amygdala may “ remember ” stimuli associated W r i t i n g

amygdala may “ remember ” stimuli associated W r i t i n g

PLEASE JUST PIKE 3 THINGS WE HAVE LEANRN FROM THE PREVIOUS DISCUSSION BOARD.

Initial Post

Consider your prior knowledge

Name 3 things that you learned in this course

Have your prescribing habits changed if you are a prescriber? If you are not a prescriber yet what have you learned about appropriate prescribing?

Response Post

Review your peers’ responses and respond to at least two classmates.

  • What did you learn?
  • Did any topics provoke interest in further learning?

A) student one

Name 3 things that you learned in this course.

One of the many things that stood out to me in this course is fear conditioning, a concept as old as Pavlov’s dogs (Stahl & Grady, 2013). In humans, fear is learned during stressful experiences associated with emotional trauma and is influenced by an individual’s genetic predisposition as well as by an individual’s prior exposure to environmental stressors that can cause stress sensitization of brain circuits (e.g., child abuse). Often, fearful situations are managed successfully and then forgotten. However, other fears that are “learned” and not “forgotten” may hypothetically progress to anxiety disorders or a major depressive episode. Hearing an explosion, smelling burning rubber, seeing a picture of a wounded civilian, and seeing or hearing flood waters are all sensory experiences than can trigger traumatic re-experiencing and generalized hyperarousal and fear in PTSD.

The amygdala may “remember” stimuli associated with that experience by increasing the efficiency of glutamate neurotransmission, so that on future exposure to stimuli, a fear response is more efficiently triggered.

In addition to fear conditioning, I saw that lorazepam could be used successfully and effectively to manage patients with PTSD. SSRIs and SNRIs are proven effective and are considered first-line treatments, but often leave the patient with residual symptoms, including sleep problems (Stahl & Grady, 2017). Thus, most patients with PTSD do not take monotherapy. Moreover, benzodiazepines are to be used with caution, not only because of limited evidence from clinical trials for efficacy in PTSD, but also because many PTSD patients abuse alcohol and other substances.

Have your prescribing habits changed if you are a prescriber?

My prescribing practices have definitely become more stringent, starting low and going slow. After precepting with a psychiatrist and pmhnp, I saw that they both like to start with non-stimulant and non-benzo medication. There is also the extra step of having to check the PDMP when prescribing controlled substances to patients at each visit.

Reference

Stahl, S. M., & Grady, M. M. (2013). Stahl’s essential psychopharmacology: The prescriber’s guide (4th ed.). Cambridge, UK ; New York: Cambridge University Press.

A) student two

Name 3 things that you learned in this course

  • Among many things that I learned in this course, getting to know about different treatment guidelines for bipolar disorder was quite interesting to me. This course exposed me (as a clinician) to how to effectively care for patients with bipolar disorder during both acute and maintenance phases using either APA, VA/DoD, or NICE treatment guidelines. I liked that some of the guidelines may be easily used as a quick reference guide. Though I preferred the APA and VA/DoD guidelines to NICE because they provided detailed and comprehensive approaches. APA treatment guidelines provide evidence-based recommendations for both assessment and treatment of Bipolar disorder and was made to help clinicians in decision making through systematically developed practice care strategies in a standardized method (APA, 2020). VA/DoD guidelines will also serve as a quick reference guide through its simplified 6 modules. Module A: Acute Mania, Hypomania or Mixed Episode. Module B: Acute Depressive Episode. Module C: Maintenance Phase. Module D: Psychosocial Interventions. Module E: Pharmacotherapy Interventions. Module F: Specific Recommendations for Management of Older Persons with Bipolar (VA/DoD, 2020).
  • Next is the use of psychotropics during pregnancy and lactation period which actually provoked my interest in further learning. I learned that the antipsychotics are generally considered safe during pregnancy and for breastfeeding infants of users. Studies have shown that use of typical antipsychotics have no adverse effects associated with their use in lactating mothers. They all have a milk/plasma ratio of less than 1, which is considered safe. Use of typical and/atypical antipsychotic is considered a good option during pregnancy and postpartum for bipolar patients (Odhejo et al., 2017). I also learned that use of valproate during first trimester has been linked to major malformation and long-term sequalae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Furthermore, use of carbamazepine in first trimester is linked to higher risk of major congenital malformation and is contraindicated. Study proved lamotrigine appears to be more favorable than other anticonvulsants. During lactation, use of valproate and lamotrigine is reported to be safe (Grover & Avasthi, 2015).
  • I was thrilled to know more about different mode of actions of both conventional and atypical antipsychotic medications. The dopamine pathways that are implicated for the positive and negative symptoms of schizophrenia.

Have your prescribing habits changed if you are a prescriber? If you are not a prescriber yet what have you learned about appropriate prescribing?

As a prescriber, I was advised to always start from lower dosages and continue slowly for all patients not just the elderly population. But I additionally learned the specific low initial dosages of different psychotropic medications and how to increase them as needed through this course. This course has been an eye-opener for me. It helped solidified my idea about the monitoring laboratory test while patients are on different psychotropics, and how to effectively manage and educate the patients.

References

American Psychiatric Association (APA). (2020). Practice Guideline For The Treatment Of Patients With Bipolar Disorder. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-watch.pdf

Grover, S., & Avasthi, A. (2015). Mood stabilizers in pregnancy and lactation. Indian journal of psychiatry. 57(2), 308–323. https://doi.org/10.4103/0019-5545.161498

Odhejo, Y. l., Jafri, A., Mekala, H. M., Hassan, M., Khan, A. M., Dar, S. K., & Ahmed, R. (2017). Safety and Efficacy of Antipsychotics in Pregnancy and Lactation. Journal of Alcoholism & Drug Dependence. 5(3). https://doi.org: 10.4172/2329-6488.1000267

U.S. Department of Veteran Affairs/Department of Defense (VA/DoD). (2020). Clinical Practice Guideline: Management of Bipolar Disorder in Adults (BD). Retrieved from