A 32 year old engineer has been uncharacteristically active for several weeks. He spends most of his time at work and gets little sleep. He has told another engineer that he is involved “in a research project that will earn me the Nobel Prize”. The engineer is irritable, and it is hard to hold his attention. A classmate from graduate school recalls that the patient behaved in a similar manner twice during stressful periods at school.
Long term drug therapy for this patient would likely include:
Correct Answer A:
Mania is described by the following:
Mania and hypomania usually develop before the patient reaches age 40, unless the patient has had prior depressive episodes. The differential diagnosis of new-onset mania in a younger person should include drug-induced mental disorders and brief reactive psychosis. If thought disorder is prominent, a primary thought disorder in the schizophrenic spectrum must be considered. If the patient is confused or disoriented, agitated delirium is a relevant consideration. The primary treatment for mania or hypomania is therapy with a mood-stabilizing drug, of which lithium was the first and is the best-studied. Patients who do not respond to lithium, those with rapid cycles between depression and mania, and those with a mixture of manic and depressive symptoms may respond well to a mood-stabilizing antiepileptic drug. These drugs are given at typical antiepileptic dosages. The effects of valproate and carbamazepine are well-established by clinical trials; gabapentin has shown mood-stabilizing effects when used as an anticonvulsant and may eventually be used as a psychiatric drug. Functionally impaired patients with prominent paranoid features, and those who fail to respond to both lithium and antiepileptic drugs, should be treated with neuroleptics.
[Internal Medicine, Stein - 5th Ed. (1998)]
A 40 year old white male is having rapid mood changes, and his speech is pressured and difficult to interpret.
These findings suggest:
Correct Answer B:
Rapid mood swings and speech that is typically pressured and difficult to interpret are characteristics of a manic episode. These features are not characteristic of the other psychiatric conditions listed.
A 30-year-old man is admitted to a locked psychiatric unit for court-ordered treatment, after threatening to kill himself. He gives a three-week history of irritable mood, sleep fragmentation, high energy, loss of appetite, a ten pound loss of weight, and racing thoughts. He states that he has had six episodes like this in the past year. He has a five-year history of bipolar disorder and is currently taking valproic acid and paroxetine. On examination, he is restless, his speech is pressured, and his affect is labile.
Which of the following would not be an appropriate intervention at this time?
Correct Answer C:
The patient is currently having an episode of mania, for which the treatment of choice is a mood stabilizer, such as valproic acid. Stopping it would likely worsen his condition. A blood level should be measured and the dosage optimized. His bipolar disorder is also a rapid cycling one, defined as four or more episodes of a mood disturbance in the past year.
A. Despite his known history of bipolar disorder, abuse of illicit drugs may be playing a role in his current presentation.
B. Antidepressants can initiate mania and they can initiate or worsen rapid cycling. In manic patients and in most patients with rapid cycling, they should be discontinued.
D. Studies suggest that ECT may be more effective than medication for the treatment of mania.
E. Milieu therapy is an important part of inpatient psychiatric treatment and refers to the use of the hospital environment itself as a therapeutic intervention. It includes such techniques as behavioral reinforcement, peer support, and structured scheduling of daily activities.
Hypertensive encephalopathy may be precipitated in patients taking monoamine oxidase inhibitors with the ingestion of foods containing high levels of which one of the following?
Antidepressants known as monoamine oxidase inhibitors work by blocking the breakdown of neurotransmitters (NT’s). When the excess NT’s don't get destroyed, they start piling up in the brain. And since depression is associated with low levels of these NT’s, increasing the NT’s ease depressive symptoms.
Unfortunately, monoamine oxidase doesn't just destroy those neurotransmitters; it's also responsible for mopping up another amine called tyramine, a molecule that affects blood pressure. So when monoamine oxidase gets blocked, levels of tyramine begin to rise, too. And that's when the trouble starts.
While a hike in neurotransmitters is beneficial, an increase in tyramine is disastrous. Excess tyramine can cause a sudden, sometimes fatal increase in blood pressure so severe that it can burst blood vessels in the brain.
Normally, MAO enzymes take care of this potentially harmful tyramine excess. But if you're taking an MAO inhibitor, the MAO enzyme can't stop tyramine from building up. This is exactly what happened when the drugs were introduced in the 1960s. Because no one knew about the tyramine connection, a wave of deaths from brain hemorrhages swept the country. Other patients taking MAO inhibitors experienced severe headaches caused by the rise in blood pressure.
Monoamine oxidase inhibitor drugs are used in the treatment of depression because they increase synaptic levels of:
Correct Answer D:
Once the brain's three neurotransmitters, known as monoamines (serotonin, norepinephrine, and dopamine), have played their part in sending messages in the brain, they get burned up by a protein in the brain called monoamine oxidase, a liver and brain enzyme.
Antidepressants known as monoamine oxidase inhibitors work by blocking this cleanup activity. When the excess neurotransmitters don't get destroyed, they start piling up in the brain. And since depression is associated with low levels of these monoamines, increasing the monoamines ease depressive symptoms.
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