing the actions of inhibitory interneurons in CSTC circuits -reduce symptoms of worry also known as α2δ ligands since they bind to the α2δ subunit of presynaptic N and P/Q VSCCs, block the release of excitatory neurotransmitters such as glutamate that occurs when neurotransmission is excessive, as postulated in the amygdala to cause fear (Figure 8-17A) and in CSTC circuits to cause worry - ANSWER Gabapentin and pregabalin key neurotransmitter that innervates the amygdala as well as all the elements of CSTC circuits - ANSWER Serotonin -regulate both the symptoms of fear and worry Noradrenergic hyperactivity in anxiety - ANSWER Norepinephrine is another neurotransmitter with important regulatory input to the amygdala, and to the prefrontal cortex and thalamus in CSTC circuits __% of the population will develop an anxiety disorder - ANSWER 30% Treatment for anxiety disorder subtypes: Generalized Anxiety Disorder - ANSWER SSRIs, SNRIs, benzodiazepines, buspirone, and α2δ ligands such as pregabalin and gabapentin Other "off-label" treatments for anxiety can include mirtazapine, trazodone, vilazodone, tricyclic antidepressants, or even sedating antihistamines such as hydroxyzine. Treatment for anxiety disorder subtypes: PTSD - ANSWER psychopharmacological treatments -not as effective as these same treatments are in anxiety disorders -more effectively aimed at comorbidities: depression, insomnia, substance abuse, and pain Benzodiazepines are to be used with caution -limited evidence from clinical trials for efficacy in PTSD -many PTSD patients abuse alcohol and other substances unique treatment for PTSD is the administration of α1 antagonists at night to prevent nightmares The amygdala hypothetically plays a central role in the _______________. Cortico-striato-thalamo- cortical (CSTC) circuits are thought to play a key role in mediating the symptom of __________. - ANSWER fear response, worry ________,_________,_________,________ are all key modulators of the hypothetical fear and worry circuits - ANSWER Serotonin, norepinephrine, alpha-2 delta ligands and GABA Amygdala-centered circuit - ANSWER Fear -panic -phobia cortico-striato-thalamo-corical (CSTC) circuit - ANSWER worry -anxious misery -apprehensive expectation -obsession Gabapentin - ANSWER Anxiolytic glutamate voltage-gated calcium channel blocker, Anticonvulsant; alpha 2 delta ligand at voltage- sensitive calcium channels -Indication: Partial seizures with or without secondary generalization, postherpetic neuralgia, restless leg syndrome, neuropathic pain/chronic pain, anxiety, bipolar disorder. -Dosing: 900-1800 mg/day in 3 divided doses Risks: CNS side effects: Sedation Ataxia fatigue nystagmus tremor Pearls: -Most use if off-label -Off-label use for first-line treatment of neuropathic pain may be justified Pregabalin - ANSWER Anxiolytic glutamate voltage-gated calcium channel blocker, Anticonvulsant; alpha 2 delta ligand at voltage- sensitive calcium channels -Indication: Diabetic peripheral neuropathy, postherpetic neuralgia, fibromyalgia, neuropathic pain associated with spinal cord injury, partial onset seizures, peripheral neuropathic pain, GAD, panic disorder, social anxiety disorder. -Dosing: IR: 150-600 mg/day in 2-3 doses, CR: 330 mg once per day Risks: -Sedation, fatigue, depression -dizziness, ataxia, slurred speech, weakness -forgetfulness, confusion -hyperexcitability, nervousness Pearls: -not recommended during pregnancy, especially during first trimester -Recommended either D/C drug or bottle feed -most popular and useful benzodiazepines for treatment of agitation -often used to induce pre-operative anterograde amnesia to assist in anesthesiology Clonazepam - ANSWER Anxiolytic BENZODIAZEPINE GABA positive allosteric modulator -Indication: Panic disorder, lennox-gastaut syndrome, akinetic seizure, myoclonic seizure, absence seizure, atonic seizure, other seizure disorders, acute mania, acute psychosis, insomnia, catatonia. -Dosing: •Seizures 1.5 mg divided into 3 doses, raise by 0.5 mg every 3 days until desired effect (up to 20 mg/day) •Panic start at 0.25mg divided into 2 doses, raise to 1mg after 3 days (max 4 mg/day) Risks: -Sedation, fatigue, depression -dizziness, ataxia, slurred speech, weakness -forgetfulness, confusion -hyperexcitability, nervousness Pearls: -not recommended during pregnancy, especially during first trimester -Recommended either D/C drug or bottle feed -Easier to taper than some other benzodiazepines because of long half-life (elimination half-life approximately 30-40 hours) Diazepam - ANSWER Anxiolytic BENZODIAZEPINE GABA positive allosteric modulator -Indication: Anxiety, acute agitation, tremor, delirium tremens, HALLUCINOSIS in acute alcohol withdrawal, skeletal muscle spasm, spasticity, athetosis, stiff-person syndrome, convulsive disorder, status epilepticus, insomnia, catatonia. -Dosing: •Oral (anxiety, muscle spasm, seizure): 2-10 mg, 2-4 times/day. •Oral (alcohol withdrawal): initial 10 mg, 3-4 times/day for 1 day; reduce to 5 mg, 3-4 times/day, continue prn Risks: -Sedation, fatigue, depression -dizziness, ataxia, slurred speech, weakness -forgetfulness, confusion -hyperexcitability, nervousness Pearls: -not recommended during pregnancy, especially during first trimester -Recommended either D/C drug or bottle feed -often the first-choice benzodiazepine to treat status epilepticus, and is administered either intravenously or rectally Propranolol - ANSWER Anxiolytic Beta blocker, antihypertensive -Indication: Migraine, tremor, hypertension, angina pectoris, cardiac arrhythmias, myocardial infaction, hypertrophic subaortic stenosis, pheochromocytoma, akathisia, parkinsonian tremor, violence, aggression, PTSD, GAD, prevention of variceal bleeding, CHF, tetralogy of fallot, hyperthyroidism. -Dosing: 40-400 mg/day Risks: -bradycardia -hypotension -dizziness -hypoglycemia -weight gain -bronchospasm, cold/flu symptoms, sinusitis, pna's -sexual dysfunction Pearls: -May worsen depression, but helpful for anxiety medication can be prescribed after an acute trauma to prevent a permanent fear response - ANSWER both β blockers and opioids -potentially mitigate the conditioning of the original traumatic memory