1445 - Psych exam 1

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Becky's adjusted

Incidence

# of new cases within a time frame

Prevalence

Total # of cases within a time frame

Resilience

Ability to adapt to tragedies, loss, trauma, severe stress

What is DSM-IV TR?

Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

Axis 1 (DSM IV-TR)

CLINICAL DISORDERS

- the reason the pt is admitted
- actual psych diagnosis

ex: Generalized anxiety, Schizophrenia, MDD

Axis 2 (DSM IV-TR)

PERSONALITY DISORDERS / MENTAL RETARDATION

- what will make it harder to treat them

ex: Personality Disorder, mild mental retardation, obsessive compulsive personality, low IQ

Axis 3 (DSM IV-TR)

GENERAL MEDICAL CONDITIONS

- all medical stuff

ex: CHF, Diabetes, just had baby, finished chemo

Axis 4 (DSM IV-TR)

PSYCHOSOCIAL & ENVIRONMENTAL PROBLEMS

- what affects them in their social issues

ex: divorce, housing, assess to health care, legal issues, retirement, therapist retired

Axis 5 (DSM IV-TR)

GLOBAL ASSESSMENT FUNCTIONING (GAF)

- functioning level

100=superior functioning
1=persistent danger to self/others

30 or below for inpatient acute care for insurance to pay

ex: 31 yr old who is unable to work or respond to family & friends

Dopamine (DA)

- fine muscle movement
- decision making

Decreased: parkinsons disease & depression
Increased: Schizophrenia & mania

Norepinephrine / Noradrenaline (NE)

- affects mood, attention & arousal
- stimulates fight or flight

Decreased: depression
Increased: mania, anxiety states, schizophrenia

Serotonin (5-HT)

- sleep regulation
- hunger
- mood states
- pain perception

Decreased: depression
Increased: anxiety states

Histamine

- alertness
- inflammatory response
- stimulates gastric secretions

Decreased: sedation & weight gain

GABA

- only one that calms
- pain perception
- muscle relaxing

Decreased: anxiety, schizophrenia, mania
Increased: reduced anxiety

Glutamate

- learning & memory

Decreased: psychosis
Increased: (NMDA) toxicity, alzheimers
(AMPA) improved cognitive performance

Acetylcholine (Ach)

- learning & memory
- affects sexual & aggressive behavior

Decreased: alzheimers, huntingtons, parkinsons
Increased: depression

Substance P

- feel less pain
- regulates mood & anxiety

Benzodizepines (BZD)

- potentiate GABA to decrease cell excitation = calming
- for sleep, anxiety
- also used for: anticonvulsant, ETOH withdrawal
- interferes with motor ability, attention & judgment

BZD sleepers (5)

- "Z-hypnotics"
- schedule IV
- quick onset
- short half lives
- can cause ataxia & amnesia

Benzodiazepines for sleep (5)

Dalmane (flurazepam)
Restoril (temazepam)
Halcion (triazolam)
Ambien (Zolpidem)
Lunesta (eszopiclone)

Benzodiazepines for anxiety (3)

Ativan (lorazepam)

Valium (diazepam)

Xanax (alprazolam)

Buspar

- reduces anxiety
- no sedative/hypnotic properties or CNS depression
- not a controlled substance
- good for Hx of addiction

TCA - Tricyclic Antidepressant

- 2nd line antidepressants

- blocks reuptake of NE & serotonin
- non-selective
- 10-14 days onset
- better to give total daily dose at night
- can't use in glaucoma

- more S/E: anticholinergic effects (blurred vision, dry mouth), esophageal reflux, ↓ BP, cardiac dysrhythmias, tachycardia, MI, & heart block
-block histamine receptors = drowsiness, sedation

Ex: Elavil, Tofranil, Anafranil, Sinequan, Pamelor, Norpramin

Tricyclic antidepressants (6)

Elavil
Anafranil
Norpramin
Adapin/Sinequan
Tofranil
Aventyl/Pamelon

SSRI - Antidepressants

- 1st line

- only blocks serotonin reuptake
- less side effects (less anticholinergic & histamine)
- faster onset of action
- more SEXUAL DYSFUNCTION
- CSS side effect
- N&V
Ex: Prozac, paxil, zoloft, celexa, lexapro, luvox

SSRI - Antidepressants examples (6)

Prozac, paxil, zoloft, celexa, lexapro, luvox

Central Serotonin Syndrome (CSS)

- caused by SSRI's (too much serotonin) and another antidepressant or St. John's Wort
- risk is greater if given concurrently with an MAOI (need 8-12 weeks in between)
- rare

Sx: abdominal pain, diarrhea, sweating, fever, tachycardia, ↑ BP, delirium, irritability, hyperpyrexia (107°), cardiovascular shock, myoclonus (seizure / fall to floor), can cause death

MAOI - Monoamine Oxidase Inhibitors & 3 examples

- last resort

- Stops tyramine breakdown which is a precursor of serotonin

- has dietary restrictions (anything fermented, dry cheese, diet pills, demerol, other antidepressants)

- S/E: OH, weight gain, edema, vertigo, change in HR, constipation, urinary hesitancy, insomnia, weakness, fatigue, hypomanic or manic behavior,...could cause stroke and hyperpyrexia

- can't give to children, cerebral vascular accident, CHF, HTN, or liver disease

EX: Nardil, Parnate, EMSAM

SSNRI - Serotonin Norepinephrine Reuptake Inhibitors & 2 Examples

- even more selective

- ↑ serotonin & norepinephrine

- good for neuropathic pain

- Ex: Effexor, Cymbalta

SND - Serotonin Norepinephrine Disinhibitors & 1 example

- minimal sexual dysfunction

- S/E: weight gain & sedation

- Remeron the only drug in this class

- prescribed: was on SSRI & had sexual dysfunction

Dopamine Norepinephrine Reuptake Inhibitor (2 examples)

Ex: Wellbutrin or Zyban

- no sexual S/E
- contraindicated in seizure disorders (anorexia, ETOH/CNS withdrawal - b/c lowers seizure threshold)

EX: Desyrel (trazadone)

- helps with insomnia (used as sleeping pill)
- need very high doses for antidepressant effects
- priapism = (erection lasting longer than 4 hours)

Lithium

- mood stabilizer
- makes patient "blah"
- drug of choice for bipolar
- effects electrical conductivity
- body can't tell difference between Lithium & Sodium (blood monitoring)

- S/E: convulsions, arrythymias, goiter, hypothyroidism, weight gain, polyuria, fine tremor, N&V

Anticonvulsants & 7 examples

- used to treat bipolar (violent pt's)

Depakote (Valproic acid): used for rapid cyclers (4x/year)
- thrombocytopenia

Tegretol:
- rash is common, anticholinergic s/e

EX: Lamictal (Steven Johnson syndrome), Klonopin, Topamax, Trileptal. Gabapentin (neurontin)

What are the only 3 meds we measure blood levels for in psych?

- Lithium (serum lithium levels)

- Depakote (platelets)

- Tegretol

Antipsychotic Meds (Typicals/conventionals) & 4 examples

- block attachment of dopamine (not selective)

- treats positive sx of schizophrenia (delusions/hallucination, violence, don't know reality)
- block everything so lots of S/E. it is why they made atypicals

- Can cause EPS: psuedoparkinsonism, akathisia/akinesia, dystonia, tardive dykinesia

- ↑ prolactin (milk in breast / no period / man boobs)

- Anticholinergic S/E / low BP / failure to ejaculate

EX: Haldol , Navene, Thorazine, prolixin

Antipsychotic Meds (Atypical) & 7 examples

- 1st line / fewer EPS

- block attachment of dopamine & serotonin (more selective)

- treat positive & negative sx of schizophrenia (isolation/avoiltion) (depression/psychomotor retardation)

- can cause metabolic syndrome (↑ weight / ↑ BS)
(Clozaril & Zyprexa are the worst)

EX: Clozaril, Risperidal, Seroquel, Zyprexa, Geodon, Abilify, Invega

Clozaril

- Atypical antipsychotic

- used after nothing else worked

- no movement disorders

- adverse s/e: suppress bone marrow & cause agranulocystosis, sore throat, fever, *flu-like symptoms (can't fight off infection)

-visit patient, draw blood, 1 week Rx & come back next week (expensive)

- common s/e: sedation, hyper salivation, tachycardia, constipation

Risperdal

- Atypical antipsychotic

- highest risk of EPS

- don't use in dementia clients = strokes

- long acting injectable form from CONSTA (has floaties/sutures in it)

Seroquel

- Atypical antipsychotic

- high sedation

- weight gain / OH

- low risk of EPS

Zyprexa

- Atypical antipsychotic

- metabolic syndrome

- weight gain

- can cause type 2 diabetes

Geodon

- Atypical antipsychotic

- cardiac side effects

Abilify

- Atypical antipsychotic

- akathesis: can't sit still

- insomnia

Invega

- Atypical antipsychotic

- consistent release

- like Risperdal

Psychostimulants & 4 examples

- ADHD

- Melancholic depression. Ritalin lose dose can help motivate depressed patients. give w/antidepressants

- blocks NE & Dopamine reuptake

- mimics NE & Dopamine

EX: Ritalin, Adderall
Nonstimulants = Straterra, Intuniv

Drug Treatment for Alzheimers & 4 examples

- maintain normal brain functions for as long as possible

- do not prevent or slow structural degeneration

EX: Aricept, Reminyl, Excelon
(Anticholinesterase Inhibitors -- destroy less ACH)

EX: Namenda
(Reduces degenerate from calcium leaving the cells)

AP

Assault precautions

- already have assaulted

Fire Precautions

Has a history of starting fires

ASP

Acute Suicide Precautions

- we stay in arms reach at all times
- 1 to 1
- can't go to activity
- no razors or cords

GSP

General Suicide Precautions

- 15 min checks
- need staff supervision for anything

NCO

Nursing Close Observation

- watch patient until we know
- like GPS

EP

Threatening to Elope

- 15 min checks
- take shoes away
- patient wears gown

SAO

- masturbating in public
- sexually touching others
- sexually acting out

Risk factors for Suicide (9)

- Psychiatric disorders (Axis 1)
- Male
- White
- No religiosity
- Divorced men
- Professionals
- Physical Illness
- War Veteran
- Abuse substances

What are 4 factors for suicide?

- Genetic
- Substance Abuse
- Low Serotonin
- Physical Illness

Freud (Suicide)

Suicide results from aggression turned inward

Karl Menninger (Suicide)

3 parts of suicidal hostility

- wish to kill
- the wish to be killed
- the wish to die

Beck (Suicide)

- hopelessness

Who's most likely to act on suicidal thoughts are those who have
- suffered loss of a loved one
- suffered a narcissistic injury
- experienced overwhelming moods like rage or guilt
- identify with a suicide victim

What do you assess in a patient regarding suicide?

- patient's risk factors
- history of suicide attempts
- medical & psychiatric diagnoses

3 Key Components of Lethality of Suicide

1) The more details included in the plan, the higher the risk

2) How quickly the person would die using the method

3) If the means are available, the risk is greater than when one still has to secure means

Sad Persons Scale

1) Sex (male)
2) Age 25 to 44 or 65⁺ years
3) Depression
4) Previous attempt
5) Ethanol use
6) Rational thinking loss
7) Social supports lacking or recent loss
8) Organized plan
9) No spouse
10) Sickness

Primary Intervention: Suicide

Educate at a young age

Activities that provide support, information, and educate to prevent suicide

Secondary Intervention: Suicide

Treatment of actual suicide attempt

Tertiary intervention: Suicide

Dealing with survivors

Interventions with the family and friends of a person who has committed suicide to reduce the traumatic aftereffects

4 advanced practice interventions

1. psychotherapy
2. psychobiological interventions
3. clinical supervision
4. consultation

Major Depression Disorder (5)

- Severe emotional, cognitive, behavioral, and physical symptoms of depression = a change in their normal functioning

- A history of one or more major depressive episodes

- No hx of manic or hypomanic episodes

- 60% can expect to have a 2nd episode

- Twice as likely in women than in men

MDD subtype: Psychotic Features (4)

- disorganized thinking

- delusions (guilt, punishment for sins, somatic issue)

- hallucinations (usually auditory, berating)

- most common

MDD subtype: Melancholic Features (4)

- no environmental stressors (endogenous)

- worse in morning but gets better as day goes on

- severe apathy, weight loss, guilt, EMA, suicidal ideation

- seen in older ladies

MDD subtype: Atypical Features (3)

- vegetative sx (overeating & oversleeping)

- younger onset, psychomotor retardation

- anxiety

MDD subtype: Catatonic Features (2)

- shut down / comatose (can get bed sores)

- nonresponsiveness, extreme psychomotor retardation, withdrawal, negativity

MDD subtype: Postpartum Onset (4)

- within 4 weeks of childbirth

- psychotic features (risk of harm to child)

- hormonal

- usually gets worse with every child

MDD subtype: Seasonal Affective Disorder (SAD) (5)

- occurs in fall/winter remits in spring

- anergia, hypersomnis, overeating, weight gain, CHO craving

- responds to light therapy

- outpatient

- low serotonin from lack of melatonin

Dysthymic Disorder

- Mild to moderate symptoms of depression experienced over most of the day, more days than not, for at least 2 years

- Usually no hospitalization / tx outpatient or never diagnosed

- Age of onset from childhood to early adulthood

- Always depressed, but not suicidal ("sad sacks")

- Functioning

How does MDD differ in children than adults?

Children:
- get in fights / in trouble / aggression
- more irritability than sadness

Adults:
Eyeore effect / slows down

The Acute Phase of Major Depression

- 6 to 12 weeks

- psychiatric management and initial treatment

The Continuation Phase of Major Depression

- 4 to 9 months

- treatment continues to prevent relapse

The Maintenance Phase of Major Depression

- 1 or more years

- continuation of antidepressants to prevent relapse

Electroconvulsive Therapy (4)

- Given when a rapid, definitive response is needed to prevent suicide & poor response to drugs

- Useful for MDD and manic (bipolar) pts who are rapid cyclers

- Potential s/e: confusion, disorientation, & short-term memory loss

- need informed consent

6 other treatments for depression

1. Transcranial magnetic stimulation
2. Vagus nerve stimulation
3. Integrative therapy
4. Light therapy
5. St. John's Wort - careful, very strong antidepressant
6. Exercise

Mild Anxiety (3)

- Occurs in the normal experience of everyday living

- Ability to perceive is in sharp focus and problem solving becomes more effective

- May have slight discomfort, restlessness, or mild tension-relieving behaviors

Moderate Anxiety (3)

- Perceptual field narrows / some details are excluded from observation

- Problem solving ability is reduced but may improve in presence of support person

- Physical symptoms: tension, pounding heart, increased pulse & respiratory rate, diaphoresis, and mild somatic symptoms

Severe Anxiety (3)

- Perceptual field is greatly reduced

- Learning & problem solving are not possible

- Person may be dazed & confused, experience a sense of doom, and have intensified somatic complaints (headache, dizziness, nausea, insomnia, hyperventalation)

Panic Anxiety (5)

- Disturbed behavior, most extreme level of anxiety

- Inability to process environmental stimuli

- Loss of touch with reality (hallucination)

- Physical behavior: erratic, uncoordinated, & impulsive

Automatic behaviors are used to reduce anxiety, but may be ineffective

Diathesis-Stress Model

- Most psychiatric disorders have genetic vulnerability (biological predisposition) & negative environmental stressors
- nature plus nurture

Freud - Anxiety

Anxiety results from the threatened breakthrough of repressed ideas or emotions, and ego defensive mechanisms keep anxiety at manageable levels

Harry Stack Sullivan - Anxiety

Anxiety is linked to emotional distress caused when early needs go unmet or disapproval is experienced (interpersonal theory)

Anxiety is contagious, being transmitted to an infant from mother or caregiver

Behaviorists - Anxiety

Anxiety is a learned response to specific environmental stimuli

Cognitive Theorists - Anxiety

Anxiety disorders are caused by distortions in an individual's thoughts and perceptions

Panic Disorders with Agoraphobia

Clinical panic attacks accompanied by fear of being in an environment or situation from which escape might be difficult, embarrassing, or not available (no one will help you)

Ex: being home alone, on a bridge, in an elevator, traveling in a car, bus, plane

Specific Phobias

Provoked by a specific object (dog or spider) or situation (storm)

They are common and usually do not cause much difficulty because people can avoid the situation/object

Social Phobias

Social Anxiety Disorder "SAD"

Provoked by exposure to a social situation or a performance situation and can cause great difficulty

Ex: fear of public speaking, performing on stage, eating in public

Obsessions

Thoughts, impulses, or images that persist and recur and that cannot be dismissed from the mind

Compulsions

Ritualistic behaviors that an individual feels driven to perform to reduce anxiety

Generalized Anxiety Disorder (GAD)

- Excessive anxiety or worry lasting for 6 months or longer

- Sx: poor concentration, tension, sleep disturbance, restlessness

Posttraumatic Stress Disorder (PTSD)

- Reexperiencing of a highly traumatic event involving actual or threatened death or serious injury to self or others to which the person responded with intense fear, helplessness, or horror

- Ex: military combat, POW, tornado, earthquake, plane accident, bombing, rape

- Symptoms usually begin within 3 months after the traumatic incident

- Sx: flashbacks, numbness, detachment, increased arousal, avoidance of stimuli associated with the trauma

Acute Stress Disorder

- Occurs within 1 month after exposure to a highly traumatic event

- To be diagnosed pt must display 3 symptoms after event (numbness, detachment, derealization, depersonalization, or dissociative amnesia)

Substance-Induced Anxiety Disorder

Symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of stopping use

Anxiety Due to Medical Condition

Physiological result of a medical condition such as pheochromocytoma, cardiac dysrhythmias, hyperthyroidism, PE

Anxiety Disorder Not Otherwise Specified (NOS)

Diagnosis used for disorders in which anxiety or phobic avoidance predominates, but the symptoms do not meet full diagnostic criteria for a specific anxiety disorder

4 assessment guidelines in anxiety

1. physical and neurological assessment
2. assess self-harm / suicide
3. psychosocial assessment
4. assess cultural differences

4 Characteristics of Somatoform Disorders

- Complaints of physical symptoms are not explainable by physiological tests

- Psychological factors and conflicts seen important in initiating, exacerbating, and maintaining the disturbance

- The patient is unable to control the symptom voluntarily

- Symptoms are not intentionally produced

Somatization disorder (3)

-many physical complaints over the years
- impaired social, occupational or other functioning
- symptoms usually from multiple systems

Hypochondriasis (3)

-preoccupation with having serious disease
- preoccupation > 6 months
- extreme worry and fear

Body Dysmorphic Disorder (BDD)

Involves preoccupation with an imagined defect in appearance, causing significant distress and impairment in social or occupational functioning

Conversion Disorder (3)

- Presence of 1 or more symptoms suggestive of a neurological disorder that cannot be explained by a known neurological, medical, or culture-bound symptom

- Identifiable stressor or conflict makes symptoms worse

-may display indifference to the condition

Factitious Disorder (3)

- Pt constantly pretends to be ill to get emotional needs met and attain the status "patient"

- 3 subtypes; those that are predominately physical, those predominately psychological, and combination of both

- Pt's tend to use the same care giver and use the ER at night when staff is less likely to know them

Munchausen Syndrome (3)

- Where a caregiver deliberately causes illness in a vulnerable dependent for the purpose of attention, sympathy, and excitement

- Most severe and chronic form of factitious disorder

- Pt's have scars from numerous exploratory surgeries to investigate unexplained symptoms

Malingering (2)

- consciously motivated act to deceive based on desire for personal gain

- Involves conscious process of fabricating illness or exaggerating a symptom for gains such as disability compensation, insurance fraud, or to evade military service, prison, or mandatory schooling

Depersonalization Disorder (4)

- A persistent or recurrent alteration in the perception of the self to the extent that the sense of one's own reality is temporarily lost occurs

- Reality testing ability remains intact

- May feel mechanical, dreamy, or detached from body

- occurs w/hypochondriasis, anxiety & personality disorders

Dissociative Amnesia (4)

- Inability to recall important personal info of a traumatic or stressful nature

- It is more pervasive than forgetfulness

- 2 types: localized (cannot remember any of the event) and selective (can remember some things but not other things)

- occurs w/conversion or personality disorders

Dissociative Fugue (3)

- Inability to recall identity and info about past and is typically accompanied by travel away form the customary locale. may be precipitated by a traumatic event
- occurs w/ PTSD

Dissociative Identity Disorder (DID) (4)

- presence of 2 or more distinct alternative or sub personality states that recurrently take control of behavior (multiple personality)

- each subpersonality has its own pattern of perceiving, relating to, and thinking about self and environment

- more common among 1st degree relatives

- occurs w/ PTSD, borderline personality disorders, sexual, eating or sleeping disorders

word salad

a jumble of unrelated words

looseness of association

unconnected phrases and topics

pharmacodynamics

the actions of the drugs on the person, biochemically and physiologically (large-scale and molecular)

pharmacokinetics

the actions of the person on the drug (absorption, excretion, etc). determines the blood level of the drug and guides the dosage

akathisia

regular rhythmic movements, usually of lower limbs
constant pacing, like dancing from side to side
- seen when taking antipsychotics

akinesia

absence or diminished voluntary motion
usually accompanied by parallel reduction in mental activity

dystonia

-abnormal muscle tonicity, impaired voluntary movement
- muscle spasms of face, head, neck & back
- S/E of antipsychotic meds

tardive dyskinesia

- involuntary tonic muscle spasms of tongue, fingers, toes, neck, trunk, pelvis
- irreversible

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