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Bipolar 1 Disorder (4)

- At least 1 episode of mania alternating with major depression

- Psychosis is common

- Onset 18yo / more common in males

- Usually 1st episode is depression / episodes increase in severity & numbers

Bipolar 2 Disorder (4)

- At least one hypomanic episode alternating with major depression

- Never full blown mania

- more suicides

- Onset 20yo / more common in females

Cyclothymia (4)

- Baby bipolar

- Hypomanic episodes alternating with minor depression episodes (at least 2 years in duration)

- Irritable hypomania

- Onset in adolescents (At least 1/2 develop bipolar disease)

Bipolar - Biological theories (4)

1. Genetic = high rates in relatives
2. Abnormal circadian genes-extreme insomnia
3. Genome that encodes an enzyme (DGKH)
4. irregularities on chromosomes 13 & 15

Lithium (Mania Bipolar) (6)

- Antimanic drug of choice used as mood stabilizer

- Reduces elation, grandiosity, flight of ideas, irritability, manipulativeness, & anxiety

- It also controls insomnia, agitation, distractibility, and threatening or assaultive behavior

- Brings down acute mania in 2 weeks

- usually given with prn benzo

- kidney, cardiac & thyroid (fries) issues

Therapeutic Lithium Levels (5)

0.5-1.5 mEq/L

Adult Mania 1.0-1.5 mEq/L

Elderly Mania 0.3-0.8 mEq/L

2.0 or ↑ Toxic

Lithium affects brain b/c body thinks its Na+

Blood levels are drawn 8-12 hours from last dose. don't take Lithium at night

Lithium Maintenance level

0.5 to 1.5 mEq/L

Lithium adult mania serum level

1.0 to 1.5 mEq/L

Lithium elderly mania serum level

0.3 to 0.8 mEq/L
because ↓ kidney function

Nuisance side effects of Lithium (6)

- Fine tremor
- Polyuria
- Mild nausea
- Thirst
- Taste like metal
- Weight gain (10-20lbs in 1 month)

Early Lithium Toxicity (10)

<1.5 mEq/L

- N/V
- Diarrhea
- Thirst
- Polyuria
- Lethargy
- Slurred speech
- Muscle weakness
- FINE tremor

* Hold meds, measure blood levels, fix dehydration

Advanced Lithium Toxicity (9)

1.5-2 mEq/L

- COARSE hand tremor
- Persistant GI upset
- Confusion
- Muscle hyperirritability
- EEG changes
- Incoordination
- Sedation

* Hold meds, assess VS, measure blood levels, fix dehydration

Severe Lithium Toxicity (12)

2-2.5 mEq/L

- Ataxic gait (drunk)
- Confusion
- ↑ urine output followed by oliguria
- EEG changes
- Blurred vision
- Chronic movement
- Seizures / Stupor
- Hypotension
- Pulmonary complications
- Coma / Death

* Hospitalization, meds stopped, excretion (emetic "puke", aminophylline "breathe", peritoneal dialysis)

6 common causes of Lithium toxicity

1. ↓ Na+ intake, so body retains Lithium
2. Diuretic therapy
3. ↓ kidney function (so lithium stays in body)
4. F&E losses (fever, sweating, vomiting) so give 0.9%NS-want to intake Na+ b/c hyponatremic
5. medical illness
6. lithium overdose (don't double dose)

Depakote (Valproic Acid) (6)

Anticonvulsant

- weight gain
- mild alopecia
- ✓ platelets for thrombocytopenia
- Liver func tests
- Used for migraine headache prevention

Depakote Therapeutic Level (3)

50-125 mcg/ml

Fatal at 800-1,000 mcg/ml

Hold if RR less than 12

Tegretol (Carbazemepine) (6)

Anticonvulsant

- Dizziness / DROWSINESS = very common
- Orthostatic Hypotension
- Bone marrow suppression
- **Agranulocytosis / Thrombocytopenia

- Assess CBC, platelets, sore throat, malaise, mouth ulcers, easy bruising & bleeding

Tegretol Therapeutic Levels (3)

4-12 mcg/ml

Toxicity usually in children ↓18yo being treated for seizures

Sx: Nystagmus (rapid involuntary eye movements), dystonia, resp depression

Trileptal & Lamictal (3)

- Anticonvulsants

- Relatively safe / no blood monitoring

- watch for Steven Johnson Syndrome with Lamictal

Atypical Antipsychotics for Bipolar (2) & 4 examples

Abilify, Zyprexa, Seroquel, Risperidal

- Sedative properties can help with insomnia, anxiety and agitation

- Seem to help stabilize mood

Typical Antipsychotics for Bipolar & 3 examples

Haldol, Thorazine, Prolixin

- Used prn for psychiatric emergencies

Antianxiety Meds for Bipolar (3) & 2 examples

Klonopin & Ativan

- Used prn
- May help stabilize mood
- Helps with agitation

ECT for Bipolar (3)

- May be used to treat severe manic behavior and those with depressive episodes

- Good for treatment-resistant individuals

- Also effective in pts with rapid cycling and paranoid destructive features and in acutely suicidal pts

Schizophrenia - General (5)

- Onset 18-19yo
- neurobiological disorder
- Usually start to see signs 2-14yo
- Earlier the onset the worse the prognosis
- Rule out other diagnosis and drug use 1st

DSM Criteria for Schizophrenia (8)

2 or more for 1 month if untreated;

- Delusions=false belief, cannot change w/logic
- Hallucinations
- Disorganized speech
- Disorganized behavior = odd behavior
-Negative Sx (affect flat, avolition=w/o motivation, alogia=w/o logic)

- Social & Occupational Dysfunction
- 6 months of continuous signs

Schizophreniform (3)

- Rare
- Sx duration less than 6 months
- Social/Occupational functioning intact

Brief Psychotic Disorder (3)

- Sudden psychosis r/t stressor or crisis (could be drugs)
- Returns to premorbid functioning
- Usually older adult

Schizoaffective Disorder (4)

- MDD or Bipolar symptoms with schizophrenic symptoms
- Don't meet all criteria for either
- Don't know what to call them
- work on the MDD or bipolar symptoms

Delusional Disorder (2)

- Nonbizarre delusions
- Can function, treat outpatient

Shared Psychotic Disorder (2)

- In a close sustained relationship the other person shares the psychotic person's delusional system

- Ex: couples, Manson followers

Induced Psychosis (6)

Caused by
- Drugs/substances
- Medical conditions
- Liver problems
- Hyperglycemic
- Not sleeping for 3-4 days

- Hallucinations

Schizophrenia Paranoid Type (8)

- Grandiose or Persecutory delusions (FBI is after you)
- Less neurological & cognitive impairment
- Better prognosis
- Auditory hallucinations (usually negative, if commanding then ↑ lethality)
- Interact as guarded, rigid, intense, controlled
- On periphery of groups & activities (won't hide)
- Sideways glances
- respond better to meds

Disorganized Schizophrenia (6)

- Early onset with childish silly affect
- Word salad, clanging
- Many negative symptoms
- Socially withdrawn & incompetent
- Unable to perform ADL's
- Poor prognosis

Catatonic Schizophrenia (5)

- Stupor "shut down" or nonpurposeful excitement "hand ringing"
- Sudden onset in 20's or 30's & prognosis is good
- Posturing, waxy flexibility, mutism, automatic obedience, echopraxia (echo movement) and echolalia (echo words)
- Often remember in detail what happened in their stupor
- When not in this state they are functioning

Chronic Undifferentiated Schizophrenia (CUT) (6)

- Combination of all other types
- Aggressive / more scary
- Extreme fragmented delusions
- Hallucinations
- Bizarre disorganized behavior
- Poor prognosis

Residual Schizophrenia (3)

- No positive signs of schizophrenia
- Mild to moderate negative signs
- many older schizophrenics display only residual sx, odd/eccentric, not blatantly psychotic anymore

Positive Symptoms of Schizophrenia (8)

- Hallucinations
- Delusions
- Bizarre behavior
- Paranoia
- Acute onset
- Normal functioning during remissions
- Normal CT scans
- Good response to antipsychotics

Negative Symptoms of Schizophrenia (11)

- Apathy
- Lack of motivation
- Anhedonia
- Poor social functioning
- Poverty of thought
- Insidious onset
- Hx of emotional problems
- Chronic deterioration
- CT scan showing atrophy
- Poor response to antipsychotic meds
- Atypicals work better

Assessment guidelines: Schizophrenia (8)

1. medical workup
2. ETOH/Substance abuse
3. Hallucinations and delusions: reality based
4. Depression and anxiety
5. History of violence
6. Medication adherence
7. Patient support
8. Global functioning

Atypical Antipsychotics for Schizophrenia - General (4) & 7 examples

- Diminish negative & positive symptoms
- Few or no EPS or TD (so better adherence)
- ↑ weight gain and more expensive
- Affect blood glucose

Abilify (aripiprazole)
Clozaril (clozapine)
Geodon (ziprasidone)
Invega (Injection)
Risperdal (risperidone)
Seroquel (quetiapine)
Zyprexa (olanzapine)

Clozaril (Clozepine) (4)

- Use when nothing else works
- Agranulocytosis in 1-3% of pts
- Weekly CBC
- Assess for fever, malaise, sore throat, flu sx

Traditional Antipsychotics for Schizophrenia - General (6) & 4 examples

- Relieve positive symptoms (NOT negative)
- EPS sx(akathisia, dystonia, pseudoparkinsonism & TD) are treated by ↓ dose or prescribing antiparkinsonian drugs
- Anticholinergic side effects
- orthostasis
- photosensitivity
- lowered seizure threshold

Haldol
Navane
Prolixin
Thorazine

3 Antiparkinonian drugs used to treat EPS

Benadryl (diphenhydramine)
Artane (trihexyphenidyl)
Cogentin (benztropine)

* Watch for urinary retention in Cogentin

Low potency/high dose traditional antipsychotic (3) & 1 example

- high sedation
- high ACh side effects
- low EPS
Ex. thorazine

High potency/low dose traditional antipsychotic (3) & 1 example

- Low sedation
- Low ACh side effects
- High EPS
Ex. Haldol

Traditional antipsychotic depot injections (2)

1. Fluphenazine decanoate (Prolixin D)
2. Haloperidol decanoate (Haldol D)

Atypical antipsychotic depot injections (1)

Risperidone (Consta)

Neuroleptic Malignant Syndrome (2) & 8 symptoms

- Occurs in less than 1% of pts taking standard antipsychotics
- Potentially fatal

Sx:
- ↓ level of consciousness
- ↑ muscle tone (rigidity)
- fever
- hypertension
- tachycardia
- tachypnea
- diaphoresis
- drooling

Mild Mental Retardation (3)

- 85%

- Academic skills to grade 6

- Minimum self support

Moderate Mental Retardation (3)

- 10%

- Academic skills to grade 2

- Provide self care/hygiene

Severe Mental Retardation (2)

- 3%

- Rudimentary communication

Profound Mental Retardation (2)

- 2%

- sensory motor problems

Pervasive Developmental Disorders (PDD) (4)

- Severe & pervasive impairment of reciprocal social interaction and communication skills, usually accompanied by stereotyped behavior, interests, and activities

- Mental retardation is often present / Long term

- Axis II

- Problems with cognitive and social skills

Autistic Disorder (11)

- Appears first 3 years of life
- Language delay or absence
- Stereotypical or repetitive langage or movement
- Lack of spontaneous make believe play
- Limited eye contact
- Indifference to affection or physical contact
- Not able to share joy or interest
- Failure to make friends
- Everything is amplified / can't filter distractions
- 4x more in boys / worse if present in girls
- 90% concordence in identical twins

Medications for Autism (3)

Atypical Antipsychotics
- Risperdal (if aggressive)
- Zyprexa

Typical Antipsychotics
- Haldol prn

Aspergers Disorder (7)

- Sustained social impairment
- Restricted repetitive behaviors
- No delay in development of language
- Intact cognitive skills / but lacking social skills
- Later onset (10-12)
- Familial pattern
- Like autism but higher functioning

Rhett's Disorder (9)

- Only seen in females
- Onset before age 4
- Persistent loss of manual skills
- Stereotyped hand movements (wringing)
- Problems with coordination and gait, impaired head growth
- Severe psychomotor retardation
- profound mental retardation
- Severe problems with expressive and receptive language
- Loss of interest in social interactions

ADHD - 3 presenting symptoms

1. inattention
2. hyperactivity
3. impulsivity

ADHD (8)

Sx must be present before age 7 and occur in 2 settings (home & school)

- Inattention
- Hyperactivity (can't sit still)
- Does not pay attention to social cues
- Acts as if driven to do something
- Talks excessively / interrupts
- Can't wait turn / impatient
- Assess for problems with enuresis & encopresis

ADHD medications (12)

Stimulants (category II)
- Ritalin, Focalin, Concerta, Adderall, Vyvanse, Cylert
- Daytrana-patch

Antidepressants
- Prozac, Wellbutrin

Alpha adrenergic agonists
- Catapres

Nonstimulants
- Straterra
- Intuniv

Oppositional Defiant Disorder (ODD) (9)

- Before age 18 (after 18=antisocial)
- "baby sociopaths"

- Recurrent pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, without serious violations of the basic rights of others

- Loses temper / angry
- Argues with adults
- Actively defies / refuses to comply
- Deliberately annoys people
- Blames others for mistakes
- Easily annoyed by others

Conduct Disorder (13)

- Same Sx as ODD but more severe and peer related
- Onset before age 10 (really bad) & marked by physical aggression. If later not as aggressive
- Males 6-16%
- Females 2-9%
- cannot yet be considered a sociopath
- No sense of right & wrong
- No remorse
- Causes harm to others and animals
- Destroys property
- Theft
- Serious violation of rules
- no empathy
- Meds & bootcamp ineffective

Tourette's Disorders (8)

- Motor & vocal tics

- Obsessions
- Compulsions
- Hyperactivity
- Distractibility
- Impulsivity
- Low self esteem --> tics

- Tx with antipsychotics

Adjustment Disorder (3)

- When it doesn't meet other DSM criteria

- Decreased performance at school
- Temporary changes in social relationships occurring within 3 months of the stress and lasting no longer than 6 months after stress has ceased

Eating disorder: Pica

persistent eating of nonnutritive substances. Ex. paint, string, cloth, etc

Eating disorder: rumination

repeated regurgitation & re-chewing of food

Eating disorder: feeding and eating disorder

child doesn't eat adequate amount of food even though food is available

Freud: Oral (0-1 year)

Development of trust

- passivity, gullibility, dependence, use sarcasm, oral focused habits like smoking, nail biting

Freud: Anal (2-3 yrs)

Delay gratification

- stinginess, rigid thought processes, OCD-or-messiness, cruelty and destructiveness

Freud: Phallic (3-5 yrs)

Identify with same sex partner

- Difficulties with sexual identity, authority figures (Oedipal & Electra complexes)

Freud: Latency (6-12 yrs)

Develop coping skills

- inadequacy, inferiority

Freud: Genital (13 yrs+)

Creative, find pleasure in love/work

- emotionally dependent, financially dependent, lack of personal identity, lacks future goals, cannot form intimate satisfying relationships

Erikson: Trust vs Mistrust (0-1 1/2yrs)

Suspicion, fear of future

Erikson: Autonomy vs Shame and Doubt (1 1/2-3yrs)

Self doubt, unsure

Erikson: Initiative vs Guilt (3-6yrs)

Agression, inadequacy, guilt

Erikson: Industry vs Inferiority (6-12yrs)

- Inferiority, difficulty working and learning, self esteem

Erikson: Identity vs Role Confusion (12-20yrs)

- No personal identity, submerse your identity in relationships or groups

Erikson: Intimacy vs Isolation (20-35yrs)

Unable to love deeply, unable to commit, egocentric

Erikson: Generativity vs Stagnation (35-65yrs)

Self absorption, cannot grow

Erikson: Ego Integrity vs Despair (65 to death)

Dissatisfied with life, denial or despair about death

Piaget Cognitive Development

Sensorimotor: (0-2yrs)
- differentiates self

Preoperational: (2-7yrs)
- here and now / no insight

Cognitive operational: (7-11yrs)
- past and present thinking / very concrete

Formal operational: (11-16yrs)
- future and abstract thinking

Maslow's Hierarchy of Needs

- Self transcendence
- Self actualization
- Self esteem
- Affiliation/belonging
- Safety/security
- Biologic/Physiologic

Have to start from the bottom before you can worry about levels above

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