Comprehensive Guide to Mental Health Laboratory Tests and Psychotropic Medications, Exams of Nursing

Download Comprehensive Guide to Mental Health Laboratory Tests and Psychotropic Medications and more Exams Nursing in PDF only on Docsity! NR 547 MIDTERM EXAM 2024-2025 ACTUAL EXAM TEST BANK 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS 5Ps to collect a client's sexual history: - ANS Partners Practices Protection from STDs Past History of STDs Prevention of Pregnancy *may consider adding another P for pleasure A 52-year-old client presents to the emergency department following a car accident. The emergency department (ED) physician is concerned that the client may have intentionally crashed her car and requests a stat PMHNP consult. In speaking with the PMHNP, the client describes persistent feelings of sadness and hopelessness. She states that she often wonders if her husband would be happier if she wasn't around anymore since she's never happy and sometimes thinks about what it would be like to just take a handful of sleeping pills and go to sleep forever. The client reports a previous suicide attempt when she was 16 but denies that she is considering killing herself right now. Based on the client's ASQ score, what is the most appropriate response? No action is necessary as the client is not currently considering suicide. Provide a brief suicide safety assessment. Alert the client's primary care physician. Provide a ST - ANS Provide a brief suicide safety assessment. Rationale: While the client's responses do not indicate a need for a stat full safety and mental health evaluation, the client requires a brief suicide safety assessment to determine whether a full mental health evaluation in necessary. It is also important to notify the client's physician or the clinician responsible for the client's care. A client has been on clozapine for 9 months. Absolute neutrophil counts (ANC) have consistently been less than 1500/microliter? At what frequency should a CBC be drawn? daily weekly every 2 weeks monthly - ANS every 2 weeks Rationale: With a normal baseline ANC, the CBC should be monitored weekly for 6 months; every 2 weeks for months 6-12; and monthly thereafter Adjustment Disorder with Anxiety - ANS DSM-5 classifies adjustment disorder as a trauma- and stressor- related disorder -presents with nervousness, worry, or jitteriness -Adjustment disorder occurs in the presence of a specific and identifiable stressor • common stressors include loss of employment, getting married, a new disability, or a natural disaster • Symptoms begin within three months of the stressor and typically last no more than six months Agoraphobia - ANS intense fear, anxiety, or panic out of proportion to the situation that occurs in two or more of the following specific scenarios: -public transportation (bus) -open spaces (parking lot or bridge) -enclosed spaces (store, theater) • Insomnia • Intellectual • Depressed mood • Somatic (muscular) • Somatic (sensory) • Cardiovascular symptoms • Respiratory symptoms • Gastrointestinal symptoms • Genitourinary symptoms • Autonomic symptoms • Behavior at interview 0-17: Mild anxiety 18-24: Mild to moderate anxiety 25-30: Moderate to severe anxiety 31-56: Severe anxiety armodafinil (Nuvigil) - ANS FDA Indications: -excessive sleepiness (OSA, narcolepsy, shift-work) RX Status: Schedule IV Normal Dosage: 150-250 mg/daily avolition - ANS lack of motivation Basic Laboratory Interpretation - ANS Complete Blood Count Comprehensive Metabolic Panel (CMP) Thyroid Function Tests Vitamin B12 Level Vitamin D Level Toxicology Screen Urinalysis (UA) Basic Laboratory Interpretation: Complete Blood Count - ANS -measures RBCs, WBCs, hemoglobin, hematocrit, and platelets -includes a differential of the WBCs -In mental health, the CBC is used to rule out medical conditions that may present with symptoms that can be attributed to both medical and psychiatric diagnoses • Ex: rule out anemia as a cause for depressive symptoms and fatigue • Ex: rule out infection as a cause of acute mental status changes RBCs: 4.5-6.0 million/microliter Hemoglobin: 12-18 grams/100 mL Hematocrit: 38%-48% Reticulocytes: 0%-1.5% WBCs (total): 5000-10,000/microliter Neutrophils: 55%-70% Eosinophils: 1%-3% Basophils: 0.5%-1% Lymphocytes: 20%-35% Monocytes: 3%-8% Platelets: 150,000-300,000/microliter Basic Laboratory Interpretation: Comprehensive Metabolic Panel (CMP) - ANS common blood test used to determine general health status -fluid and electrolyte balance, status of the body's metabolism, liver function, and kidney function -used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels -rule out medical conditions that could cause symptoms • Ex: changes in mood or cognition Sodium (Na+): 136-145 mEq/L Postassium (K+): 3.5-5.0 mEq/L Chloride (Cl-): 95-105 mEq/L Bicarbonate (HCO3-): 22-28 mEq/L Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl Cholesterol, serum: REC<200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl -Kidney Tests • Creatinine, serum 0.6-1.2mg/dl • Urea nitrogen, serum (BUN) 7-18mg/dl -Liver Tests • Alanine aminotransferase (ALT), serum: 8-20 U/L • Aspartate aminotransferase (AST), serum: 8-20 U/L • Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl -caused by upper airway obstruction during sleep • leads to periods of apnea and heavy snoring -commonly diagnosed in adults aged 40-60 -Risk factors: obesity and family hx central sleep apnea (CSA) sleep-related hypoventilation Breathing-related sleep disorders -typically present with excessive daytime sleepiness -trouble concentrating during the day, mood changes, awakening with a dry mouth or sore throat, morning headaches, or decreased libido -Partners may endorse snoring, apneic periods, and abrupt awakenings accompanied by gasping or choking. Brief Psychiatric Rating Scale (BPRS) - ANS -used to assess clients who present with symptoms of psychosis. -consists of 24 categories, each scored between 1-7. -scale varies, scores may be broadly interpreted with higher numbers indicating more severe illness -may be used over time to evaluate treatment. Brief Psychotic Disorder - ANS an acute psychosis, often precipitated by stress -Symptoms last for less than 1 month -clients experience full remission with a full return to function Callie is an 18-year-old college student who reports to the healthcare provider that she feels anxious "about everything." Her restlessness and irritability have impacted her relationship with her significant other. She reports no significant past medical or mental health history. She states that her anxiety started about 8 months ago when she decided to transfer from her local community college to a large state university to pursue a law degree. During the law program's orientation attended by 300 students, she learned that only 100 students would be selected out of 300 applications for the fall admission. She began feeling inferior that she would not be one of the students accepted. She also started thinking about "plan B," assuming that her grades are not "good enough" to get her selected for the program. She told the PMHNP that she was preparing for the rejection because she does not measure-up to the other appli - ANS generalized anxiety disorder Rationale: Callie has persistent symptoms of anxiety accompanied by restlessness and irritability. The thoughts are unrealistic since she has pre-determined that she is not good enough for the law program without evidence to support that feeling. She also compares herself to strangers where she automatically assumes that they are better prepared for the program than she is. She decides not to apply to the law program based on these unsubstantiated thoughts. Catatonia - ANS psychomotor syndrome that presents as a decreased reactivity to one's environment -typically occurs in tandem with other medical or psychiatric disorders • most often associated with schizophrenia, affective disorders, autism, and infectious disease -Clinical signs: • immobility, mutism, withdrawal, refusing to eat, staring, negativism, posturing, and rigidity. -failure to recognize and treat can lead to increased mortality CDC recommends that adults sleep ____ hours per night - ANS 7-9 Changing from one antipsychotic medication to another: - ANS -req specific dosage adjustments. -Guidelines include: • DAYS 1 - 7, Approx. 25% of target dose • DAYS 8 - 21, Approx. 50% of target dose • DAYS 22 - 35, Approx. 75% of target dose • DAY 36, Target dose Example: RX: aripiprazole 5 mg Dispense: #64 Sig: Take ½ tablet once a day for 7 days; then, take 1 tablet once a day for 14 days; then, take 1 ½ tablets once a day for 14 days; then, take 2 tablets once a day. Refills: 0 Circadian Rhythm Sleep-Wake Disorders - ANS occurs when this endogenous, 24-hour cycle is disrupted, causing excessive daytime sleepiness, insomnia, or both -Disruptions in sleep schedule due to illness or shift work may cause transient disorder, while non-24- hour sleep-wake disorder may cause chronic disturbances in sleep -common disorder of clients with blindness due to their inability to see light. Clinician-Rated Dimensions of Psychosis Symptom Severity Scale - ANS -can help the provider to determine the degree of impairment from (+), (-), and cognitive symptoms -Each item is scored & interpreted independently -may be used to monitor tx success & the need for additional follow-up CUS - ANS chronic unpredictable stress Delusional Disorder - ANS involves a person having prominent delusions without hallucinations -tend to have false beliefs that involve real-life situations • ex: belief that they are being followed or that others are plotting against them -often retain their personalities and are more functional socially Ella is a 17-year-old who presents to the clinic with her mother. Her mom reports that Ella will not go to the basement in their home, and she is concerned about the behavior. During the interview, Ella confirms that even thinking about going to the basement causes her extreme anxiety because she knows that there are spiders in the basement. She has had her phone taken away in the past because she will not go to the basement to gather her laundry, but she states, "I will take the punishment because it is better than being around those spiders." She states she has been afraid of spiders for as long as she can remember. Which of the following is the most appropriate ICD-10-CM code for Ella? 40.2 Specific phobias 40.218 Specific phobia - animal F40.298 Other specified phobia F40.9 Phobia, phobic - ANS 40.218 Specific phobia - animal enuresis - ANS involuntary discharge of urine -children: tx anticholinergic Erectile dysfunction - ANS AKA impotence -the inability to get and/or maintain a penile erection that is firm enough for sexual relations -can be due to physical or psychological causes • affect any of the areas of the brain, reproductive hormones, emotions, nerves, muscles, and/or blood vessels that are involved with the phenomenon of erection • most common physical causes include heart disease, atherosclerosis (clogged blood vessels), high blood pressure, nerve damage, and stroke • most common psychological causes include stress, anxiety, depression, or communication issues with the sexual partner Erica is a 24-year-old with a newly diagnosed schizophreniform disorder. She is a current smoker. She does not use alcohol or other drugs. She has no medical history. Which of the following would be the least appropriate initial medication for Erica? aripiprazole lurasidone olanzapine quetiapine - ANS olanzapine Rationale: Olanzapine requires up to 30% increased dosage for clients who smoke concurrently. Initiating a medication that does not interact with smoking is preferable. Esme is a 22-year-old client who presents to the clinic with her mother. Esme appears quiet and withdrawn with very little emotional expression. Her mother reports that for the last couple of years, Esme has gradually disengaged from all her friends. After graduating from high school, she left for college but started hearing voices telling her that she was ugly and stupid. She stopped attending class or completing her work. When asked directly about her symptoms, Esme provides very short, one-to- two-word responses in a monotone voice. Which of the following symptoms is Esme exhibiting? Select all that apply. anosognosia alogia avolition asociality blunted affect depersonalization catatonia anhedonia hallucinations delusions - ANS alogia avolition asociality blunted affect hallucinations Rationale: Esme is experiencing the following symptoms of psychosis: alogia: short answers, using few words to communicate avolition: lack of initiative, withdrawal from work/school asocialtiy: lack of relationships, reduced social interactions blunted affect: decreased facial expressions and voice inflections hallucinations: perceptual experiences in the absence of external stimuli Esme has not provided enough information to support the following symptoms at this time: anhedonia: inability to experience pleasure anosognosia: functional inability to recognize illness depersonalization: a perception that the body is floating, changing, or detached catatonia: lifeless, trance-like state with lack of response or movement delusions: fixed false, irrational beliefs Excitatory vs sleep-promoting neurotransmitters - ANS Excitatory -acetylcholine -norepinephrine -histamine -serotonin -orexin first line medication treatment: Social anxiety disorder - ANS -Sertraline -Paroxetine -Drug therapy takes 4 weeks to see effects First-line psychotropic medications used to treat anxiety disorders are: - ANS selective serotonin reuptake inhibitors (SSRIs) that act on the serotonin system and indirectly on the GABA system -There are also non-benzodiazepine anxiolytics that may help manage anxiety symptoms, including buspirone, gabapentin, and propranolol -Also, Clonidine or Guanfacine may be used with children -Treatment is usually continued for 6 to 12 months -SNRI's and SSRI's have become the first-line pharmacological intervention follow-up monitoring for clients diagnosed with a psychotic disorder - ANS -symptom assessment and review of medications and side effects -Periodic laboratory testing -Weekly follow-up is recommended for most clients for the first three months then once to twice per month thereafter depending on clinical progress Functional neuroimaging studies of GAD show: - ANS increased activation of the amygdala and reduced activation in the prefrontal cortex, indicating heightened activation of the fear response with diminished capacity for reasoning GAD anxiolytic treatment - ANS Pros -decreased adverse effects -decreased drug interactions Cons -limited effectiveness Time to efficacy -2-4 weeks Agents -buspirone GAD Benzodiazepine treatment - ANS Pros -highly effective -rapid onset -can be used PRN Cons -multiple adverse effects -fall risk -risk of misuse Time to efficacy -immediate Agents -Alprazolam (Xanax) -Clonazepam (Klonopin) GAD nonpharmacologic tx - ANS Relaxation or meditation Art or music therapy Yoga or other exercise Acupuncture Prayer or spiritual counselling -High-intensity aerobic exercise is a good complement to first-line therapy GAD often presents with physical symptoms, including: - ANS restlessness or edginess fatigue difficulty concentrating irritability muscle tension sleep disturbance GAD SSRIs/SNRIs treatment - ANS Pros -highly effective Cons -increased drug interactions -risk of hyponatremia Time to efficacy -up to 6 months Agents -Escitalopram (Lexapro) Harry is a 44-year-old who presents with complaints of excessive daytime sleepiness. He sleeps 9-10 hours per night but wakes up feeling groggy and confused. He frequently attends educational seminars for work, and he finds that he is constantly "drifting off" during the presentations. He falls asleep every night after dinner while watching television (TV). He denies the use of prescription, over-the-counter, or illicit drugs, or alcohol other than 1-2 beers every Sunday during football season. Does Harry meet the requirements for hypersomnolence disorder? yes no unable to determine - ANS unable to determine Rationale: Although Harry presents with some cardinal symptoms of hypersomnolence disorder, such as excessive daytime sleepiness, sleep inertia, and impairment in occupational functioning, additional information is needed to make the diagnosis. The provider must ensure that Harry's symptoms are not better explained by another disorder, such as a medical disorder, breathing-related sleep disorder, or other sleep disorder. having two parents with schizophrenia gives their children a ______ risk of developing schizophrenia as an adult - ANS 40% risk Helmut is a 58-year-old who has a history of alcoholism and liver failure. He presents to the emergency department with his wife, who is concerned about recent changes in his behavior, including a decrease in mobility and verbal response. He will not follow instructions during the examination. Facial grimacing is noted. His physical exam is positive for ascites and asterixis. A CT scan shows no acute concerns. His blood ammonia level is elevated. Based on DSM-5-TR criteria, what is the most appropriate diagnosis for Helmut at this time? - ANS hepatic encephalopathy (572.2) and catatonic disorder due to hepatic encephalopathy (293.89). rationale: Helmut is experiencing signs and symptoms consistent with hepatic encephalopathy, including a negative CT scan, ascites, asterixis, and elevated blood ammonia level. He meets diagnostic criteria for catatonia as he has four symptoms: stupor, mutism, negativism, and grimacing. Hoarding disorder - ANS -Persistent difficulty discarding or parting with possessions, regardless of their actual value. -difficulty is due to a perceived need to save the items and to distress associated with discarding them -difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use -The hoarding causes clinically significant distress or impairment in social, occupa-tional, or other important areas of functioning -The hoarding is not attributable to another medical condition Holden is a 14-year-old who presents to the clinic with his parents. His mother notes that he has stopped showering, seems disinterested in activities in which he had previously engaged and in peer interaction, and echoes words that others have said. These behaviors have increased over the past two months. Holden's urine toxicology is negative. Based on the DSM-5-TR, does Holden meet diagnostic criteria for schizophreniform disorder? yes no Unable to determine - ANS No Rationale: Holden's behaviors have lasted for at least one month, but less than six months. His behaviors are not attributable to a substance. Holden displays two of the five required symptoms for the diagnosis of schizophreniform disorder. He displays catatonic behavior with echolalia and has negative symptoms of asociality and avolition. He does not, however, display one of the three required behaviors for diagnosis: delusions, hallucinations, or disorganized speech. An alternate diagnosis should be considered. Hypersomnolence Disorder - ANS -excessive quantity of sleep, difficulty awakening or staying awake, and difficulty awakening -may sleep longer than 9 hours per night but the sleep does not feel restful or restorative -Daytime naps are common, as are unintentional sleep episodes while reading or watching TV -Confusion and memory impairment (sleep inertia) common upon awakening Insomnia - ANS -one of the most common sleep disorders -dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep -diagnosis of insomnia requires complaints occurring at least 3 nights a week for 3 months or more -Persistent insomnia is associated with: • decreased concentration, attention, and quality of life • increased irritability • increased risk of major depressive disorder, hypertension, and myocardial infarction Insomnia tx - ANS Nonpharmacologic -Cognitive-behavioral therapy (CBT) • most effective long-term treatment for insomnia and sleep disruptions • Sleep hygiene is an essential component of CBT Pharmacologic -Most OTC & prescription sleep aids are recommended for short-term use only -Only a few medications are approved for long-term therapy • zolpidem modified release, eszopiclone, & ramelteon James is a 24-year-old who presents to the clinic with complaints of sleep disturbances. He states that he is unable to sleep through the night most nights. This has been occurring for the past 4 months. What additional information will support a diagnosis of insomnia? James is struggling with staying awake at work and his performance is suffering. Medical Diagnoses Associated with Sexual Dysfunction: Dyspareunia - ANS Medical Cause: -surgical procedures on genitalia -infected or irritated hymenal remnants -episiotomy scars -Bartholin gland infections -vaginitis and cervicitis -endometriosis -adenomyosis -thinning vaginal mucosa and decreased lubrication Medical Diagnoses Associated with Sexual Dysfunction: Male Erectile Disorder - ANS Medical cause: -Disease Factors • diabetes • cardiovascular disease • chronic kidney disease • cancer -Lifestyle Factors • alcohol • obesity • smoking Medical Diagnoses Associated with Sexual Dysfunction: Male Hypoactive Sexual Desire Disorder and Female Interest/Arousal Disorder - ANS Medical Cause: -major illness or surgery, particularly when body image is affected -central nervous system (CNS) depressants or medications causing testosterone production Medical Diagnoses Associated with Sexual Dysfunction: Other Female Sexual Dysfunction - Orgasmic Disorders - ANS Medical Cause: -Endocrine disease • diabetes • hypothyroidism • primary hyperprolactinemia Medical Diagnoses Associated with Sexual Dysfunction: Other Male Sexual Dysfunction - Delayed Ejaculation - ANS Medical Cause: -surgery on the genitourinary (GU) tract -Parkinson's disease -other neurologic disorders involving the lumbar and sacral regions of the spinal cord Medical Diagnoses that Mimic Anxiety - ANS -Certain medications and substances may cause symptoms of anxiety -Anxiety symptoms may also present as part of another primary mental disorder • Depression, substance abuse, and schizophrenia can all have anxiety components -Baseline labs help rule out a medical diagnosis or other condition • CMP, TFT, toxicology screen Medical Diagnoses that Mimic Psychotic Disorders - ANS Alzheimer's disease Huntington disease brain tumors Creutzfeldt-Jakob disease adrenal disorders Rationale: Medical conditions that commonly present with psychotic symptoms include Alzheimer's disease, Huntington disease, multiple sclerosis, brain tumors, head trauma, Creutzfeldt-Jakob disease, syphilis, viral encephalitis, hepatic encephalopathy, adrenal disorders, and vitamin B12 deficiency. medications or substances commonly cause symptoms that mimic psychosis - ANS cephalosporins steroids amphetamines alcohol marijuana Rationale: Medications with side effects mimicking psychosis include cephalosporins, penicillin, anticholinergics, steroids, amphetamines, cocaine, alcohol, marijuana, and hallucinogens. Medications/substances that cause drowsiness: - ANS antihistamines benzodiazepines opioids beta-blockers muscle relaxants tricyclic antidepressants alcohol multivitamin and an antihistamine as needed for allergies. Based on the DSM-5-TR (APA, 2022) criteria, w - ANS Female sexual interest/arousal disorder Rationale: Ming is 37 years old, and still has regular periods. Her decreased libido for 6 or more months is indicative of female sexual interest/arousal disorder, especially since she and her partner are newly married and report an "incredible" sex life before the onset of symptoms. Occasional vaginal dryness is typical, given that she takes an antihistamine occasionally. There is no apparent medical cause for her decreased libido; therefore, Ming meets the DSM-5-TR criteria (APA, 2022) for female sexual interest/arousal disorder. Minh is a 19-year-old who presents to the emergency department after a suicide attempt. She is medically stable. She states that she has experienced auditory hallucinations for the past 3-4 weeks and "could not take them anymore." She also complains of depressed mood, loss of interest in activities, and feelings of hopelessness for the past few months. Her toxicology reports on admission were negative. Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), what is the most appropriate diagnosis for Minh? include ICD-10 code: - ANS schizoaffective disorder depressive type F25.1 Rationale: Minh presents with major depressive episode concurrent with hallucinations. This disturbance is not attributable to a substance. The most appropriate diagnosis for Minh is schizoaffective disorder depressive type F25.1 modanifil (Provigil) - ANS FDA Indications: -excessive sleepiness (OSA, narcolepsy, shift-work) RX Status: Schedule IV Normal Dosage: 150-400mg/daily most common mental illness in the United States - ANS Anxiety disorders -Anxiety impacts approximately 18% of the adult population and 25% of children ages 13-17 each year Narcolepsy - ANS -recurrent periods of napping or falling asleep without warning several times per day -may be accompanied by cataplexy -clients with narcolepsy may also present with hypocretin (orexin) deficiency and abnormal REM sleep latency • cerebrospinal fluid analysis, nocturnal polysomnography (PSG), and a multiple sleep latency test (MSLT) should be completed before diagnosis Narcolepsy and Excessive Daytime Sleepiness - ANS currently no cure for narcolepsy -wake-promoting substances such as modafinil or armodafinil or stimulants such as amphetamines and their derivatives are sometimes used • Other meds for excessive sleepiness & sedation from obstructive sleep apnea, narcolepsy, shift work, and non-24-hour sleep-wake disorder include sodium oxybate and tasimelteon *"Wake-promoting" agents have a risk for abuse Neurotransmitters involved in anxiety: - ANS Norepinephrine- excitatory Serotonin- quick turnover GABA-inhibitory Other Brain Chemicals HPA axis-cortisol Corticotrophin Releasing Hormone- CRH Brain-Derived Neurotrophic Factor-BDNF Obsessive-Compulsive and Related Disorders - ANS -obsessive-compulsive disorder (OCD) -body dysmorphic disorder -hoarding disorder -trichotillomania (hair-pulling disorder) -excoriation (skin-picking) disorder -substance/medication-induced obsessive-compulsive & related disorder -obsessive-compulsive & related disorder due to another medical condition -other specified obsessive-compulsive & related disorder (e.g., nail biting, lip biting, cheek chewing, obsessional jealousy, olfactory reference disorder [olfactory reference syndrome]) -unspecified obsessive-compulsive & related disorder Obsessive-compulsive disorder (OCD) - ANS characterized by persistent, uncontrollable thoughts or actions that occur over an hour or more per day -one of the top 20 illness-related disabilities worldwide obstructive vs central sleep apnea - ANS obstructive: physically closed airway r/t obesity, tonsils, etc central: cns problem bc the brain is forgetting to SIGNAL the lungs to breathe OCD - ANS -presence of obsessions and/or compulsions -Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted -compulsions are repetitive behaviors or mental acts that an indi-vidual feels driven to perform in response to an obsession or according to rules that must be applied rigidly only _____________ is approved by the Food and Drug Administration (FDA) for preventing suicide in clients with schizophrenia - ANS clozapine Orexin Receptor Antagonists - ANS Orexin is a neurotransmitter that assists with alertness and wakefulness • REM sleep behavior disorder involves arousal during REM sleep with accompanying vocalizations and complex motor behaviors, such as kicking, running, or punching • Restless legs syndrome (RLS) Parts of the Initial Psychiatric Interview - ANS Identifying data Source and reliability Chief complaint Present illness Past psychiatric history Substance use/abuse Past medical history Family history Developmental and social history Review of systems Mental status examination Physical examination Formulation DSM-5 diagnoses Treatment plan Patients with a hx of childhood trauma: cuts response and remission rate of SSRIs __________ - ANS in half Patients with anxiety disorders often show increased activity in the ______________ and _______________ - ANS amygdala and prefrontal cortex Performance anxiety (beta-blockers) - ANS Beta-blockers are recommended for clients who have an awareness of physiological symptoms such as tachycardia or tremor associated with performance anxiety -Beta-blocker or benzodiazepine 30-60 min before performace Persons with schizophrenia are typically noted to have: (brain) - ANS enlarged ventricles within the brain with atrophy of the frontal and temporal lobes, hippocampus, and amygdala Pharmacologic agents implicated in female sexual dysfunction: - ANS -antihypertensives -CNS stimulants -tricyclic antidepressants -SSRIs -Monoamine oxidase inhibitors (MAOIs) in early treatment Pharmacologic agents implicated in male sexual dysfunction: - ANS -cyclic drugs -other mood drugs -antipsychotics -chlordiazepoxide (Librium) -antihypertensives -barbiturates -antiparkinsonians -morphine -antidepressants -cardiovascular drugs -antibacterials -anticholinergics -cocaine, cannabis, heroin -alcohol phobia - ANS an intense fear of a specific situation or object -The fear associated with a phobia is not in proportion to the actual danger associated with the situation or object -often occur after experiencing or witnessing a traumatic event -typically develop in childhood -Types of phobias: • natural or environmental (lightning, water, tornado) • injury (dentist, injections) • animal (specific animals, insects) • situational (enclosed spaces) • other (loud noises, clowns) Positive and Negative Syndrome Scale (PANSS) - ANS -clinician-rated tool to identify and differentiate the presence of (+) and (-) symptoms of psychosis -commonly used in research settings Positron emission tomography (PET) scans have shown reduced ___________________ in patients with anxiety - ANS serotonin binding Prioritizing Client Complaints and Questions - ANS Use client-centered communication techniques -Strategies • Acknowledge the client's list of questions and concerns and review the list with the client with a statement such as, "I see you have a list of concerns; let's look at it together." • Mutually negotiate what to cover during the visit, use of positive language Anxiety -Generalized anxiety symptoms: Where, when, who, how long, how frequent. -Panic disorder symptoms: How long until peak, somatic symptoms including racing heart, sweating, shortness of breath, trouble swallowing, sense of doom, fear of recurrence, agoraphobia. -Obsessive-compulsive symptoms: Checking, cleaning, organizing, rituals, hang-ups, obsessive thinking, counting, rational vs. irrational beliefs. -Posttraumatic stress disorder: Nightmares, flashbacks, startle response, avoidance. -Social anxiety symptoms -Simple phobias, for example, heights, planes, spiders, etc. Psychosis -Hallucinations: Auditory, visual, olfactory, tactile. -Paranoia. -Delusions: TV, radio, thought broadcasting, mind control, referential thinking. -Patient's perception: Spiritual or cultural context of symptoms, reality testing. Other -Attention-deficit/hyperactivity disorder symptoms. -Eating disorder symptoms: Binging, purging, excessive exercising psychosis - ANS disruptions in thoughts and perceptions leading to a disconnection from reality -symptoms may include abnormal behaviors and sensations, including catatonic behavior -may be acute or chronic -Although psychosis is categorized as a psychiatric disorder, it commonly occurs as a secondary condition due to underlying endocrine, vascular, immunologic, or metabolic problems -Drugs, other substances, or other psychiatric conditions such as depression or mania may also cause symptoms Psychosis and ____________ are strongly associated - ANS suicide -leading cause of premature death among individuals with schizophrenia psychosis neurobiological factors: Environmental Triggers - ANS Regular Cannabis Use Exposure to Early Life Trauma -Sexual Abuse -Emotional Abuse -Emotional Neglect -Bullying psychosis neurobiological factors: genetics - ANS -Many genes play a role in the likelihood that an individual will develop schizophrenia as do epigenetic factors • Heritability for schizophrenia may be as high as 79% • links gene-environment interaction to the diagnosis of schizophrenia psychosis neurobiological factors: Neural networks - ANS Dopamine pathways explain the positive and negative symptoms seen in schizophrenia and psychosis -as well as the side effects associated with antipsychotic medications psychosis neurobiological factors: Neural signaling - ANS Dopamine Role in Psychosis -leading hypothesis is that psychosis and schizophrenia are associated with a dysfunction of the neurotransmitter dopamine (DA) • Traditionally, schizophrenia and psychosis symptoms have been associated with a surplus of dopamine, since medications that block dopamine, specifically D2, have been found to reduce the positive symptoms of schizophrenia -schizophrenia symptoms are related to "out of tune" dopamine -Dopamine dysfunctions are also involved in other conditions that cause psychosis, such as severe depression, certain medical disorders, and substance abuse psychosis neurobiological factors: Neuroanatomy Several areas of the brain are associated with the symptoms of schizophrenia. When brain circuitry in the prefrontal cortex malfunctions, patients may experience symptoms. Match the brain area with malfunctioning circuitry with the symptoms produced: Area of brain: Mesocortical and ventromedial prefrontal cortex Dorsolateral Orbitofrontal and connections to the amygdala Symptoms: aggressive, impulsive symptoms negative and affective symptoms cognitive symptoms - ANS Mesocortical and ventromedial prefrontal cortex: negative and affective symptoms Dorsolateral: cognitive symptoms Orbitofrontal and connections to the amygdala: aggressive, impulsive symptoms Psychosis Safety and Lifespan Considerations: Adolescence - ANS -onset in adolescence is often insidious -Initial signs: -motor • may include abnormalities in gait, balance, and coordination, irregular muscle contractions, or tremors Psychosis: Cognition symptoms - ANS Attention Working memory Verbal memory Visual memory Executive functioning Processing speed Social conditioning Psychosis: Factors strongly correlated with suicide risk - ANS -young age -male gender -high level of education other factors: -history of prior suicide attempts -comorbid substance use -presence of depressive symptoms -active hallucinations -delusions Psychosis: Motor Symptoms - ANS Motor delay Dyscoordination EPS -Parkinsonism -Dyskinesia Psychosis: Negative Symptoms - ANS Affective flattening Alogia Anhedonia Amotivation Asociality Psychosis: Positive Symptoms - ANS Hallucinations Delusions Thought disorder Hostility Excitability RAISE - ANS (Recovery After an Initial Schizophrenia Episode) provides specific schizophrenia-related resources for newly diagnosed clients. Restless legs syndrome treatment - ANS Dopamine agonists -pramipexole (Mirapex), ropinirole (Requip) • adverse effects: daytime somnolence, nausea Iron -Check serum iron levels. • Provide supplementation if needed Gabapentin/ pregabalin -severe or painful RLS Risk factors for developing anxiety: - ANS -genetic predisposition (family history of anxiety) -being female -recent life stressors -chronic physical illness -lack of support during childhood rumination - ANS compulsive fretting; overthinking about our problems and their causes -responds to atypical antipsychotics Sari is a 34-year-old female who is engaged to be married in one month. This will be her second marriage. She has been divorced for three years. Her fiancé, who is also divorced, has arranged for Sari to meet his three teenagers. Sari learns through a mutual friend of hers and the fiancé, that his teenagers, although hesitant, are willing to meet her. On the day of the arranged meeting, Sari is asked to arrive to the restaurant to meet the teens prior to the fiancé's arrival because he has been held up at a meeting. Sari agrees but starts to feel uneasy about it. She is concerned that they will not accept her because of her previous divorce and the fact that she is not their mother although they were willing to meet her. The closer she got to the restaurant, the more uneasy she felt to the point of disorientation. Just before entering the restaurant, she turned around and called her fiancé to inform him that her - ANS generalized anxiety disorder panic disorder panic attack social anxiety Rationale: Sari feels like she will be judged by the teens because she is not their mother. She avoids the situation by creating an excuse for not meeting them at the restaurant. The feelings are unwarranted since the teens agreed to meet with Sari. Screening and Psychiatric Rating Scales - ANS Evidence-based screening tools and psychiatric rating scales -can help the provider identify symptoms and assess their severity and can assist with the evaluation of response to treatment Screening tools for sleep/wake disorders - ANS -Insomnia Severity Index • eval falling & staying asleep, amount of sleep, & satisfaction with current sleep patterns • combination of scores provides the level of severity and impact on the client -STOP-Bang • brief questionnaire can be used to screen for breathing-related sleep disorders -Restless Legs Syndrome Rating Scale • used to ID the severity of RLS -Dysfunctional Beliefs and Attitudes about Sleep (DBAS) • questionnaire evaluates attitudes & expectations r/t sleep • scale helps ID opportunities for using cognitive-behavioral interventions to improve sleep -Morningness-Eveningness Questionnaire • used to ID sleep-wake habits r/t circadian rhythms SDOH: social and structural factors that impact mental health - ANS • Discrimination, racism, social exclusion • Adverse early life experiences • Poor education • Unemployment, underemployment, job insecurity • Poverty • Neighborhood deprivation • Food insecurity • Poor housing quality and housing instability Second Generation Antipsychotics (SGA) - ANS Pines -olanzapine (Zyprexa) -quetiapine (Seroquel) -asenapine (Saphris) -clozapine (Clozaril) Many Dones and a Rone -risperidone (Risperidol) -paliperidone (Invega) -ziprasidone (Geodon) -iloperidone (Fanapt) -lurasidone (Latuda) 2 Pips and a Rip -aripiprazole (Abilify) -brexpiprazole (Rexulti) -cariprazine (Vraylar) Sedating Antidepressants - ANS -Certain serotonergic agents are used for insomnia and may be an appealing option in clients with concurrent depression • trazodone (Desyrel) • amitriptyline (Elavil) • mirtazapine (Remeron) -agents may be prescribed as an adjunct to offset the stimulating effects of other antidepressants -Common Adverse Effects: Sedation, Anticholinergic effects, Weight gain, Daytime sleepiness, Dizziness, Dry mouth -Precautions: Hepatic impairment, Cardiac impairment, Hypertension, Older adults Selective mutism - ANS characterized by a consistent failure to speak in social situations in which there is an expectation to speak (e.g., school) even though the individual speaks in other situations. -significant consequences on achievement in aca-demic or occupational settings -interferes with normal social communication separation anxiety disorder - ANS fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate -persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation -reluctance to go away -nightmares and physical symptoms of distress Sexual dysfunction - ANS any difficulty in experiencing satisfaction from a sexual act in one of the four phases of the sexual response cycle: excitement, plateau, orgasm, or resolution -may result from biological, psychological, or social causes -may be lifelong, acquired, generalized, or situational -Symptoms must be present for a minimum of six months before diagnosis -Sexual Desire Inventory • self-rated scale to measure sexual desire Sexual dysfunction tx: - ANS Pharmacologic: -Phoshodiesterase (PDE) inhibitors (erectile dysfunction & vaginal lubrication) -Hormone therapy (increase sex drive) -Antiandrogens & antiestrogens (compulsive sexual behavior in men) -Dopaminergics (increased libido, function) -SSRIs/Tryclics (premature ejaculation) Surgical -Male Prostheses -Vascular Surgery Psychosocial -Dual-Sex Therapy -Behavior Therapy -Group Therapy -Hypnotherapy -Sex Therapy Shelby is a 31-year-old who presents to the emergency department with her husband. She is 32 weeks pregnant. Her husband noted that a few days ago, she began having bizarre behaviors, including avoiding eye contact, exhibiting tangential speech, and expressing delusions that she is being followed and tracked by the CIA and that they are planning to steal her baby. Shelby has no medical or psychiatric history, and she is not on any medications. She has abstained from alcohol during pregnancy and does not use other drugs. Based on DMS-5-TR, does Shelby meet the criteria for brief psychotic disorder? yes no Unable to determine - ANS Unable to determine Rationale: Shelby may meet diagnostic criteria for brief psychotic disorder (298.8) with peripartum onset, but a diagnosis cannot be confirmed at this time. Shelby exhibits delusions and disorganized speech. The symptoms cannot be better explained by another medical or psychiatric illness or substance. Shelby's symptoms began a few days ago. If symptoms resolve within one month, this is an appropriate diagnosis. If not, an alternate diagnosis should be considered. Sigourney is a 47-year-old who presents to the clinic with complaints of anxiety. She states that certain situations seem to trigger her anxiety, including using the subway, attending concerts and movies, and going to the corner bodega. She states that these types of situations make her fear that she will be trapped in the event of an emergency. To cope, she has been walking rather than using public transportation and using an online ordering app for grocery delivery. She has not been to a concert or movie theater in years and feels that she has lost some friends because of her reluctance to attend. Based on the DSM-5-TR, does Sigourney meet diagnostic criteria for agoraphobia? - ANS Yes Rationale: Sigourney meets the following diagnostic criteria for agoraphobia: she has marked anxiety about using public transportation and being in enclosed spaces and crowds. She fears a situation because she worries about her ability to escape. She has changed her behaviors to avoid situations that cause her anxiety, and she has caused social impairment in her life. Silexan - ANS branded extract of lavender -available by prescription in many countries and over the counter as CalmAid through the Nature's Way product line in the U.S. -pharmacologic properties are similar to many CAM therapies -research supports its efficacy for GAD Sleep Assessment - ANS onset, course, and duration of sleep difficulty psychological stressors life changes shift-work and occupation daytime activities naps sleep schedule bedtime presleep routines sleeping environment number of hours slept onset of sleep sleep maintenance early awakenings level of fatigue, impact on mood, activities of daily living, performance previous treatments *If more information is needed, it may be helpful to have the client complete a sleep diary over two weeks Sleep Cycle Stages - ANS Stage 1: Drowsy -Short period of non-REM sleep, includes drowsiness & drifting off to sleep; can quickly awaken; eye movements, breathing, & heart rate slow, but occasional muscle twitches occur Stage 2: Light Sleep -Avoid electronics. Diet & Medications -Avoid stimulants late in the day (caffeine, nicotine, alcohol, etc.). -Schedule stimulant meds for the morning. -Avoid OTC sleep aids. -Avoid heavy meals before bed; eat light snack if hungry. Sleep/wake homeostasis - ANS the function that tracks the body's need for rest and controls the amount and intensity of sleep -affected by light and dark • If the eyes perceive light, melatonin production is suppressed, leading to wakefulness Social Anxiety Disorder - ANS AKA social phobia -condition in which typical, everyday social interactions cause significant anxiety, self-consciousness, fear of embarrassment, or a feeling of being judged negatively by others -may worry about the presence of physical symptoms that others may notice such as trembling or blushing -derealization, or a feeling of "spacing out," may occur -Causes likely include a combination of genetic and environmental factors -past year: 7% of adults and 9% of adolescents -DSM-5-TR defines social anxiety disorder as an individual's fear of acting in a way that might cause judgment by others -anxiety is persistent, lasting greater than six months Social Anxiety Disorder (SAD) treatments - ANS cognitive behavioral therapy, medications, or a combination of both -Medications for SAD: • First try SSRI & SNRIs • Then Benzodiazepines • Then MAOIs (SSRI/SNRI must be out of system) Social Determinants of Health (SDOH) - ANS the conditions in which individuals are "born, grow, live, work, and age" that contribute to the development of both physical and psychiatric pathology over the course of one's life" sodium oxybate (Xyrem) - ANS FDA Indications: -narcolepsy with cataplexy and excessive daytime sedation RX Status: Schedule III Normal Dosage: 6-9g/night Substance/medication capable of producing substance/medication-induced anxiety disorder - ANS Alcohol Caffeine Cannabis Phencyclidine Other hallucinogen Inhalant Opioid Sedative, hypnotic, or anxiolytic Amphetamine-type substance (or other stimulant) Cocaine Other (or unknown) substance Symptom-Directed Treatment - ANS Psychiatric medication is generally prescribed in a transdiagnostic manner in which symptoms rather than diagnoses guide clinical practice Symptoms of Panic Attacks: - ANS -Palpitations, pounding heart, or accelerated heart rate -Trembling or shaking -Paresthesias (numbness or tingling sensations) -Sensation of shortness of breath or smothering -Derealization (feelings of unreality) or depersonalization (feeling detached from oneself) -Feeling of choking -Feeling of chest pain or discomfort -Nausea or abdominal stress -Feeling dizzy, unsteady, light-headed or faint -Chills or heat sensations Symptoms of Psychosis: Disorganized Behavior - ANS disordered or impaired behavior or communication -childlike silliness -unpredictable agitation -inappropriate clothing for the weather -poor hygiene Symptoms of Psychosis: Thought Disorder - ANS impairment in the process of thinking and difficulty organizing thoughts in a logical pattern. -incoherent speech -loose associations risperidone - ANS risperidone Rationale: Amiodarone is a moderate CYP3A4 inhibitor. Risperidone does not interact with CYP3A4 inhibitors or inducers. Treat or Refer: Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. - ANS Refer Rationale: Clients with hyperthyroidism have elevated T3 levels. Hyperthyroidism is associated with anxiety symptoms. Client can be reevaluated for anxiety once hyperthyroid treatment has been initiated and T3 levels are within normal limits. Treat or Refer: Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. - ANS Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated. Treat or Refer: Julio is a 66-year-old who presents with depression. His vitamin D level 11 ng/mL. - ANS Refer Rationale: Vitamin D deficiency is associated with depressive symptoms. The PMHNP may refer or treat vitamin D deficiency depending on the level of comfort of the provider. Treat or Refer: Leo is a 49-year-old who presents with fatigue. His hemoglobin is 15 g/dL and hematocrit is 42%. - ANS Begin treatment Rationale: The hemoglobin and hematocrit are within normal limits. This client's complaint of fatigue is not due to anemia. Begin treatment based on a complete evaluation. Treat or Refer: Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is 32. - ANS Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Treat or Refer: Terri is a 79-year old who presents with confusion. She has positive urine leukocyte esterase. - ANS Refer Rationale: A positive Urine Leukocyte Esterase indicates the presence of a urinary tract infection (UTI) , which may cause confusion. Refer this client for treatment of the UTI. Treat or Refer: Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L. - ANS Refer Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH levels are within normal limits. Treatment for Erectile Dysfunction: - ANS Pills -Phosphodiesterase-5 inhibitors • first line therapy -Alpha-adrenergic blockers can also be used Injections -Papaverine (PDE inhibitor) ± phentolamine (α-adrenergic blocker) Alprostadil (PGE1) Penile Implants Suppositories Vacuum Devices treatment of psychotic disorders - ANS complex -Decision-making about medications is influenced by treatment response and side effects, as well as the phase of illness (acute vs. stable) -antipsychotics as well as other medications, psychotherapy, and close collaboration between providers and the client's support system -Treatment goal setting should be client-driven, though some clients may be too ill or agitated to participate in the process -care should include the client's wishes, safety is of paramount importance • Providers may need to initiate treatment and/or hospitalization against a client's will treatment of psychotic disorders: Nonpharmacologic - ANS Psychosocial Therapy -provides the opportunity to build a therapeutic alliance, provide education, and instill hope -CBT, improve cognitive distortions and help provide insight into their illness -Social skills training and group therapy -Family-oriented therapies -Case management -vocational therapy and supported employment Rationale: The ICD-10 code is G47.26 Circadian sleep-wake disorder (G47.26) shift work type. Uday has difficulty falling and staying asleep and meets the criteria for insomnia; however, he changed shifts at work. The symptoms are consistent with a circadian sleep-wake disorder, shift work type. Unfortunately, medications used to treat the positive symptoms can inadvertently worsen negative symptoms because the antipsychotics cannot reduce dopamine in specific areas of the brain. Therefore, by reducing dopamine in the ________________, we further reduce the dopamine in the _______________ region - ANS mesolimbic system, mesocortical Usually, social anxiety disorder causes distress and anxiety in specific social situations such as: - ANS - making small talk with others -meeting new people -performing in front of others (called performance anxiety) Which of the following laboratory tests are indicated for a client who is taking olanzapine? Select all that apply. BMI CBC HbA1C Lipid panel Kidney function tests - ANS BMI HbA1C Lipid panel Rationale: Monitoring should include fasting glucose or hemoglobin A1C, lipid profile, weight, and BMI at regular intervals during the first year of antipsychotic therapy and then annually. Which of the following medical conditions is likely to present with symptoms that mimic anxiety? hypothyroidism hyperthyroidism dysrhythmias irritable bowel syndrome anemia diabetes type 2 migraine headache covid-19 rheumatoid arthritis menopause - ANS hyperthyroidism dysrhythmias irritable bowel syndrome migraine headache rheumatoid arthritis menopause Rationale: Medical conditions that commonly present with symptoms that mimic anxiety include endocrine disorders including hyperthyroidism and adrenal dysfunction cardiac disorders including angina and dysrhythmias, GI conditions including irritable bowel syndrome and GERD, inflammatory conditions including lupus and rheumatoid arthritis, neurological disorders including migraine headaches and seizures, and respiratory conditions including asthma and COPD. Changes in the menstrual cycle, including PMS and menopause, may also cause symptoms that mimic anxiety. Which of the following medical or psychological conditions are likely to include symptoms that impact sleep and waking? Select all that apply. Alzheimer's dementia congestive heart failure hypertension thyroid disease conjunctivitis bipolar disorder - ANS bipolar disorder thyroid disease congestive heart failure Alzheimer's dementia Rationale: Medical and psychological conditions that commonly impact sleep and waking include congestive heart failure, musculoskeletal disorders, heartburn, diabetes, kidney disease, thyroid disease, Parkinson's disease, Alzheimer's dementia, bipolar disorder, anxiety, schizophrenia, post-traumatic stress disorder (PTSD), and depression. Which of the following medications or substances commonly cause symptoms that mimic anxiety? bupropion nasal decongestants metoprolol levothyroxine Insulin albuterol cocaine alcohol caffeine morphine - ANS bupropion nasal decongestants