119 terms

1445 - Psych exam 1

Becky's adjusted
# of new cases within a time frame
Total # of cases within a time frame
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)

- the reason the pt is admitted
- actual psych diagnosis

ex: Generalized anxiety, Schizophrenia, MDD
Axis 2 (DSM IV-TR)

- what will make it harder to treat them

ex: Personality Disorder, mild mental retardation, obsessive compulsive personality, low IQ
Axis 3 (DSM IV-TR)

- all medical stuff

ex: CHF, Diabetes, just had baby, finished chemo
Axis 4 (DSM IV-TR)

- what affects them in their social issues

ex: divorce, housing, assess to health care, legal issues, retirement, therapist retired
Axis 5 (DSM IV-TR)

- 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
- alertness
- inflammatory response
- stimulates gastric secretions

Decreased: sedation & weight gain
- only one that calms
- pain perception
- muscle relaxing

Decreased: anxiety, schizophrenia, mania
Increased: reduced anxiety
- 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)
- 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)
SSRI - Antidepressants
- 1st line

- only blocks serotonin reuptake
- less side effects (less anticholinergic & histamine)
- faster onset of action
- 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)
- 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

- 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
- 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
- Atypical antipsychotic

- highest risk of EPS

- don't use in dementia clients = strokes

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

- high sedation

- weight gain / OH

- low risk of EPS
- Atypical antipsychotic

- metabolic syndrome

- weight gain

- can cause type 2 diabetes
- Atypical antipsychotic

- cardiac side effects
- Atypical antipsychotic

- akathesis: can't sit still

- insomnia
- Atypical antipsychotic

- consistent release

- like Risperdal
Psychostimulants & 4 examples

- 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)
Assault precautions

- already have assaulted
Fire Precautions
Has a history of starting fires
Acute Suicide Precautions

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

- 15 min checks
- need staff supervision for anything
Nursing Close Observation

- watch patient until we know
- like GPS
Threatening to Elope

- 15 min checks
- take shoes away
- patient wears gown
- 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?
- get in fights / in trouble / aggression
- more irritability than sadness

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
Thoughts, impulses, or images that persist and recur and that cannot be dismissed from the mind
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
the actions of the drugs on the person, biochemically and physiologically (large-scale and molecular)
the actions of the person on the drug (absorption, excretion, etc). determines the blood level of the drug and guides the dosage
regular rhythmic movements, usually of lower limbs
constant pacing, like dancing from side to side
- seen when taking antipsychotics
absence or diminished voluntary motion
usually accompanied by parallel reduction in mental activity
-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