Neuroscience & Mental Health: Neurons, Brain, Neurotransmitters & Disorders, Exams of Nursing

Download Neuroscience & Mental Health: Neurons, Brain, Neurotransmitters & Disorders and more Exams Nursing in PDF only on Docsity! ANCC Study Book Ch 2-7, 9-17 Questions with Answers 2024 The 9 Nurse Practitioner Core Competencies \ n ✔Scientific Foundations Leadership Quality Practice Inquiry Technology and Information Literacy Policy Health Delivary System Ethics Independent Practice Facilitating factors for growth of the NP role: \ n ✔Consumer demand Acceptance of APN role Emergence of PMHNP role Decreasing stigma Emphasis on integrated healthcare services Constraining factors for growth of NP role: \ n ✔Growing competition in job market Reimbursement issues: Medicaid/private insurance Overlapping scopes of practice with other NPS Concerns regarding reimbursement fraud and abuse in coding and billing Scope of practice and need for collaborative dr. What are the state legislative statues regarding NP practice \ n ✔State legislative statues grant legal authority for NP practice, provide title protection (who can be called NP), define advanced practice, our state laws define scope of practice, place restrictions on practicesand set NP credentialing requirements. Grounds for disciplinary action by our state legislature statues: \ n ✔Practicing without valid license, falsifying records, Medicare fraud, inappropriate nursing judgement, inaccurate documentation, failure to follow accepted nursing standards. Collaborative agreement \ n ✔AKA protocol that describes what types of drugs may be prescribed and defines oversight for NP practice. Statutory laws for NPs \ n ✔Regulation differ by state, they further define scope of practice and may provide restrictions in practice unique to that specific state. Licensure \ n ✔Process by which a government agency authorizes individuals to work in a given occupation Credentialing \ n ✔Process used to protect the public by ensuring a minimum level of professional competence. Certification for NPs \ n ✔Provides title protection, determines scope of practice, determines the NP has met specified standars, assures public the NP has mastery of a specific body of knowledge and skills to function in that specialty. ANCC American Nurses Credentialing Center \ n ✔is a subsidiary of the ANA and is the only certifying body for psychiatric APN. Scope of practice: \ n ✔Defines NP roles and actions, identifies competencies asumed to be held by all NPs in a particular role, varies broadly from state to state. For PMHNP they are identified in the PMHNP scopes and standards of practice. Standards of practice: \ n ✔authoritative statements regarding quality and type of practice that should be provided, provide a way to judge nature of care provided, reflect professional agreement focused on minimum levels of accepted performance, can be used to legally describe standards of care that must be met, and may be precise protocols that must be followed OR more general guidelines that recommend actions. Professional role responsibilities: \ n ✔Confidentiality, HIPAA, the Health Information Technology for Economic and Clinical Health Act, Telehealth, exceptions to guaranteed confidentiality, informed consent, and ethics. Confidentiality \ n ✔protection of privacy without diminishing access to quality care, protected under federal statute through Medical Record Confidentiality Act, requires consent and signed authorization to release records. HIPPA \ n ✔Health Insurance Portability and Accountability Act. the first national comprehensive privacy act. Health Information Technology for Economic and Clinical Health Act (HITEC) \ n ✔law promoting the adoption and use of health information technology to improve individual and popuation based health outcomes. It can improve quality, safety, efficacy, effectiveness and outcomes. Used for e-scribing, computerized order sets, and tracking care/avoiding duplication of services. Telehealth \ n ✔Use of phome/videoconfrencing to deliver mental health care in rural areas. Must follow same standards as in person care. Must be practiced in accordance with international, federal and state regulations. Must provide for emergency care of client. HIPPA regualtions must be followed. Exceptions to guaranteed confidentiality: \ n ✔When appropriate person/organization determines need for info outweighs confidentiality. Pt is harm to self or others Info is given to attorney in litigation Releasing records to insurance company Court order, subpoenas, or summons Meeting state requirements for mandatory reporting of disease or conditions Competency \ n ✔A legal (NOT medical) term. A determination that a pt can make reasonable judgement and decisions regarding medical treatment. A person is considered competent until a court rules otherwise. If incompetenct, the court appoints a healthcare guardian. Involuntary commitment \ n ✔Legal situation in which people are hospitalized in psychiatric facilities against their will. Process may differ from state to state. Clients maintain civil liberties except ability to come and go. Amount of time they can be kept differs by state. Basic criteria for involuntary commitment \ n ✔1. Person has a diagnosed mental illness 2. Person is harm to self or other 3. Person is unaware/unwilling to accept the severity of the disorder. 4. Treatment is likely to improve function Voluntary commitment \ n ✔Client admitted based on chosen willingness to comply with treatment program. Client maintains all civil liberties. Role of NP with scholarly activities: \ n ✔publishing, lecturing, preceptorship, CEUs NP Mentoring \ n ✔An experienced professional helping a less experienced colleague. Client Advocacy by NP \ n ✔stand up for pt rights and empower them to become their own advocae, reduce stigma, help pt find services, promote mental health by joining a professional organization (ANA, APNA, ISPN) NP role in health policy \ n ✔NP has legal/ethical responsibility to be client advocate. Participate in health policy activities, testify at public meetings, lobby, work with media to bring awareneess Phases of policy making \ n ✔formulation, implementation, and evaluation Risk assessment \ n ✔Monitoring high risk situations and non-healthy behaviors Risk management \ n ✔Decisions and strategies to minimize risk Advanced Directives \ n ✔Legally binding in all 50 states A patient's statement to declare their wishes for healthcare and dying. *It should be considered as an aspect of relapse planning for clients with chronic psych disorders. AKA durable power of attorney for healthcare or healthcare proxy. Living Will \ n ✔Not legally binding in all states Document prepared while client is mentally competent to designate preferences for care if client becomes incompetent or terminally ill. Culture bound syndrome \ n ✔Specific behaviors related to a persons culture and not linked to a psych disorder. Culture \ n ✔Beliefs, customs, and traditions of a specific group of people. NP can provide more comprehensive care if s/he is sensitive to cultural issues. Cultural influences \ n ✔Family, ethnicity, community, environment Family \ n ✔group of adults and children who are usually related and the adults carry out essential functions of providing food, clothing, safety, and education of children. Family initially teaches the beleif patterns, religion, cultur, and mores of a society Ethnicity \ n ✔Self-identified affiliation or identity within a group of people bound by common ancestry and culture. Community \ n ✔Group of families, often sharing same race, tribe, or culture who have beleiefs or behavior not shared by others. Environment \ n ✔-Both physical and psychosocial factors, general circumstances of a persons life. -Social contacts, housing, climate, altitude, temp, air pollution, flouride in water, water contamination, crime, poverty, transportation Homelessness \ n ✔A temporary or permanent condition of not having a legal home address. Majority of homeless families are headed by: \ n ✔a single parent, usually a woman. -Female headed households are at high risk of homelessness if she has limited education and job skills, low pay employment, limited access to affordable housing. -Teen mothers also at risk due to lack of income/education that older parents have, Reasons for homelessness \ n ✔mental illness, addiction, poverty, unemployment, inadequate public assistance, domestic violence, lifestyle choice _________________ of homeless have co-occurring substance use disorder and serious mental illness \ n ✔~50% Schizophrenia accounts for _________ to ___________ of US homeless population. \ n ✔15-45% Homeless people with co-occurring disorders are at greater risk for: \ n ✔violence, med and treatment non-compliance Strategies for reducing homelessness: \ n ✔outreach, integrated care, colocation of services, supportive services to persons in their housing, prevention (d/c planning, resources, transition of care). Migrants \ n ✔a worker who moves from their permanent residences to take agricultural jobs in different locations Seasonal workers \ n ✔a person who travels from their permanent residence seasonally for agricultural employment It is estimated that more than ________________ migrant and seasonal workers work in the US \ n ✔3 million High prevalence of mental illness among migrant and seasonal workers can be attributed to: \ n ✔working conditions, problems with acculturation, isolation, discrimination, impaired access to healthcare. They have high rates of depression, anxiety and substance abuse. Sexual identity \ n ✔one's identification with various categories of sexuality Gender identity \ n ✔Our sense of being male or female Possible influences of gender identity: \ n ✔-Biological factors: pre and post natal hormones and gene expression -Social factors: gender messages from family, mass media and cultural attitudes. Gender dysphoria \ n ✔Overall term used to describe negative or conflicting feelings about one's sex or gender roles Asexual \ n ✔Having no sexual attraction to others Transgender \ n ✔Individuals whose gender identity does not conform to to gender norms Transexual \ n ✔a person who emotionally and psychologically feels that they belong to the opposite sex. Some change bodies surgically or hormonally. LGBTQ \ n ✔Lesbian, Gay, Bisexual, Transgender, Questioning Sexual behavior \ n ✔The way a person expresses his or her sexual feelings Its estimated that between __________ and _______ of US prisoners have severe mental illness. \ n ✔15 - 24% Forensic \ n ✔Relating to the application of scientific knowledge to legal problems and proceedings (dental, anthropolgy, medical) Forensic science \ n ✔Application go broad range of sciences to answer questions of interest to the legal system (ie UV light, microscopes, lasers) Forensic vs Correctional nursing \ n ✔Forensic: client relationship based on crime committed and investigational aspect of ineraction. Corrections: nurse-client relationship based on offenders currnet mental/medical conditions. Id \ n ✔The part of the mind in which innate instinctive impulses and primary processes are manifest. Freud's term for our inborn basic drives(hunger, sex, aggression) "I want..." - present at birth Ego \ n ✔Freud's term for a balancing force between the id and the demands of society "I think..., I evaluate" Responsible for logical thinking and use of defense mechanisms Superego \ n ✔The part of the personality in Freud's theory that is responsible for making moral choices/values, regulated by guilt and shame, "I should..." Conflict is usually dealt with through use of.... \ n ✔defense mechanisms Cognitive Theory \ n ✔Jean Piaget Believes that human development evolves through cognition, learning and comprehending 4 stages of cognitive development (sensorimotor, preoperational, concrete operations, formal operations) Sensorimotor \ n ✔Piaget stage for birth to 2 years Object permanence Preoperational \ n ✔Piaget stage for 2 to 7 years More extensive use of language, symbolism, and magical thinking Concrete Operations \ n ✔Piaget stage for 7 to 12 years Child begins to use logic, develops concept of reversibility and conservation Reversibility \ n ✔The realization that any change in the shape, position, or order of matter can be reversed mentally (water and ice) Conservation \ n ✔Ability to understand that the shape of an object can change (clay) Formal Operations \ n ✔Piaget's final stage of cognitive development, characterized by the ability to think abstractly 12 years - adult Interpersonal Theory \ n ✔Harry Stack Sullivan Behavior occurs becasue of interpersonal dynamics and experiences that influence one's personality development called the self system Interpersonal Development \ n ✔Sullivan stages of developmental tasks Sullivan development stage of infancy \ n ✔Birth - 18 months, oral gratification, anxiety Sullivan development stage of childhood \ n ✔18 months - 6 years, delayed gratification Sullivan development stage of juvenile \ n ✔6-9 years, forming of peer relationships Sullivan development stage of pre-adolescence \ n ✔9-12 years, same sex relationships Sullivan development stage of early adolescence \ n ✔12-14 years, opposite sex relationships Sullivan development stage of late adolescence \ n ✔14-21 years, self-identity developed Hierarchy of Needs \ n ✔Maslow's theory that lower motives must be met before advancing to higher needs. Physiological, safety, belongingness/love, esteem, cognitive, aesthetic, self- actualization Health Belief Model \ n ✔Becker theory that people don't always do screenings or preventitive measures because of the following factors: perception of suspeptibilty, seriousness of illness, perceived benefits of treatment, perceived barriers to change, expectations of efficacy. Transtheoretical Model of Change \ n ✔Precontemplation Contemplation Preparation Action Maintenance Termination Precontemplation \ n ✔1st stage of theoretical model -No intention of changing behavior Contemplation \ n ✔2nd stage of of transtheoretical model -Considering a change within the next 6 months Preparation \ n ✔3rd stage of transtheoretical model -Client getting ready to make a change. Action \ n ✔4th stage of theoretical model -Person is engaging n specific actions towards change Maintenance \ n ✔5th stage of theoretical model -Person is engaging in behaviors to prevent relapse Motivational Interviewing \ n ✔Miller & Rollnick A client-centered counseling style that manifest through specific techniques and strategies. Builds on Theoretical Model of Change Social Learning Theory \ n ✔Bandura's view of human development. Behavior of children can be learned through the observations of others. Self-efficacy is the perception of one's ability to perform a certain task at a certain level of accomplishment. Self Efficacy \ n ✔Bandura Believing you can do something Can be a predictor of success. Theory of Cultural Care \ n ✔Leninger Regardless of culture, care is unifying focus of nursing Theory of Self Care \ n ✔Orem Activities that maintain life, health, and well-being Interpersonal Theory or therapeutic nurse-client relationship \ n ✔Harry Sack Sullivan, Peplau 1st significant psych nrsg theory Interventions occur within therapeutic nurse-client relationship Orientation-Working-Termination phases Caring Theory \ n ✔Watson caring is essential component of nursing "Carative" factors Reflective practice \ n ✔Systematically looking back and learning from past practice and experience. Links practice to theory. Conflict resolution \ n ✔Directed by a neutral 3rd party for a "win win" situation Arbitration \ n ✔Settlement of a dispute by a person or panel chosen to listen to both sides and come to a decision Professional civility \ n ✔Respectful behavior toward others Research utilization \ n ✔The process by which knowledge generated from research becomes incorporated into clinical practice Evidence based practice \ n ✔Basing one's practice and decisions about patient care on research findings rather than tradition Research utilization process \ n ✔Critique research, synthesize findings, application of findings & measurement of outcomes PICO method of developing a clinical question: \ n ✔patient, intervention, comparison, outcome Qualitative Hierarchy \ n ✔1. RCTs, meta-analysis, or systemic review 11. Mental health utilization Health care home \ n ✔Defined by the ACA as an approach to primary care that provides coordinated care to persons with multiple, chronic health condistions, including mental health and substance abuse. Team based care that builds on community supports. Conflict of interest \ n ✔A conflict between self-interest and professional obligation (relationships with drug companies, gifts, referrals, fee splitting). Rights of clients \ n ✔Confidentiality Least restrictive environment Consent for treatment and withdraw consent at any time 4 components of Health Policy Development: \ n ✔Process, policy reform, policy environment, policy makers. Process of healthcare policy development \ n ✔Formulation, implementation, evaluation Policy reform \ n ✔Changes in programs and practices Policy environment \ n ✔Places that process takes place such as government, media, public. Policy makers \ n ✔Key players and stakeholders that make the actual choices to create a public policy Branches of law \ n ✔Executive, Legislative, Judicial neuron \ n ✔a nerve cell; the basic building block of the nervous system function of neuron \ n ✔receive and conduct electrical impulses from one part of the body to another cell body \ n ✔The largest part of a typical neuron; contains the nucleus and much of the cytoplasm. AKA soma. axon \ n ✔The long nerve fiber that conducts away from the cell body of the neuron to connect with other neurons and cells. AKA stem dendrites \ n ✔branchlike structures that receive messages from other neurons and send the signal toward the cell body 2 divisions of the nervous system \ n ✔Central and peripheral nervous systems. Extensive networka of specialized cells that carries information to and from all parts of the body Central Nervous System \ n ✔Brain and spinal cord Peripheral Nervous System \ n ✔The nervous system outside the brain and spinal cord; the sensory and motor neurons that connect the central nervous system to the rest of the body Peripheral Nervous System is comprised of: \ n ✔Somatic and Automatic nervous system Somatic Nervous System \ n ✔Voluntary division of the peripheral nervous system that controls the body's skeletal muscles Two parts of the Autonomic Nervous System \ n ✔Sympathetic and Parasympathetic Autonomic Nervous System \ n ✔Regulates "involuntary activity" in the heart, stomach, and intestines to maintain homeostasis. Sympathetic Nervous System \ n ✔Fight or flight, prepares body for stress, stimulates or increases activity of organs. Parasympathetic Nervous System \ n ✔Rest and Digest, the division of the autonomic nervous system that calms the body, conserving its energy Brain tissue is categorized as either ________or __________ ___________ \ n ✔Grey or white matter Grey matter is composed of \ n ✔nerve cell bodies and dendrites; the working area of the brain that contains synapses and is the area of neuronal activity. White matter \ n ✔the myelinated axons of neurons Outermost surface of the brain (cerebral cortex) is structured to contain grooves and dips of corrugated wrinkles within the brain tissue that provide _______________________ \ n ✔anatomical landmarks or reference points. It also increases brain surface area to expand working area and communication area Grooves and dips of brain are named by________ & __________ \ n ✔size and depth Sulci \ n ✔SHALLOW grooves or furrows in the cerebral hemispheres. Fissures \ n ✔Deep grooves in the brain Cerebrum \ n ✔The largest part of the brain which is divided into 2 halves (right and left cerebral hemispheres). Gyri \ n ✔Elevated ridges of tissue in the cerebral hemispheres. The brain is divided into the _____________ and _______________ \ n ✔cerebrum and brainstem Left hemisphere of cerebrum \ n ✔Dominant in most people, controls most right- sided body functions. Right Hemisphere of cerebrum \ n ✔Controls the left side of the body; creative, intuitive, spacial Corpus callosum \ n ✔The largest bundle of white matter (axons) connecting th two cerebral hemispheres. Each of the 2 hemispheres of the cerebrum is divided into: \ n ✔four major lobes which work in an integrated and interactive mannerand with discint function Four lobes of the cerebrum \ n ✔frontal, parietal, occipital, temporal Frontal lobe \ n ✔Part of the brain associated with motor control, coordination, reasoning, decision making, impulse control, language, personality, and long-term memory storage. Problems with frontal lobe can lead to \ n ✔personality changes, emotional and intellectual changes Premotor area \ n ✔Frontal lobe function that coordinates muscle movement for complex, learned sequential motor activities Association cortex \ n ✔Frontal lobe function that allows for multimodal sensory input to trigger memory and decision making Seat of executive functions \ n ✔Frontal lobe function of working memory, reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, impulse control, behavioral cueing, intelligence, abstraction. Broca's area \ n ✔Language area in the prefrontal cortex that helps to control speech expression Temporal lobe functions \ n ✔A region of the cerebral cortex responsible for hearing, memory, emoion, integration of vision with sensory information, and language (Wernicke's area), Wernicke's area \ n ✔part of the temporal lobe involved in receiving and understanding speech Problems in temporal lobe can lead to: \ n ✔visual or auditory hallucinations, aphasia, amnesia Occipital lobe function \ n ✔visual processing Problems in occipital lobe can lead to: \ n ✔visual field defects, blindness, visual hallucinations Neurotransmitters are released at the synaptic cleft as result of: \ n ✔an electrical activity (action potential) The two phases of action potential: \ n ✔depolarization and repolarization Depolarization \ n ✔State in which the polarity of the neuron is reversed as sodium and calcium ions rush into the cell. Excitatory response. Repolarization \ n ✔Period during which potassium ions diffuse out of the cell or chloride eners the cell. Inhibitory response. Excitatory response \ n ✔Depolarization Involves OPENING of sodium and calcium channels with these ions going INTO the cell Inhibitory response \ n ✔Repolarization. Occurs when a neuron's firing rate decreases due to inhibition from another neuron. Neurotransmitters \ n ✔Chemicals synthesized from dietary substrates that carry signals from one cell/neuron to another Substrate \ n ✔a surface on which an organism grows or is attached, the material or substance on which an enzyme acts enzyme \ n ✔specialized proteins that speed up chemical reactions Problems in either the structure or the chemistry of the synapse interrupts normal flow of impulses and stimuli leading to: \ n ✔symptoms commonly seen in mental health disorders categories of neurotransmitters \ n ✔monoamines, amino acids, cholinergic, neuropeptides monoamines \ n ✔"Biogenic -amines": dopamine, epinephrine, norepinephrine and serotonin. (biogenic=produced by living things) biogenic \ n ✔produced by living things Classification criteria for neurotransmitters \ n ✔1. present in nerve terminal 2. stimulation of neuron must cause sufficient release of neurotransmitter to cause action to occur at post synaptic membrane 3. Effects of exogenous transmitter on post-synaptic membrane must be similar to those caused by stimulation of presynaptic neuron 4. A mechanism for inactivation or metabolism of the neurotransmitter must exist in the area of the synapse. 5. Exogenous drugs should alter the dose-response curve of the neurotransmitter in a manner similar to naturally occuring synaptic potential. nerve terminal \ n ✔end of the axon from which neurotransmitter molecules are released, also called the synaptic bouton exogenous \ n ✔externally caused rather than produced within an organism or system dopamine \ n ✔a neurotransmitter that regulates motor behavior, motivation, pleasure, and emotional arousal epinephrine \ n ✔Neurotransmitter secreted by the adrenal medulla glands in response to stress - also known as adrenergic system. A catecholaminer norepinephrine \ n ✔aka catecholamines - produced in the locus cereus of the pons. Precurser is tyrosine, it is removed from synaptic cleft and returned to storage by reuptake. Implicated in mood, anxiety and concentration disorders. serotonin \ n ✔a neurotransmitter, known as an indole, that serves as the precursor to tryptophan and is removed from the synaptic cleft and returned to storage via an active reuptake process. Impicated in mood and anxiety disorders. Produced in the raphe nuclei of brainstem. adrenal gland \ n ✔Produces Hormones: Epinephrine, Corticosteroids, and Norepinephrine catecholamine \ n ✔a class of amines that includes the neurotransmitters dopamine, norepinephrine, and epinephrine, all which have similar chemical structures adrenal medulla \ n ✔the inner part of the adrenal gland that secretes adrenalin adrenal cortex \ n ✔outer section of each adrenal gland; secretes cortisol, aldosterone, and sex hormones indole \ n ✔a particular chemical structure found in serotonin (and LSD). raphe nuclei \ n ✔nuclei located in the pons that participate in the regulation of sleep and arousal - serotonin is produced here L-tryptophan \ n ✔an amino acid supplement commonly used for depression, obesity, insomnia, headaches and fibromyalgia. Increases risk of serotonin syndrome if taken with SSRI, MAOI, or St. Johns wort. Serotonin is precurser to tryptophan. serotonin syndrome \ n ✔SSRI or MAOI induced autonomic instability hyperthermia seizures coma or death 5HT \ n ✔Abbreviation for serotonin. Serotonin is formed by hydroxylation and decarboxylation of tryptophan. amines \ n ✔compounds containing amino groups amino acids \ n ✔organic compounds containing amine and carboxyl functional groups, along with a side chain specific to each amino acid. long chains of amino acid are also called proteins. GLUTAMINE ASPARTATE GABA GLYCINE amino groups \ n ✔nitrogen atom bonded to 2 hydrogen atoms- NH2 Aspartate \ n ✔excitatory neurotransmitter - works with glutamine GABA \ n ✔A universal inhibitory neurotransmitter in the brain. Site of action of BZDs, alcohol, barbituates, and other CNS depressants. Glycine \ n ✔an inhibitory neurotransmitter, works with GABA Glutamate \ n ✔The most common neurotransmitter in the brain. Excitatory. Involved in memory, excitatory neurotransmitter, oversupply causes migrains or seizures thyroid \ n ✔below the voice box; regulates body metabolism and causes storage of calcium in bones glial \ n ✔Cells in the nervous system that support, nourish, and protect neurons cholinergics \ n ✔stimulates parasympathetic nervous system: acetylcholine \ n ✔A neurotransmitter that enables learning and memory and also triggers muscle contraction neuropeptides \ n ✔Brain chemicals, such as enkephalins, dynorphins and endorphins, that regulate the activity of neurons. Decreased amount of neuropeptides is thought to cause substance abuse Enzymatic destruction \ n ✔occurs inside terminal cytosol or synapse - the neurotransmitter can be destroyed by the enzymes monoamine oxidase (MAO) in the cortisol or catechol-O-methyl transferase (COMT) intracellularly or in the synapse After the neurotransmitter reaches the presynaptic neuron, it may either: \ n ✔diffuse off its receptor to be destroyed by enzymes OR transported back to presynaptic neuron for reuse. cytosol \ n ✔intracellular fluid portion of the cytoplasm acetylcholine imbalance causes these psychiatric presentations: \ n ✔Decrease = Alzheimers, impaired memory Increase = Parkinsonian symptoms dopamine imbalance causes causes these psychiatric presentations: \ n ✔Decrease = substance abuse, anhedonia, Parkinson's Increase = Schizophrenia, psychosis 2. Magnetic Resonance Imaging (MRI) 3. Functional Imaging: EEG and evoked potentials test MEG: magnetoencephalography - similar to EEG but detects different electrical activities SPECT: single photon emission computed tomography PET: positron emission tomography 4. Combined structural and functional imaging: functional MRI, 3D event related functional MRI, flourine magnetic spectroscopy, dopamine D2 receptor binding MRI advantages and disadvantages \ n ✔Technique that provides a series of 2D images. Advantages: can view brain structur close to the skull and can separate white matter from grey matter, readily avaiable, resolution of brain tissue is superior to CT scanning. Disadvantages: expensive, multiple contradictions (pacemaker, metal implants, ventilator, claustraphobia) Functional imaging \ n ✔Measures function of areas of the brain through assessment of blood flow. EEG, MEG, SPECT, PET. Mainly used for research. PET \ n ✔Positron emission tomography that provides a visual display of brain activity. Expensive, requires extensive resources and support team SPECT \ n ✔Single photon emission tomography - provides info on cerebral flow, limited availability, expensive Genomics \ n ✔the branch of genetics that studies organisms in terms of their genomes (their full DNA sequences) to determine genetic disorders in families Pedigree symbols indicate: \ n ✔gender, marital status, adoption, twins, pregnancy, conditions, consanguinity (relatives having children, common ancestry) Autosomal dominant may be present in more than one generation and in up to ______ % of offspring when one parent is affected. \ n ✔50% (ex. Marfan syndrome) Marfan Syndrome \ n ✔Hyperflexible joints, arachnodactyly, aortic dissection, lens dislocation Recessive trait \ n ✔A genetic trait that lacks the ability to manifest itself when a dominant gene is present, appears onl in one generation X-linked disorders \ n ✔are caused by faulty genes on an X chromosome (fragile X syndrome, color blindness) Genetic counseling \ n ✔A process of communication that deals with the occurrence or risk of a genetic disorder in a family Chromosome \ n ✔structures of DNA (deoxyribonucleic acid) in the nucleus of cells that carry genetic information. There are normally 23 pairs (46 total) in humans. DNA \ n ✔A complex molecule containing the genetic information that makes up the chromosomes. It is made up of 2 twisted, paired strands, composed of sugars linked by 4 nucleotide bases - adenine (A), thymine (T), cystocine (C) and guanine (G) specifying the amino acids that make proteins. A is always paired with T and G is always paired with C. Genes \ n ✔sequence of DNA that codes for a protein and thus determines a trait Messenger RNA \ n ✔mRNA that transports information from DNA in the nucleus to the cell's cytoplasm, codes for an amino acid Human Genome Project \ n ✔In 2003 an international collaborative effort mapped and sequenced the DNA of the entire human genome. The genome is a complete set of DNA. Phenotype \ n ✔An organism's appearance or other detectable characteristic (i.e. fast metabolizer of CYP4502D6 medications) Personalized medicine is health care based on \ n ✔genetic variability Gene therapy \ n ✔The process of inserting normal genes into human cells to correct genetic disorders Studies of Population Genetics \ n ✔Family studies that investigate the occurrence of disorders in 1st degree relatives (parents, siblings, offspring and 2nd degree relatives (grandparent, aunts, uncles, cousins) Twin studies \ n ✔compare concordance rates (presence) of a disorder in a monozygotic (identical) and dizygotic (fraternal) twins Adoption studies \ n ✔analysis of how traits vary in individuals raised apart from their biological relatives Genetic heritability range of psychiatric disorders \ n ✔40-90% Environmental risk factors \ n ✔prenatal insults, stress, infections, poor nutrition, town exposure, catasrophic loss, physical and sexual abuse Most diseases are multifactorial, caused by both: \ n ✔environmental and genetic factors; single gene disorders are rare Single nucleotide polymorphisms are \ n ✔variations of DNA sequence by a single nucleotide Reduced penetrance of a gene decreases chances of \ n ✔disease in person at genetic risk Variable expression of a gene for a disorder occurs at: \ n ✔the cellular level Pharmacogenomics \ n ✔the study of genetically determined variations in the response to drugs Pharmaco-genetic testing helps identify presence of: \ n ✔gene variants that may help determine dosing of medications Testing for presence of HLA-B*1502 allele is required by FDA in people of Asian descent prior to prescribing: \ n ✔anticonvulsant carbamazepine due to risk of Stevens-Johnson Syndrome and toxic epidermal necrolysis (TEN) allele \ n ✔one of the alternative forms of a gene that governs a characteristic, such as hair color Toxic epidermal necrolysis \ n ✔Severe form of Steven-Johnson Syndrome with over 30% body surface involved Steven-Johnsons Syndrome \ n ✔-Life threatening -Skin: blistering, rash, detachment of epidermis -Meds that can cause: carbamazepine, lamotragine AMPA and MNDA \ n ✔Specific receptors found on the dendrites of post-synaptic neurons that bind glutamate Primitive reflexes in infants \ n ✔reflexes that are present in infancy but disappear with maturation head lag reflex \ n ✔when the infant is lifted the head will fall back flexion reflex \ n ✔moves a limb away from a painful stimulus rooting reflex \ n ✔a baby's tendency, when touched on the cheek, to open the mouth and search for the nipple grasping reflex \ n ✔when touched on the palm of the hand, a baby will wrap his fingers tightly around the stimulus Moro reflex \ n ✔when startled, an infant throws his arms out, spreads his fingers, then grabs with fingers and arms glabellar reflex \ n ✔tap forehead and infant blinks Babinski \ n ✔fanning and curling toes when foot is stroked Stereognosis \ n ✔ability to recognize objects by feeling their form, size, and weight while the eyes are closed Graphesthesia \ n ✔Ability to identify letters, numbers, or shapes drawn on the skin Neurological soft signs \ n ✔Dyskdiadochokinesia, astereognosis, choreiform movements, tics, agraphesthesia, facial grimacing, impaired fine motor movements, abnormal blinking, abnormal motor tone. Choreiform movements \ n ✔uncontrolled, quick, jerky dysrhythmical movements Normal BMI \ n ✔-PMHNP says normal BMI is 20-25 -Child with >85% BMI is at greater risk of being overweight. -High BMI is risk factor for DM, heart disease, stroke, HTN, osteoarthritis, and some forms of cancer. Head, skin, nail assessment components \ n ✔Color, integrity, lesions of skin, skin turgor, skin temperature, moles, hair texture/distribution, nails (clubbing, splitting, onychomycosis), cap refill, cranial nerve VII (facial nerve) onychomycosis \ n ✔abnormal condition of a fungus in the nails cancerous moles ABCDE \ n ✔Asymmetry, color, diameter > 6mm, elevation Eye assessment \ n ✔Snellen, peripheral vision, confrontation tests, inspect sclera, assess corneal sensation with cotton wisp, papillary reaction, accommodation, 6 cardinal fields of gaze, corneal light reflex, examine inner aspect of eyes with ophthalmoscope. Be aware that many psychotropics can cause blurry vision. Six cardinal fields of gaze \ n ✔ Quetiapine (Seroquel) can cause what medical condition: \ n ✔Cataracts Ear assessment \ n ✔Configuration, position, alignment of auricles, whisper test, audiometer, external auditory canals, tympanic membrane should be translucent pearly gray without retractions or bulges Nose and sinus assessment \ n ✔Note if external nose is smooth, intact, symmetric, midline, has discharge, is flaring. Assess patency, sense of smell. Assess internal nasal cavity for patency or septal deviation. Palpate maxillary and frontal sinuses. Neck assessment \ n ✔Palpate lymph nodes for swelling or masses (postaurical, tonsillar, submandibular, submental, anterior cervical), thyroid usually not palpable unless very thin person, check for carotid pulse/bruits Back assessment \ n ✔Assess skin, respiratory pattern, cervical, lumbar, sacral spine, thoracic expansion, percuss posterior chest for tympany, auscultate for vesicular, bronchovesicular, or adventitious breath sounds. Thorax and lungs assessment \ n ✔Assess respiratoy rate, depth, regularity, ease. Note anterio-posterior diameter which should be less than transverse diameter. Percuss anterior chest for resonance and note quality of percussion notes, auscultate anterior chest for lung sounds Breast exam \ n ✔Inspect breasts in different positions, look for dimpling, retractions, orange peel appearance. Palpate for lumps, including Tail of Spence, palpate axillary and epitrochlear lymph nodes. Palpate supraclavicular lymph nodes known as sentinel or Virchow nodes. Be aware that atypical APs can cause galactorrhea. Galactorrhea \ n ✔Milk production outside of lactation, can be caused by atypical APs Virchow nodes \ n ✔Palpate supraclavicular lymph nodes known as sentinel or Virchow nodes during breast exam. Heart assessment \ n ✔-Inspect, palpate, auscultate carotid pulse -Palpate peripheral pulses, check for symmetry (carotid, brachial, radial, femoral, popliteal, pedal, posterior tibial) -Assess rate, rhythm, amplitude, and contour -Assess anatomical location of apical pulse -Palpate precordium for pulsations, thrills, heaves, and lifts. -Auscultate heart sounds with bell and diaphragm and note characteristics of 1st and 2nd heart sounds -Assess for JVD *Be alert for possible EKG changes if clients on TCAs or APs. *Be aware that lithium and anorexia nervosa can cause peripheral edema. 1st and 2nd heart sounds \ n ✔Lub-dub. 1st- AV valves close. 2nd- aortic and pulmonary valves close Abdominal assessment \ n ✔Inspect contour of abdomen, check for scars, aortic pulsations/bruits, umbilical cord in newborn, bowel sounds. Percuss abdomen, note areas of tympany and dullness over organs and a distended bladder, percuss size of liver and spleen, palpate for masses/tenderness. palpate liver and spleen which are NOT normally palpable. Tympany \ n ✔high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine Musculoskeletal assessment \ n ✔Assess posture alignment, body parts symmetry, muscle strength of upper and lower extremities, muscle tone, strength, ROM, pain with movement, deformities, crepitus, passive ROM, hip dysplasia in infants, scoliosis in children/adolescents. Common indicators of physical child abuse \ n ✔History of unexplained fractures, burns, hand or bite marks, injuries at various stages of healing, evidence of neglect, bruising on padded parts of body. Thyroid Function Tests \ n ✔Measurement of T3, T4, and TSH in the bloodstream Thyroid gland \ n ✔Endocrine gland that surrounds the trachea in the neck. Takes iodine from circulating blood, combines it with amino acid tyrosine, and converts it to thyroid hormones T3 and T4. It stores T3 and T4 until they are released into the bloodstream under the influence of TSH released from pituitary gland. The _____ ________ of the thyroid hormones is the true determinant of thyroid status. \ n ✔free portion Free thyroxine T4 (FT4) normal values: \ n ✔0.8-2.8ng/dl FT4 composes a small portion of the total thyroxine, is available to tissues, and is the ______________ ______________ form of this hormone. \ n ✔metabolically active FT4 test is commonly done to determine: \ n ✔thyroid status, evaluate thyroid therapy, and r/o hypo/hyperthyroidism Diseases that have INCREASED thyroid levels include: \ n ✔Graves disease, thyrotoxicosis due to T4, Hashimoto's thyroiditis, acute thyroiditis Grave's Disease \ n ✔immune system attacks thyroid gland which causes it to secrete more thyroid hormone Thyroid Storm \ n ✔(Thyrotoxic crisis, thyrotoxicosis) - abrupt onset, severe hyperthyroidism. Hashimoto thyroiditis \ n ✔Autoimmune destruction of the thyroid gland that is a major cause of primary hypothyroidism Hashimoto versus Graves \ n ✔Hyperthyroidism in Graves' disease is caused by thyroid-stimulating autoantibodies to the TSH receptor (TSHR), whereas hypothyroidism in Hashimoto's thyroiditis is associated with thyroid peroxidase and thyroglobulin autoantibodies. Disease that have DECREASED thyroid levels: \ n ✔Primary hypothyroidism, secondary hypothyroidism (pituitary insufficiency), tertiary hypothyroidism (hypothalamic failure), thyrotoxicosis due to T3, renal failure, Cushing syndrome, cirrhosis. Cushing syndrome \ n ✔group of signs and symptoms produced by excess cortisol from the adrenal cortex Free thyroxine levels can be affected by: \ n ✔Increased levels from heparin, aspirin, propranolol Decreased levels from furosemide or methadone Normal values for TSH \ n ✔2-10mU/l What is the major intracellular cation? \ n ✔Magnesium; 40-60% is stored in bone and muscle, with 30% in cells. A small amount is in the serum, where 1/3 is bound to plasma proteins and the rest is in ionized form. Regulation of Mg metabolism is primarily by the: \ n ✔kidney cation \ n ✔an ion with a positive charge anion \ n ✔an ion with a negative charge neutral atom \ n ✔number of protons = number of electrons Low serum levels of Mg causes __________ conservation \ n ✔renal conservation Which electrolyte is a cofactor in intracellular enzyme reactions? \ n ✔Magnesium. Mg also is a cause of neuromuscular excitability. Increased levels of Mg can cause: \ n ✔Addison's disease, adrenalectomy, renal failure, DKA, dehydration, hypothyroidism, hyperthyroidismm. If MG > 2.5mEq/L --> n/v, muscle weakness, bradycardia, respiratory depression, decreased skeletal muscle contractions. Decreased levels of Mg can cause or be caused by: \ n ✔Hyperaldosteronism, hypokalemia, DKA, malnutrition, alcoholism, GI loss, malabsorption syndrome, pregnancy induced hypertension. If > 2.5mEq/l --> depression, confusion, irritability, increased reflexes, muscle weakness, ataxia, nystagmus, tetany, convulsions. n Mg levels can be altered by: \ n ✔antacids, laxatives with Mg, lithium, salicylate. All persons aged ________ and older should receive flu vaccine. \ n ✔6 months Don't use _________ in <2 or >49 years of age \ n ✔LAIV vaccine HPV recommended for girls at \ n ✔age 11 or 12 HPV4 can be given to boys aged 9-26 to prevent \ n ✔genital warts MMR should not be given to which patients \ n ✔pregnant, cancer, HIV T-cells <200, high doses steroids or blood transfusion in past 2 weeks DTAP should not be given to anyone \ n ✔> 7 years Shingles (herpes zoster) vaccine is recommended for anyone aged: \ n ✔>60 who has had the chickenpox. Don't give to people with weakened immune systems Shingles \ n ✔a condition caused by the infection of neurons in dorsal root ganglia by the varicella zoster virus Varicella contraindications \ n ✔pregnant, weakened immune, HIV/AIDS with T-cell <200, cancer, high-dose steroids Tanner Stages of Development \ n ✔ Screening for women 18-39 \ n ✔monthly skin and oral exams, yearly b/p, good, urinalysis, PE, pap at age 21 or 3 years of having sex, pelvic exam, STD testing Screening for women 40-49 \ n ✔monthly skin and oral exam, yearly b/p, blood, urinalysis, PE, PAP (every 2 or 3 years after 3 consecutive negative smears), STD, ECG every 4 years Screening for women 50+ \ n ✔monthly skin and oral, abc, bmp, ash, u/a, PE, pap (not recommended >65 if not high risk), pelvic, STD, mammo every 2 years, bone density every 2 years at 65 (or 60 if increased risk). ECG every 4 years, sigmoidoscopyoscopy or similar test every 5 years through age 75. If + test then colonoscopy every 10 years. Screening for men 18-39 \ n ✔monthly testicle, skin, oral. yearly b/p, abc, bmp, ash, u/a, STDs for gay/bi men up to age 64. all persons 13-64 should have yearly HIV test Screening for men 40-49 \ n ✔Monthly testicle, skin, oral exam. Yearly b/p, blood tests, u/a, PE, ECG every 4 years. Screening for men 50+ \ n ✔monthly testicle, skin, oral. Yearly blood tests, u/a, PE, and ECG every 3 years. Every 5 years through 75 sigmoidoscopy, colonoscopy every 10 years if needed. Secondary Prevention \ n ✔Early detection of problems in an at risk population. Telephone hotlines crisis intervention, disaster response. Primary prevention \ n ✔prevention in which all members of the community receive the treatment. Smoking prevention, stress mgmt. for students, DARE for kids. Tertiary Prevention \ n ✔Activities directed toward rehabilitation rather than diagnosis and treatment. Case mgmt. for housing or vocational needs, social skills training. Biological risk factors \ n ✔Genetic predisposition, poor nutritional status, poor overall health Psychological risk factors \ n ✔Poor self concept, external loss of control, poor ego defenses Social risk factors \ n ✔Stressful occupation, low socioeconomic status, poor level of social integration Preventative factors \ n ✔factors that prevent or protect the person form the disorder Coping mechanisms \ n ✔Behaviors that facilitate a healthy response to stress Biological preventative factors \ n ✔no hx of mental illness, healthy nutritional status, and good overall health Psychological preventative factors \ n ✔good self esteem, internal locus of control, healthy ego defenses Social preventative factors \ n ✔low stress occupation, higher socioeconomic status, higher level of education. Normal potassium levels \ n ✔3.5-5.0 Normal chloride levels \ n ✔98-106 mEq/L Chloride is a major anion in the _________________ fluid \ n ✔extracellular Transport of chloride is \ n ✔passive The passive transport of chloride follows active transport of sodium so increases or decreases are proportional to changes in sodium. \ n ✔ Increased chloride levels can be caused by: \ n ✔acidosis, hyperkalemia, hypernatremia, dehydration, renal failure, Cushings syndrome, hyperventilation, anemia. Increased chloride can be caused by \ n ✔alkalosis, hypokalemia, hyponatremia, GI loss, diuresis, over hydration, Addison's, burns. What are the symptoms of increased or decreased chloride levels: \ n ✔there are no specific symptoms K+ balance is regulated by: \ n ✔kidney, aldosterone levels, insulin secretion, and changes in pH. Hyperkalemia causes: \ n ✔acidosis, insulin deficiency, Addisons, ARF, hypoaldosteronism, infection, dehydrationHypokalemia causes: Potassium is a major _________________ electrolyte \ n ✔intracellular K+ is required for glycogen deposition in __________ and ____________ muscle cells \ n ✔liver and skeletal K+ functions \ n ✔maintains resting membrane potential and assists in conduction of nerve impulses, maintenance of normal cardiac rhythms, and skeletal and smooth muscle contraction. Hypokalemia causes: \ n ✔alkalosis, excess insulin, GI loss, laxative abuse, burns, trauma, surgery, Cushings syndrome, hyperaldosteronism, thyrotoxicosis, anorexia nervosa, diet deficient in meat and vegetables. Approximately _______ % of Caucasians are poor metabolizers of P450 2D6 enzyme \ n ✔10 Approximately ______ % of Asians have reduced activity of P450 2D6 enzyme. \ n ✔20 Cytochrome P450 INHIBITORS \ n ✔Bupropion Clomipramine Cimetidine Clarithromycin Fluoroquinolone's Grapefruit/juice Ketoconazole Nefazodone SSRIs Cytochrome P450 INDUCERS \ n ✔Carbamazepine Hypericum (St. John's Wort) Phenytoin Phenobarbital Tobacco Enzyme ________________ can increase the serum level of other drugs that are substrates of that enzyme, thus possibly causing toxic levels. \ n ✔inhibitors Liver disease will affect liver enzyme activity and 1st pass metabolism, possibly resulting in _____________ plasma drug levels \ n ✔toxic Kidney disease or drugs that reduce renal clearance (such as NSAIDS) may _________________ serum concentrations of drugs that are excreted by the kidneys (such as lithium) \ n ✔increase Older adults are more sensitive to psychotropics due to: \ n ✔decreased intracellular water, protein binding, low muscle mass, decreased metabolism, and increased body fat concentration. Agonist effect \ n ✔Drug binds to receptors and activates a biological response Inverse agonist effect \ n ✔Drug causes the opposite effect of agonist, binds to same receptor Partial agonist effect \ n ✔Drug does not fully activate the receptors Antagonist effect \ n ✔Drug binds to the receptor but does not activate a biological response Neurotransmitters or drugs may be excitatory or inhibitory depending on the type of ______ channel they gate. \ n ✔ion ion \ n ✔atom that has a positive or negative charge Excitatory response \ n ✔Depolarization Involves OPENING of sodium and calcium channels with these ions going INTO the cell Inhibitory response \ n ✔Repolarization Involves the OPENING of chloride channels so chloride goes into the cell, potassium leaves, or both Potency \ n ✔Amount of drug necessary to elicit a biologic effect; refers to the drug's strength Therapeutic Index \ n ✔The ratio between the toxic and therapeutic concentrations of a drug. Drugs with high therapeutic index have a __________ margin of safety, while those with a low therapeutic index have a ________ margin of safety. \ n ✔high, low (if high = therapeutic dose is far from the toxic dose and if low = therapeutic dose and toxic dose are close together). Tolerance \ n ✔A state in which a person's body becomes less responsive to a drug Tachyphylaxis \ n ✔Rapid decrease in response to a drug Typical antipsychotics \ n ✔Medications to treat Schizophrenia, Developed in the 1950's (older drugs) Chlorpromazine, thioridazine, fluphenazine, haloperidol, Atypical antipsychotics \ n ✔Clozapine Risperidone Olanzapine Sertindole Quetiapine Ziprasidone Paliperidone Mood Stabilizer \ n ✔A category of medication that minimizes mood swings. Tricyclic antidepressants \ n ✔Antidepressant drugs which increase the amount of serotonin and norepinephrine directly. MAOIs \ n ✔-ar- (PANAMA = parnate, nardil, marplan) (foods with tyramin contraindicated) SNRIs \ n ✔serotonin-norepinephrine reuptake inhibitors Benzodiazepines \ n ✔The most common group of antianxiety drugs, which includes Valium and Xanax. Anxiolytics (non-BZDs) \ n ✔Drugs that reduce feelings of anxiety - Buspar ADHD medications \ n ✔Drugs that tend to increase central nervous system activation and behavioral activity. ritalin, concerta, adderal (stimulants/dopamine); straterra (norepinephrine) Guanfacine indication in MH \ n ✔ADHD: Tenex, Intuniv Clonidine indication in MH \ n ✔ADHD, withdrawal: Kapvey, Catapres Atomoxetine indications in MH \ n ✔ADHD, Strattera Antidepressants that can be used in mgmt. of ADHD: \ n ✔desipramine (Norpramin) , venlafaxine (Effexor), bupropion (Wellbutrin) Schedule I \ n ✔Drug has no accepted medical use, high potential for abuse (heroin, MJ) Schedule II \ n ✔High abuse potential and requires special DEA to order drugs (morphine, fentanyl, methadone, codeine, oxycodone) Schedule III \ n ✔Has accepted medical use, and the abuse potential is less than with Schedule I and II drugs (appetite suppressant, testosterone). Refills limited to 5, need renewed every 6 months Schedule IV \ n ✔Abuse potential exists, but less than Sch III. Examples are: Ambien, Darvocet and Lorazepam, benzos Schedule V \ n ✔Limited abuse potential; consists of preparations containing limited quantities of narcotics. Most cough syrups containing codeine. FDA pregnancy rating for medications \ n ✔ Teratogenic risks of benzodiazepines: \ n ✔Floppy baby syndrome, cleft palate Teratogenic risks of Tegretol (carbazepine) \ n ✔Neural tube defects Teratogenic risks of Lithium \ n ✔Epstein anomaly Teratogenic risks of Depakote \ n ✔Cleft palate, neural tube defects, specifically spina bifida Medications that can induce depression \ n ✔Beta blockers, steroids, interferon, accutane, some retroviral drugs, antineoplastic drugs, benzos, progesterone Medications that can induce mania \ n ✔Steroids, Antabuse (disulfiram), INH, antidepressants in people with bipolar disorder Medications that can cause false positive drug screens \ n ✔See page 119 in ANA review text for full list Average age of MDD is \ n ✔mid 20s MDD risk increases for women during reproductive years. Risk is equal before puberty and after \ n ✔menopause What percentage of people with MDD by by suicide? \ n ✔15% If untreated, an episode of MDD can last how long? \ n ✔4 months or longer Risk factors for MDD: \ n ✔genetics, female, postpartum period, medical comorbidity, single marital status, significant environmental stressors, including multiple losses. How to prevent and screen for MDD: \ n ✔at risk family education, community education to reduce stigma, convey s/s and emphasize treatment. Tools used to screen for depression: \ n ✔PHQ9, Beck Depression Inventory, Hamilton Depression Rating Scale or Edinburgh Postnatal Depression Scale PHQ9 \ n ✔Screens for depression in primary care populations with medical co- morbidities Edinburgh Postnatal Depression Scale \ n ✔ Beck Depression Inventory \ n ✔0-9 = none 10-18 = mild 19-29 = mod-severe 30-63 = severe Hamilton Depression Rating Scale \ n ✔ A few days or weeks prior to onset of MDD, the patient often has a prodromal episode consisting of high levels of subjective ___________ and _______ ________ \ n ✔anxiety and mild depression MDD in children can manifest as \ n ✔irritable mood, somatic complaints, social withdrawal. LESS COMMON symptoms in children (prior to adolescence) include psychosis, motor retardation, hypersomnia, increased appetite) Diagnostic criteria for MDD includes unintentional weight loss of ______ % of body weight and increased craving for carbs and sweets \ n ✔5 Depressive symptoms that begin within 2 months of a loved one/significant loss and don't persist beyond _____ months are generally considered bereavement, not MDD. \ n ✔2 Lab tests to r/o other causes of MDD \ n ✔CBC, BMP, Thyroid function tests, b@, folate levels and sleep study if suspicion of other sleep disorder. Drug tox. Medications that can causes altered mood states: \ n ✔steroids, estrogens, antihypertensives, anti-parkinsons, antineoplastics, antibacterials, antifungals, Accutane, BZDs Hypertensive crisis \ n ✔Main adverse effect of MAOI's. Can happen if MAOI is taken with meperidine, decongestants, TCAs, APs, St. Johns Wort, L-tryptophan, stimulants, asthma medications Tx: D/C MAOI, give Phentolamine, stabilize fever Combining MAOI with a __________ agent is contraindicated \ n ✔serotonergic - it could cause serotonin syndrome. Serotonin Syndrome \ n ✔Similar to NMS but caused by serotonin medications, and has HYPERreflexive muscle activity, mild: shivering and diarrhea severe: muscle rigidity, fever, and seizures Tx: cyproheptadine, anticonvulsants, autonomic support in severe cases. Can be fatal in OD. Non-pharmacological treatments for MDD \ n ✔ECT, TMS, VNS, phototherapy, individual therapy How does ECT work? 3 mechanisms of action \ n ✔-Neurotransmitter Theory: increases dopamine, serotonin, norepinephrine. -Neuroendocrine Theory: releases hormones prolactin, TSH, pituitary hormones, endorphins, and adrenocorticotropic hormone -Anticonvulsant Theory: exerts anticonvulsant effect which produces an antidepressant effect Possible contraindications to ECT: \ n ✔cardiac disease, compromised pulmonary status, history of brain tumor/injury, anesthesia/medical complications. Possible adverse effects of ECT: \ n ✔cardiovascular effects, headaches, muscle aches, drowsiness, memory disturbances, confusion. Transcranial Magnetic Stimulation for MDD: \ n ✔Direct stimulation of the cerebral cortex induced by magnetic fields generated outside the skull. Session last about 40 minutes and typical course is 5 sessions per week for 6 weeks. SE: minimal but include headache, scalp discomfort, tingling or twitches to facial muscles, lightheadedness, hearing discomfort from tapping noise. Rare seizures reported. Vagal Nerve Stimulation for MDD: \ n ✔Pacemaker like device placed in left side of chest to stimulate left branch of the vagal nerve. Transcutaneous devises being tested. OP but anesthesia required. SE: from pulse generator stimulating the vagus nerve - voice changes, hoarse, cough, throat/neck pain, chest spasms, dyspnea, on exertion, tingling of skin, dysphagia. Vagus nerve \ n ✔Tenth cranial nerve with branches to the chest and abdominal organs. Phototherapy for MDD/SAD \ n ✔Treatment of seasonal affective disorder by daily exposure to bright light. 2,500-10,000 lux light for 30 minutes up to 2 hours, 1-2 times daily Risk factors for suicide: \ n ✔Male >45 Female >55 Divorced, single, separated White Living alone Psychiatric disorder Physical illness Substance abuse Previous suicide attempt Family history of suicide Recent loss Male gender What percentage of older adults are more likely to die within first year of moving into an LTC? \ n ✔65% Pseudodementia \ n ✔MDD in elderly Often misinterpreted as dementia Skill deficit \ n ✔inability to perform a functional skill despite physical ability, such as in dementia Performance deficit \ n ✔Skill is intact but the person is unmotivated to respond, as in dementia Executive functioning \ n ✔Cognitive abilities such as abstract thinking, planning, organizing, and carrying out of behaviors (maintain calendar, do bills, prioritize activities) Instrumental ADLs \ n ✔Complex activities: cooking, cleaning, shopping, finances, working, transportation SSRI discontinuation syndrome \ n ✔Flu-like symptoms, fatigue, myalgia, decreased concentration, N/V, impaired memory, paresthesia, shock like sensations, irritability, anxiety, insomnia, crying without provocation, dizziness, vertigo Clients who have had ______ or more episodes of MDD usually require lifelong medication \ n ✔3 Persistent Depressive Disorder (Dysthymia) \ n ✔similar to MDD but with less acute symptoms, more chronic and without psychotic or vegetative manifestation. Etiology similar to MDD. Women are _____ to ____ times more likely to develop PDD than men. \ n ✔2-3 Clinical findings in mania or hypomania \ n ✔word clanging in severely ill, inflated sense of abilities, bordering on delusional, impaired short term and recall, can be concrete on abstract testing, resists treatment. word clang association \ n ✔alteration in speech in which the client chooses words based on sound, rather than meaning If 1st manic episode occurs after age 40, it's likely caused by a medical condition such as: \ n ✔endocrine disorder, hyperthyroidism, intoxication or withdrawal, medications, antidepressants, ECT, light therapy. Pharmacological treatment of bipolar disorder \ n ✔Mood stabilizing agents (Lithium is gold standard, anticonvulsants, Lamictal. Avoid antidepressants, especially in rapid cyclers Black box warning for carbamazepine (Tegretol) \ n ✔Agranulocytosis and aplastic anemia Black box warning for valproic acid/divalproex (Depakene/Depakote) \ n ✔Hepatotoxicity, pancreatitis, teratogenic Black box warning for lamotragine (Lamictal) \ n ✔Serious rash, SJS Lithium toxicity \ n ✔Diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination Common co-morbidities with bipolar disorder \ n ✔Hypothyroidism and substance abuse Presentation of mania in adolescents: \ n ✔often associated with antisocial behavior, substance abuse and prodromal period of significant behavioral symptoms (truancy, failing grades) Women need to be on contraceptives if sexually active and taking which drugs for bipolar disorder. \ n ✔Lithium, Depakote (divalproex sodium), Tegratol (carbamazepine) are teratogenic. Cyclothymic Disorder \ n ✔CHRONIC fluctuating mood disorder with less severe symptoms that bipolar disorder. NUMEROUS periods of hypomanic and dysthymic symptoms. Prevalence of cyclothymic disorder is: \ n ✔0.4% to 1% - it is insidious, chronic, and begins early in life. 15-45% of persons with cyclothymic disorder subsequently develop bipolar disorder. Patient with cyclothymic disorder is often described as: \ n ✔temperamental, moody, unpredictable, inconsistent, unreliable. NO psychotic episodes. Cyclothymic disorder usually begins in adolescence - onset later in life usually suggests: \ n ✔general medical condition such as multiple sclerosis. Level I anxiety \ n ✔Mild - normal level experienced by all, which functions to motivate Level II anxiety \ n ✔Moderate - normative level experienced by most in response to significant stressors Level III anxiety \ n ✔Severe - pathological level - autonomic nervous system triggered, fight or flight, pupils dilate, VS increase, diaphoresis, muscle rigid, hearing decreased, pain threshold increased, urinary frequency, diarrhea. Level IV anxiety \ n ✔Panic - pathological level - severe symptoms, pale, hypotension, poor hand-eye coordination, muscle pain, dizzy, SOB. Ataques de nervios \ n ✔Latin American cultural syndrome manifested by trembling, crying screaming. Usually experienced in presence of others with relief felt afterwards. Khal (wind) attacks \ n ✔Cambodian and other Asian cultures syndrome of neck soreness and tinnitus. Anxiety disorders are the most common group of psychiatric disorders. Symptoms significantly impair and functioning and occur more days that not for a period of at least ________________ \ n ✔six months Psychodynamic theory of anxiety - Freud believed that anxiety initially occurs to the stimulation of birth and need for the infant to : \ n ✔adapt to the changed environment. Subsequent anxiety results from intrapsychic conflict. According to Freud, anxiety signals the person to deal with the ____________ - ________ conflict. \ n ✔Id-superego Interpersonal Theory of anxiety - humans are goal directed toward attainment of: \ n ✔satisfaction and security needs. Sense of self becomes based on person's perception of how others view him/her. Neurobiological Theory of Anxiety - pathological anxiety results from neurobiological deficits in brain. These deficits are genetically mediated by what areas of the brain? \ n ✔limbic system, midline brainstem area, and sections of the cortex. HPA axis \ n ✔Hypothalamus, pituitary, adrenaline release hormones, central to the body's response to stress Prevalence of anxiety in the US: \ n ✔28% Anxiety disorders are more common in girls/woman with the exception of: \ n ✔OCD, social phobia Most anxiety disorders manifest in adolescence and early adulthood. Median age of onset is: \ n ✔11 years of age Risk factors for anxiety: \ n ✔1st degree relative (8x more likely than general pop), limited range of coping mechanisms, history of trauma, high level of parental distress affect child's ability to cope. Hamilton Rating Scale \ n ✔Used for screening anxiety Most medications known to improve symptoms of anxiety act in/directly on the: \ n ✔GABA system First line treatment for chronic anxiety: \ n ✔SSRI's Non-Benzodiazepine anxiolytics: \ n ✔Buspirone (Buspar), Gabapentin (Neurontin), Beta Blockers (propanolol, atenolol). Non pharmacological anxiety management: \ n ✔Behavioral therapy (systemic desensitization, exposure therapy, relaxation therapies, biofeedback), CBT, interpersonal therapies, community self help groups, alternative therapies. Adverse medication reactions that mimic/produce anxiety \ n ✔caffeine, nicotine, anticholinergics, antihistamines, antipsychotics, steroids, bronchodilators, anesthetics. Panic Disorder \ n ✔An anxiety disorder that consists of sudden, overwhelming attacks of terror, often associated with feeling of impending doom. Occurs without warning and in absence of any real danger. More common in women. Jung's Self Rating Scale \ n ✔used for anxiety Yale-Brown Scale \ n ✔used for OCD Diagnostic criteria for panic disorder \ n ✔discrete episodes of 4 or more symptoms having a sudden onset and peaking within 10 minutes of onset. Differential diagnoses for panic disorder \ n ✔hyperthyroidism, hyperparathyroidism, pheochromocytosis, vestibular function, seizure disorders, SVT, CNS stimulant use, PTSD, separation anxiety disorder Panic symptoms are atypical, such as \ n ✔vertigo, LOC, incontinence, headache, slurred speech, amnesic patterns after attacks. Pharmacological management of panic disorder \ n ✔SSRI, BZD as bridge, Buspar Non-pharmacological treatments for panic \ n ✔CBT, group or individual therapy, exposure, relaxation therapy Agoraphobia \ n ✔fear of being in a place or situation from which escape is embarrassing, difficult, or impossible -Two or more increased arousal symptoms: difficulty falling asleep, irritability, anger, difficulty concentrating, hyper vigilance, exaggerated startle response. -Symptoms cause significant distress/impair ADLs - Symptoms usually occur within 3 months of trauma - Duration of symptoms highly variable - remit within 3 months in 1/2 cases, common waxing and waning of sx R/T internal and external cues that resemble the trauma. Differential diagnoses for PTSD: \ n ✔Adjustment disorder, brief psychotic disorder, acute stress disorder, intrusive thoughts in OCD PTSD treatments: \ n ✔SSRIs, TCAs (NOT BZDs) Antipsychotics for flashbacks, alpha antagonists such as Prazosin for nightmares (off-label use). CBT, Exposure therapy with Response Prevention (ERP), supportive group therapy, relaxation therapy, eye movement desensitization and reprocessing (EMDR) Childhood considerations for PTSD \ n ✔expression of fear and horror occurs in disorganized or agitated behavior, repetitive play behaviors show themes or aspects of trauma, frightening dreams without recognized content are common. Types of dissociative disorders: \ n ✔dissociative amnesia, depersonalization or derealization, and dissociative identity disorder. Dissociation \ n ✔a defense mechanism that protects a person from overwhelming anxiety by emotionally separating. It causes gaps or interruption in the person's memory. Depersonalization or derealization \ n ✔persistent feeling of oneself not being real, or environment not being real; reality testing remains intact. It is generally perceived as uncomfortable. Etiology can be physical or psychological (seizures, migraines, etoh, anxiety, traumatic stress) DID is characterized by 2 or more distinct personality states known as: \ n ✔"alters". Theses states are generally split off from one another, leading to gaps in recall of everyday events. Etiology of DID \ n ✔history of severe physical and/or sexual trauma in childhood. Comorbid with PTSD, symptoms cause significant distress and impaired functioning. Body dysmorphic and hoarding disorder insight \ n ✔ranges from good to poor to absent (fixed delusion). Preoccupation causes considerable distress. Excoriation disorder \ n ✔recurrent skin picking that results in lesions. R/O meth use or SIB. Psychotic \ n ✔implies inability to test reality Disorganized behavior \ n ✔unusual behavior ranging from childlike silliness to anger Schizophrenia causes disturbances in many areas of functioning \ n ✔cognition, perception, emotion, behavior, eye movement, socialization 3 Neurobiological theories of schizophrenia \ n ✔Three area of functioning: genetics, neurodevelopment, and neurobiological defects. Schizophrenia and genetics \ n ✔50% risk in monozygotic twins 15% risk in dizygotic twin of person w/ schizophrenia 40% risk in children if both parents have schizophrenia Intrauterine insults may contribute to schizophrenia \ n ✔prenatal exposures to toxins/virals, O2 deprivation, maternal malnutrition, substance abuse, illness. Genetic defects in the neurodevelopment in schizophrenia are believed to cause \ n ✔abnormal neural cell development, connection, organization, and migration. This includes inadequate synapse formation, excessive pruning of synapses, and excitotoxic death of neurons. Neurobiological defects in schizophrenia: \ n ✔Several abnormal brain structures have been identified in people with schizophrenia: enlarged ventricles, smaller frontal and temporal lobes, reduced symmetry in temporal, frontal and occipital lobes, cortical atrophy, decreased cerebral flow, hippocampal and amygdala reduction. Suspected chemical neuron transmission alterations in schizophrenia: \ n ✔excess dopamine in mesolimbic pathway, decreased dopamine in the mesocortical pathway, excessive glutamine, decreased GABA, decreased serotonin. Typical demographics of person with schizophrenia: \ n ✔Urban born, 1st born, lower socioeconomic status, born in winter/early spring. More common in men whose onset is usually 18-25 years old Schizophrenia in women \ n ✔Onset usually 25-35 years old. Less premorbid function that men. Tend to have paranoid delusions and more hallucinations than men. Earlier age of onset of schizophrenia has: \ n ✔poorer premorbid functioning, more evidence of brain abnormalities, more prominent negative symptoms, more cognitive impairment, have poorer prognosis. Later age of onset in schizophrenia \ n ✔tens to be women, has less evidence of structural abnormalities, has less cognitive impairment, has better prognosis. Possible risk factors for schizophrenia; \ n ✔genetics (1st order relative), prenatal exposure to flu/virus, prenatal malnutrition, OB complications, CNS infection in early childhood. Schizophrenia is an illness of \ n ✔information processing w/ behavior and cognitive symptoms. What % of ppl with schizophrenia never marry? \ n ✔60-70% DSM5 criteria for schizophrenia \ n ✔2 or more of the following frequently are present during a 1 month period and at least one must be delusions, hallucinations, or disorganized speech. Delusions Hallucinations Disorganized speech Grossly disorganized behavior Negative symptoms Significant social or occupational dysfunction Duration of symptoms lasts for at least 6 months Negative symptoms tend to appear 1st as illness develops. Positive symptoms seem to decrease over time but negative symptoms persist. Negative symptoms are more debilitating. Factors predictive of good prognosis: \ n ✔high level of premorbid functioning, acute onset, later age of onset, clear precipitating event, married/partnered, good support, positive symptoms, short interval between onset and treatment, absence of brain abnormalities, family history of mood disorders, no family history of schizophrenia PE findings in schizophrenia: \ n ✔Abnormal saccadic eye movement, poor hand- eye coordination, "clumsy", narrow or wide set eyes, highly arched palate, subtle malformations of the ears. Neurological non-localizing soft signs: astereognosis, dysdiadochokinesia, impaired fine motor moment, left-right confusion, mirroring. Neurological localizing hard signs: weakness, decreased reflexes saccadic \ n ✔term describing back and forth movements of the eyes, such as in reading dysdiadochokinesia \ n ✔impaired ability to perform rapid alternating movements astereognosis \ n ✔inability to judge the form of an object by touch (e.g., a coin from a key) mirroring \ n ✔Matching certain behaviors of another person loose association \ n ✔thoughts that have little or no logical connection to the next thought tangential \ n ✔merely touching; slightly connected; digressive referential \ n ✔believe newspaper articles, TV shows, songs, are directed directly at them Considerations in children with schizophrenia \ n ✔hallucinations and delusional content less rich, elaborate, and bizarre. Visual hallucinations more common that auditory. Perform annual eye exam if patient on typical antipsychotic or _______________ \ n ✔Seroquel (quetiapine) Standardized rating scales for schizophrenia symptoms \ n ✔Positive and Negative Syndrome Scale Brief Psychiatric Rating Scale Scale for Assessment of Positive Symptoms Scale fo Assessment of Negative Symptoms Schizophreniform Disorder vs Schizophrenia \ n ✔duration is at lest 1 month but less than 6 months, including prodrome, active illness period, and residual symptom phase. Does not require impaired social or occupational functioning for diagnosis. Schizophreniform demographics \ n ✔Five-fold increase in men, lifetime prevalence of 0.11 percent. Schizoaffective Disorder \ n ✔Uninterrupted period of illness in which the person experiences psychotic symptoms similar to those seen in schizophrenia as well as mood symptoms similar to major depressive disorder. Presence of delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Two subtypes of schizoaffective disorder \ n ✔Depressive: prominent mood symptoms are of the depressive type only Bipolar: when predominant mood symptoms are manic or mixed type Schizoaffective demographics \ n ✔Less than 1% M=F Depressed type more common in oder persons Men with it tend to have more antisocial behaviors Delusional Disorder \ n ✔A psychotic disorder in which the primary symptom is one or more delusions, lasting for at least one month. Psychosocial functioning not impaired except the content of the delusion. Seldom any other symptoms; in rare case may have hallucinations or mood disturbance. Delusional Disorder demographics and risk factors \ n ✔0.2-0.3% of population in US Mean age of onset 40 years Men more likely to have paranoid delusions Women are more likely to have delusions of erotomania Risk factors: disorders of the limbic system and basal ganglia erotomania \ n ✔Delusional belief, more common in women than men, that someone is deeply in love with them. Infrequently has strong sexual content. Focus of love is usually a famous/powerful person. Leads to obsessive behaviors such as surveillance or stalking. grandiose delusion \ n ✔delusional content that focuses on having some great talent, skill or knowledge. May have religious content such as prophecy or deity connections. jealous delusion \ n ✔delusional content focuses on false belief that client's spouse/partner is being unfaithful, belief has no connection with realistic evidence, usually seen in men. persecutory delusion \ n ✔a person's false belief that someone is plotting against him or her with the intent to harm, spy on them mixed delusion \ n ✔no clear dominant theme for the delusional content Brief Psychotic Disorder \ n ✔disorder with sudden onset of psychotic symptoms lasting at lest one day but less than a month Demographics of Brief Psychotic Disorder \ n ✔unknown incidence, occurs more in younger clients 20-30 years old, family history of psychotic disorder, person returns to premorbid functioning Shared Psychotic Disorder \ n ✔Folie a Deux, two people share and create a delusional system. Aside from delusions content, client's behavior is otherwise normal. Chronic disease with poor prognosis if relationship continues. If the pair separates = good prognosis. 2 common cognitive disorders \ n ✔delirium and dementia cognitive disorder \ n ✔a complex general medical condition resulting in changes in memory, relationships, and behavior, They result from injury, medical condition, substance use/abuse, reaction to meds, etc. Delirium \ n ✔A syndrome and not a disease, with an acute onset that causes short- term changes in cognition. Subtypes of delirium \ n ✔Hyperactive, hypoactive, mixed One year mortality rate for delirium is \ n ✔up to 40% Prevalence of delirium: \ n ✔6-56% of hospitalized patients 15-53% in oder post op patients 70-87% of elderly ICU patients 60% nursing home patients 25% in clients with cancer 80% in terminal patients nearing death Confusion Assessment Method \ n ✔Used to assess DELIRIUM Neurological abnormalities seen in delirium \ n ✔tremors, incoordination, urinary incontinence, myoclonus, nystagmus, asterixis (flapping motion of wrists), increased muscle tone and reflex Illusions \ n ✔Inaccurate perceptions seen in delirium DELIRIUM Mnemonic for medical considerations \ n ✔Drugs Electrolyte abnormality Low O2 Infection Reduced sensory output Intracranial Urinary or renal retention Myocardial Delirium in children \ n ✔R/T immature brain development, often mistaken for uncooperative behavior, most common in febrile states, especially common with anticholinergic medications Dementia Types \ n ✔Dementia of Alzheimers (DAT) Vascular Dementia Dementia due to HIV Pick's Disease Creutzfeldt-Jakob Disease Huntingdon's Disease Lewy Body Disease Pick's Disease \ n ✔Frontotemporal dementia, neuronal loss, gliosis, and Pick's body present, more common in men, personality/behavioral changes in early stage. Kluver-Bucy syndrome: hypersexuality, hyperorality, placidity Creutzfeldt-Jakob disease \ n ✔Rapidly progressive, fatal disease of the central nervous system. Death usually occurs within 6 months. Occurs mainly in adults in middle age or older. Huntingdons Disease \ n ✔Subcortial type of dementia, memory, language, insight usually intact until late stages. High incidence of depression and psychosis. Lewy Body \ n ✔Caused by Lewy inclusion bodies in the cortex. Has hallucinations about animals and children. Parkinson features (bradykinesia, cogwheel rigidity, tremor). *Adversely react to antipsychotics. Clinical signs of late stage HIV dementia \ n ✔Global cognitive impairment, mutism, seizures, hallucinations, delusions, apathy, mania. Death usually occurs within 6 months. Dementia of Alzheimers Type \ n ✔Most common type, gradual onset, progressive decline, hallmark amyloid deposits and neurofibrillary tangles. Vascular dementia \ n ✔2nd most common dementia type, formerly called multi- infarct dementia, primarily caused by CV disease, most common in men with Incidence of SUD \ n ✔-Ages 18-24 have highest prevalence >50% of those with psychiatric disorder have comorbid SUD -Persons with schizophrenia are 4x more likely to have SUD than general population. -Persons with bipolar affective disorder are 5x more likely to have SUD than general population nucleus accumbent \ n ✔ The most commonly abused illegal substance in US: \ n ✔marijuana The most commonly abused LEGAL substance in US: \ n ✔alcohol Alcohol use demographics \ n ✔Men = 90% have used alcohol Women = 70% have used alcohol Rates are higher in African Americans, Hispanic Americans, Native Americans. Lowest rates in Asian Americans. Lifetime risk of alcohol abuse disorder in US is 15% 55% of fatal MVAs r/t DUI 50% of crimes in US committed r/t alcohol Fetal Alcohol Syndrome occurs in _________ of all infants born to females with alcohol use disorder \ n ✔1/3 S/S fetal alcohol syndrome: \ n ✔low birth weight/height, microphthalmia, short palpebral fissure, mid face hypoplasia, smooth or short philtrum, this upper lip Alcohol Abuse Screens \ n ✔AUDIT, S-MAST, CRAFFT, COWS, CAGE Specific criteria needed to identify substance use as ABUSE: \ n ✔Maladaptive pattern of use occurring for at least 12 month period of sustained use. MUST be accompanied by repeated failure fulfill major role obligation, use in situation that is dangerous (DUI), abuse continues despite multiple problems related to substance use patterns (legal, interpersonal, social) DSM5 criteria for SUD: \ n ✔pattern of repeated use that leads to clinically significant impairment with 3 or ore of the following symptoms within a 12 month period: Tolerance Withdrawal Using larger amount than intended Persistent craving or unsuccessful attempts at cutting down Large amounts of time obtaining or recovering from effects Activities decreased because of use Use despite consequence Diagnostic criteria for substance withdrawal \ n ✔Two or more of the following symptoms within several hours or days of reduction of substance: hand tremor insomnia autonomic hyperactivity (sweating, tacky, hypertensive) N/V hallucinations/illusions psychomotor agitation anxiety seizures Lab findings in person with alcohol dependance \ n ✔AST/ALT>2.0 Elevated glutamyltransferase, mean corpuscular volume, PT, uric acid, cholesterol, triglycerides. Decreased Mg, Ca, K, BUN, Hgb, Hct, platelet count, albumin DTs not likely to occur within the first _____ to ______ hours after last drink \ n ✔24 to 72hours Do not use Antabuse (disulfiram) until person has been alcohol free for ____ hours \ n ✔12 Ego-syntonic \ n ✔Pattern of behavior based on personality can be perceived by the person as comfortable. Behavior consistent with personality, person generally fails to recognize problem, person does not seek treatment. Ego-dystonic \ n ✔Pattern of behavior based on personality can be perceived by the person as uncomfortable. Behavior inconsistent with personality, causes discomfort/concern to the person, person generally recognizes the problem, person often seeks treatment. Personality disorders are chronically maladaptive patterns of behavior that cause \ n ✔functional impairment in work, school, and relationships. maladaptive affective traits \ n ✔overly affectual patterns of response maladaptive behavioral traits \ n ✔poor impulse control maladaptive cognitive traits \ n ✔unrealistic perceptual patterns of response maladaptive social traits \ n ✔maladaptive, unsatisfying interpersonal patterns of response Pt unlikely to recognize problem/seek help f maladaptive patterns of behavior are \ n ✔ego-syntonic CLUSTER A personality disorders \ n ✔Odd, unusual, eccentric, asocial. Paranoid, schizoid, schizotypal CLUSTER B personality disorders \ n ✔Dramatic, affective instability Antisocial, borderline, histrionic, narcissistic CLUSTER C personality disorders \ n ✔Anxious Avoidant, dependent, OCD Two common theories of personality disorder: \ n ✔1. Psychodynamic theory based on early separation problems and dysfunctional family patterns 2. Biological: genetics, reduced grey matter volume in prefrontal cortex, limbic system deregulation, decreased serotonin, increased norepi, dysregulation of dopamine receptors and trauma = laters brain patterns of response. Cluster A assessment \ n ✔Patterns of pervasive distrust and suspiciousness with odd and unusual behavior. Distrust not usually at psychotic level but can display brief psychotic episodes under stress. Limited social network, poor interpersonal relationships, limited disclosure, compliments often misinterpreted, pathological jealousy, difficult to get along with, appears cold, high control needs, rigid and critical of others, often highly litigious, negative perceptions of others; often biased/prone to stereotypes. Difference in cluster A disorders are in degree of \ n ✔suspiciousness and mistrust in behavioral manifestations of those traits. Cluster B assessment \ n ✔Patterns of pervasive affective and interpersonal disruption. Fluctuating emotional states. Disturbances not usually at psychotic level but can display brief psychotic episodes under stress. Of all the clusters of PD, which one may require hospitalization during period of active symptoms and pt is under significant stress? \ n ✔Cluster B Schizoid Personality Disorder \ n ✔A pattern of detachment from social relationships and a restricted range of emotional expression Schizotypal personality disorder \ n ✔marked and persistent unusual perceptions, social anxiety, odd behavior or speech Antisocial personality disorder \ n ✔A personality disorder in which the person exhibits a lack of conscience for wrong-doing. More common in men, dx usually before 18, conduct disorder as a kid, high substance abuse Borderline personality disorder \ n ✔Condition marked by extreme instability in mood, identity, and impulse control. Hx of abuse common. Assessment for cluster C personality disorders \ n ✔Persuasive anxiety, fear. Usually not psychotic. Hx of avoidant behavior, procrastination, not following thru, fear of rejection/criticism, difficulty relaxing. -Avoidant Personality Disorder -Dependent Personality Disorder -OCD Autism \ n ✔ Diagnostic screening tools for autism \ n ✔Modified Checklist for Autism in Toddlers (M-CHAT) Autism Diagnostic Observation Schedule (ADOS-G) Ages and Stages Questionnaires (ASQ) Rett Syndrome \ n ✔progressive disorder that affects cognitive, motor, social, and language. Normal head circ. at birth but deceleration of head growth at 5-48 months. Loss of previously acquired purposeful hand skills between 5-30 months. Scoliosis. R/O as diff dx for autism. Asperger Syndrome \ n ✔Less severe form of autism, characterized by difficulties with social interaction Childhood disintegrative disorder \ n ✔normal intellectual and social development, then show severe regression into autism Medications for autism \ n ✔Sx mgmt: APs, antidepressants, naltrexone, clonidine, and stimulants to diminish self-injurious and hyperactive and obsessive behaviors. Anorexia nervosa \ n ✔An eating disorder in which an irrational fear of weight gain leads people to starve themselves Russel's sign \ n ✔Calluses/scars on the knuckles or dorsal hand from self-induced vomiting Binge Eating Disorder \ n ✔An eating disorder in which a person repeatedly eats large amounts of food at one time at least 2 days weekly for 6 months. Neurobiological facts in eating disorders: \ n ✔decreased hypothalamus norepi activation, dysfunction of lateral hypothalamus, and decreased serotonin Eating disorder incidence \ n ✔85-95% females Affects 0.28% of the pop. Bulimia affects 1% of gen pop Onset usually 14-18 years Anorexia has weight loss less than what % of expected weight \ n ✔85% Restricting type anorexia \ n ✔The individual drastically restricts food intake and does not binge or purge Bulimia Nervosa \ n ✔A serious eating disorder marked by binging twice weekly for 3 months, alternating with methods to avoid weight gain. Symptoms of anorexia \ n ✔inverted T waves, ST depression, prolonged QT hypothermia, yellow skin, dry skin, lanugo, peripheral edema, hypertrophy of salivary glands, russel's sign. Symptoms of bulima \ n ✔Weight usually WNL Dental erosion Russel's sign Hypertrophy of salivary glands Rectal prolapse Labs in Anorexia Nervosa \ n ✔Hypokalemia and hypomagnesemia Hypoglycemia (prolonged state?) Decreased LH and FSH Thrombocytopenia, anemia, neutropenia Labs in Bulimia \ n ✔Hypokalemia and hypomagnesemia Hypotension and hyponatremia (laxatives?) Metabolic acidosis/alkalosis (binge/purge?) Elevated serum amylase Bradycardia Diff diagnoses for eating disorders \ n ✔OCD Schizophrenia (?) Med for anorexia \ n ✔none. Treat associated symptoms (depression, anxiety) Med for bulimia \ n ✔fluoxetine is FDA approved. SSRIs and TCAs helpful for reducing frequency of binge/purge Intellectual Disability \ n ✔Occurs in 1% population Onset prior to 18 years of age and during developmental period. includes low intellect and adaptive functioning. Based on adaptive functioning and NOT IQ scores. IQ scores are less valid on lower end of IQ range Heredity accounts for 5% of cases Inborn errors of metabolism (Tay-Sachs) Chromosomal abnormalities Prenatal exp. to alcohol or infection Perinatal probs account for 10% of cases General Medical Conditions during infancy/childhood account for 5% of cases - infections, brain trauma, exposure to toxins. No clear etiology in 30-50% of cases Fetal alcohol syndrome (FAS) \ n ✔A collection of congenital (inborn) problems associated with excessive alcohol use during pregnancy. Indistinct philtrum in FAS \ n ✔vertical groove on the midline of the upper lip ID physical exam findings \ n ✔Oblique eye folds Small, flat skull Large tongue Broad hands/stumpy fingers High transverse palm crease High cheekbones Small height Abnormal finger and toe prints Cryptorchism Congenital heart defects Early dementia Hypothyroidism Cryptorchism \ n ✔Undescended testicles 75% of people PDD have comorbid \ n ✔intellectual disability Meds for ID \ n ✔Treat concomitant psychopathology: ADHD, depression, anxiety, schizo, etc Aggressive or SIB can be controlled with APs and mood stabilizers. Disruptive mood dysregulation disorder \ n ✔Childhood depressive disorder that is diagnosed in children older than 6 but younger than age 18. Sx: chronic dysregulated mood frequent temper outbursts severe irritability Affects 2-5% of child/adolescents Higher incidence in boys an school age children than girls and adolescents Risk factors: comorbid ADD and ADHD MEDS: treat symptoms, SSRI, mood stabilizers and atypical APs can be helpful. Stage 1 sleep \ n ✔NREM, transitional stage from wakefulness to sleep. 5% of total normal sleep cycle. Stage 2 sleep \ n ✔NREM, specific ECG waveforms, 50% of total sleep Stages 3-4 sleep \ n ✔NREM, slow-wave sleep period. Deepest level of sleep. 20- 25% of total sleep cycle. REM occurs cyclically throughout the night, alternating with NREM on average every _________ minutes. \ n ✔80-100 REM \ n ✔a recurring sleep state during which dreaming occurs NREM \ n ✔a recurring sleep state during which rapid eye movements do not occur and dreaming does not occur. Stages 1-4 REM increases in duration toward____________ \ n ✔morning Children/adol have large amounts of _____ _____ sleep. \ n ✔slow-wave Slow wave sleep \ n ✔stages 3 and 4. Most difficulty awakening someone in SWS, and people feel most groggy when awakened.