NU 673 Final Study Guide.NU 673 Final Study Guide., Exams of Nursing

Download NU 673 Final Study Guide.NU 673 Final Study Guide. and more Exams Nursing in PDF only on Docsity! 1 Psychiatric Mental Healthcare Nursing I NU673 Unit 15 Final Exam 1. Know the difference in major depressive disorder, persistent depressive disorder, bipolar disorder, and disruptive mood dysregulation disorder. a. Major depressive disorder: Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn't worth living b. Persistent depressive disorder Persistent depressive disorder, also called dysthymia (dis- THIE-me-uh), is a continuous long-term (chronic) form of depression. You may lose interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy. These feelings last for years and may significantly interfere with your relationships, school, work and daily activities. If you have persistent depressive disorder, you may find it hard to be upbeat even on happy occasions — you may be described as having a gloomy personality, constantly complaining or incapable of having fun. Though persistent depressive disorder is not as severe as major depression, your current depressed mood may be mild, moderate or severe. Because of the chronic nature of persistent depressive disorder, coping with depression symptoms can be challenging, but a combination of talk therapy (psychotherapy) and medication can be effective in treating this condition. c. Bipolar disorder formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly. Episodes of mood swings may occur rarely or multiple times a year. While most people will experience some emotional symptoms between episodes, some may not experience any. Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy). d. Disruptive mood dysregulation disorder: Disruptive mood dysregulation disorder (DMDD) is a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts. The symptoms of DMDD go beyond a “bad mood.” DMDD symptoms are severe. Youth who have DMDD experience significant problems at home, at school, and often with peers. They also tend to have high rates of health care service use, hospitalization, and school suspension, and they are more likely to develop other mood disorders. 2. Know the DSM 5 criteria for diagnosis of depressive disorders. a. Disruptive Mood Dysregulation Disorder: i. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. ii. The temper outbursts are inconsistent with developmental level. iii. The temper outbursts occur, on average, three or more times per week. 2 iv. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). v. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D. vi. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. vii. The diagnosis should not be made for the first time before age 6 years or after age 18 years. viii. By history or observation, the age at onset of Criteria A–E is before 10 years. ix. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. x. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. xi. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). xii. Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. xiii. The symptoms are not attributable to the physiological effects of a substance or another medical or neurological condition. b. Major Depressive Disorder i. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. ii. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. 161 4. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 5. Insomnia or hypersomnia nearly every day. 6. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 7. Fatigue or loss of energy nearly every day. 5 vi. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.) vii. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism). e. Substance/Medication-Induced Depressive Disorder i. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities. ii. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2): iii. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. iv. The involved substance/medication is capable of producing the symptoms in Criterion A. v. The disturbance is not better explained by a depressive disorder that is not substance/medication-induced. Such evidence of an independent depressive disorder could include the following: vi. The symptoms preceded the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced depressive disorder (e.g., a history of recurrent non-substance/medication-related episodes). vii. The disturbance does not occur exclusively during the course of a delirium. viii. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ix. Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. f. Depressive Disorder Due to Another Medical Condition i. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture. ii. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. iii. The disturbance is not better explained by another mental disorder (e.g., adjustment disorder, with depressed mood, in which the stressor is a serious medical condition). iv. The disturbance does not occur exclusively during the course of a delirium. v. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. vi. Coding note: The ICD-9-CM code for depressive disorder due to another medical condition is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code depends on the specifier (see below). vii. Specify if: 1. (F06.31) With depressive features: Full criteria are not met for a major depressive episode. 2. (F06.32) With major depressive–like episode: Full criteria are met (except Criterion C) for a major depressive episode. 6 3. (F06.34) With mixed features: Symptoms of mania or hypomania are also present but do not predominate in the clinical picture. g. Other Specified Depressive Disorder i. This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The other specified depressive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. This is done by recording “other specified depressive disorder” followed by the specific reason (e.g., “short- duration depressive episode”). ii. Examples of presentations that can be specified using the “other specified” designation include the following: 1. Recurrent brief depression: Concurrent presence of depressed mood and at least four other symptoms of depression for 2–13 days at least once per month (not associated with the menstrual cycle) for at least 12 consecutive months in an individual whose presentation has never met criteria for any other depressive or bipolar disorder and does not currently meet active or residual criteria for any psychotic disorder. 2. Short-duration depressive episode (4–13 days): Depressed affect and at least four of the other eight symptoms of a major depressive episode associated with clinically 3. 184 4. significant distress or impairment that persists for more than 4 days, but less than 14 days, in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for recurrent brief depression. 5. Depressive episode with insufficient symptoms: Depressed affect and at least one of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persist for at least 2 weeks in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety and depressive disorder symptoms. h. Unspecified Depressive Disorder i. This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The unspecified depressive disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). 1. When prescribing medications what are some teaching points you want to educate the patient on before they start the medication? -When to take the medication, what time of day, and with or without food. -Are there any side effects of the medications? Risk factors? -Are there any black box warnings? -When should the patient expect to start feeling better on the medication? 7 -What should the patient do if they experience uncomfortable side effects or serious side effects from the medication? -When should the patient follow up after starting a medication? 2. When assessing a patient who has major depression and may be experiencing anhedonia, anergia, and avolition what are some of the best communication techniques to use when speaking with the patient? If the patient appears catatonic in behavior; moving slowly, slowed speech, monotone, monosyllables, or thought blocking, would you want to approach them in conversation as you would with a regular conversation or would you want to be clear, direct, concise, and to the point with communication? a. Negative symptoms include decreased thought and speech productivity (alogia), loss of ability to experience pleasure (anhedonia), decreased initiation of goal-directed behavior (avolition), and speech with little or no change to their tone, little or no change in their facial expression, even if they are talking about something upsetting or exciting (affective flattening). Disorganized symptoms include disorganized speech (frequent derailment and incoherence), and disorganized behavior and attention. • Reassurance of safety in the hospital • Reassurance of improvement with treatment despite feeling “stuck” • Familiar objects and people, ie. friends & family • Limit number of people who interact with the patient • Avoid premature pressure for the patient to speak or move • Attempt non-verbal forms of communication, ie. writing, hand gestures • Be mindful that most patients recall the experience 3. Know the difference in monitoring of patients who are on different precautions; suicide, elopement, assault/homicidal, and self-harm. What are the differences in level of observations such as; the differences in line of sight and one to one. a. Suicide precautions: 1:1 i. Suicide Assessment and Precautions – 1. Collaborate with the patient and family to identify the need for inpatient care. 2. Inform the patient and family of the patient’s rights and responsibilities while an inpatient. 10 5. What are the common problems patients have with sleep cycles when experiencing depression? a. Sleep disturbance is almost always present i. Typically problems occur with middle or terminal insomnia ii. Hypersomnia can be present iii. Diurnal variations van be rpesent 6. Know the symptoms and DSM 5 criteria for Bipolar 1 disorder with mania. How would you approach a patient with mania in conversation? a. Manic Episode i. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). ii. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: iii. Inflated self-esteem or grandiosity. iv. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). v. More talkative than usual or pressure to keep talking. vi. Flight of ideas or subjective experience that thoughts are racing. vii. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. viii. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). ix. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). x. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. xi. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition. xii. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. xiii. Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. b. Communication strategies i. Active listening ii. Making positive requests for change iii. Calmly expressing your feelings about the person’s behavior iv. Problem solving together v. Reaching a compromise together vi. Communicating about positive things 7. Know the definition and symptoms of emotional or mood lability. a. Emotional lability is the tendency to shift rapidly and dramatically between different emotional states. 11 b. A labile mood is characterized by emotions that shift quickly, drastically, and uncontrollably. Labile mood is typically associated with an underlying health condition. It can be a symptom of a mental health condition , or it can occur with conditions that affect the brain. c. Symptoms i. Uncontrollable laughter ii. Crying (without a specific cause) iii. Less tolerance for frustration iv. Overreaction to situations v. Emotional outbursts that are unrelated to the current situation vi. Emotions being expressed do not reflect how the person is actually feeling vii. Emotional episodes follow a pattern of ramping up, then slowly decreasing viii. Episodes cause significant distress and interfere with daily functioning ix. Symptoms are not a side effect of medications 8. When would you as a PMHNP recommend the use of lithium? What are important teaching and educational points for a patient you are starting on lithium? How often do you want to monitor lithium levels? What would you do if the levels come back sub-therapeutic, normal, or elevated? a. Lithium has been a first-line treatment for bipolar disorder for more than 50 years and recent research suggests that early identification and treatment of bipolar disorder with lithium can alter the progression of the illness. lithium should be prioritized in the treatment sequencing to stabilize moods and reduce suicide risk in manic and depressive episodes of bipolar disorder. b. Lithium has neurotrophic and neuroprotective actions. Through the upregulation of BDNF and other brain growth factors, lithium improves the proliferation, differentiation, growth, and regeneration of cells and strengthens synapses and synaptic efficiency. Lithium's neuroprotective effects are anti-inflammatory and halt the disease-related progression of neuronal and glial cell death, normalize ionic and cell membrane activity and neurotransmission (e.g., glutamate and calcium), and reverse brain volume reductions (gray and white matter) in the hippocampus, amygdala, and prefrontal cortex. Persons who might respond best to lithium monotherapy for acute treatment mania are those with classic euphoric grandiose mania, few prior episodes of illness, a mania-depression-euthymic course, and those with a family history of bipolar disorder. c. Lithium carries a FDA boxed warning for lithium toxicity. Serum lithium levels >1.5 mEq/L are considered toxic. Toxicity is characterized by a worsening of the common side effects, weakness, and lack of coordination, and at higher levels, severe multi-organ damage. d. The most common adverse effects associated with lithium are nausea, diarrhea, fine motor tremor, polyuria, mild thirst, and weight gain Gastrointestinal symptoms (e.g., nausea, diarrhea) can be reduced by taking lithium with meals and with multiple dosing regimens. Although lithium carries a significant risk for weight gain, it does not appear to increase the risk for diabetes mellitus, in contrast to antipsychotic mood stabilizers e. The organs most at risk for adverse effects from long-term lithium treatment are the thyroid, parathyroids, and kidneys. According to Nestsiarovich et al. (2020), lithium-related weight gain is most likely due to its effects on appetite, the thyroid gland (hypothyroidism), and kidneys (diabetes insipidus with increased consumption of high-calorie liquids). The signs of lithium-induced hypothyroidism are weight gain, lethargy, mental slowing, depression, dry skin, and cold intolerance. The signs of lithium-induced hyperparathyroidism are weakness, fatigue, renal stones and insufficiency, and osteoporosis. f. Lithium is associated with a higher risk for kidney disease than the other drugs used to treat bipolar disorders (Nestsiarovich et al., 2020). The risk for lithium-induced kidney disease increases with higher serum levels, episodes of toxicity, and treatment duration (Gitlin et al., 12 2016; Van Alphen et al., 2021). Polyuria and polydipsia are common side effects of lithium and are generally reversible; however, long-term exposure can cause irreversible structural damage to nephrons and decreased responsiveness to antidiuretic hormone, resulting in the production of excessive amounts of dilute urine that can lead to dehydration (nephrogenic diabetes insipidus). The progression to severe or very severe kidney disease is approximately 5% after 10 to 29 years of lithium treatment (Aiff et al., 2015 ). g. The most common reasons for early discontinuation by patients were nausea, diarrhea, psychological reasons (e.g., fear of adverse effects, perceived lack of effectiveness, emotional blunting), tremor, polyuria/polydipsia/diabetes insipidus, and weight gain. h. Lithium diet i. Drinking 8 to 10 glasses of water every day: Dehydration can cause lithium levels in the blood to rise. Drinking a consistent amount of water each day helps to ensure stable levels [21]. ii. Keeping your salt and caffeine intake about the same each day: A sudden increase in salt or caffeine intake can reduce lithium levels (and vice versa). The key is to remain consistent [21]. iii. Avoiding alcoholic beverages: Alcohol can alter your lithium levels – and it is generally not a good idea in people with mental health conditions [22]. iv. Taking lithium with food or milk: this can help reduce stomach-related side effects, like nausea, vomiting, and diarrhea. i. Therapeutic serum range if 0.5-1.2 mEq/l. The target serum lithium level for acute treatment of episodes is 0.8 mEq/L to 1.2 mEq/L for adults (0.4 mEq/L to 0.8 mEq/L for older adults). Careful patient education and monitoring to prevent toxicity is important, as higher plasma lithium levels or toxicity can increase the risk for chronic kidney disease. j. Trough lithium levels should be assessed approximately 7 days after initiation and 7 days after every dose increase until therapeutic range is achieved. k. Baseline levels thyroid function, serum creatinine, BUN, pregnancy test, ECG (patients>50) l. Lithium level, thyroid and renal function, and plasma calcium should be assessed at 6 months and at least annually during the first year and yearly thereafter and as clinically indicated. i. For older adults, the ISBD recommends more frequent monitoring: 1. (a) lithium level, serum creatinine, eGFR, and blood urea nitrogen every 3 to 6 months 2. (b) thyroid stimulating hormone, fasting glucose, fasting lipids, triglycerides, weight, and calcium every 6 to 12 months; and 3. (c) routine cognitive screening every 12 months. Drugs that interfere with lithium excretion and increase the risk for toxicity should be avoided, including angiotensin-converting enzyme inhibitors, nonsteroidal anti- inflammatory medications, and cyclooxygenase 2 inhibitors. m. What to do if i. the level is low (typically < 0.6 mmol/l ) 1. If the patient is well and the levels are consistently low but within the documented specified range for that patient (this would be unusual but might be the specialist recommendation), do not alter dose 2. If the patient is unwell and pattern of levels have been bordering on the lower end of the range: - Assess compliance - Increase the dose if appropriate - Recheck the level in 5 days 3. If the low level is inconsistent with the trend, i.e. a one off: - Assess compliance 6 - Consider other factors, e.g. drug interactions, excess intake of fluid, brand change - Recheck the level ii. If the level is within therapeutic range (typically 0.6-1.0 mmol/l) 1. If the patient is well and tolerating lithium, do nothing! 15 achieve a healthy intake of food, or who need to withdraw from drugs or alcohol. Our multidisciplinary team creates a care plan for each patient to help stabilize symptoms and get through the crisis and a plan for continued treatment. ii. Crisis, suicide, homicide 10. What are some symptoms to be aware of that a patient may be hypomanic or about to experience a mania relapse? Insomnia. I can tell I’m hypomanic when I wake up before the alarm clock with my mind buzzing, full of a flurry of ideas. I throw myself into whatever project I’m working on at the time before I’ve even brushed my teeth or had my morning coffee. Inability to listen to other people. When I’m hypomanic, I seek out more social interactions, but when I’m with friends, I do most of the talking, and people have a hard time getting a word in. Spending beyond my means. Whether I’m thrift store shopping or browsing Amazon multiple times a day, when I’m hypomanic I feel a constant, compulsive urge to buy things I don't need. Unrealistic overconfidence. When I’m hypomanic, I feel like a supermodel. In my mind, everyone finds me irresistible. When I look in the mirror, I see a gorgeous knockout staring back at me, even if I haven’t combed my hair or put on makeup that day. Not taking care of myself. With my hypomania comes a ramped-up focus on goals, so I’m constantly jumping from one project to another without stopping to take care of myself. Taking a break between tasks to feed myself or shower seems trivial and unnecessary. Inability to focus. I love movies and books. I can tell I’m hypomanic when I can’t even sit still long enough to finish watching an hour and a half movie, because my mind constantly drifts to the dozen tasks I feel I need to scratch off my to-do list. I also enjoy quiet time escaping into a good book, but one of the biggest telltale signs is when I find myself reading the same sentence over and over again, unable to comprehend it. Hypersensitivity to stimuli. From a siren in the distance to a wafting scent from someone’s shampoo, when I’m hypomanic, I’m more acutely aware of my surroundings. Colors appear brighter, smells seem more pungent, and even faint noises can be deafening. Obsessing over things. It’s part of my personality to obsess a bit over subjects I’m interested in, but when I’m hypomanic, my passion is amplified. From researching the best cashew cheese recipe to watching NASA videos, it seems like everything I’m interested in has become my new lifelong goal, and—to the detriment of my valuable time—I feel helpless to curb my enthusiasm. 1. Talking rapidly, unable to be understood easily: it’s often difficult to be able to tell if you are speaking quickly. One way to test this is to ask yourself if everyone else around you seems like they’re speaking slowly. Are they having a difficult time understanding you? Are they asking you to slow your speech? It may be easier to test yourself by picking up on others’ cues. 2. Irritability and frustration: if you find yourself more easily frustrated or irritated by others, especially over matters or incidents that normally wouldn’t bother you, this could be a sign that mania is setting in. 16 3. Restlessness or fidgety behavior: stop and notice what your body is doing. Are you able to sit still? Do you need to keep moving your fingers or tapping your feet? Test yourself by taking a moment to sit still in a quiet room. Can’t stop moving? It could be the onset of mania. 4. Inability or unwillingness to sleep: have your sleeping habits changed recently? Even if you feel like you have lots of energy, any changes in the amount you’re sleeping could be an indicator of a manic or depressive episode. 5. Disorganized or easily distracted: have you started a project but haven’t been able to follow through? Are you bouncing from task to task and can’t focus? Are you taking on more than you can chew? 6. Not keeping commitments or sticking to a schedule: it’s important to stick to a schedule when you have bipolar disorder. Are you having a difficult time sticking to your routine or keeping appointments? 7. Overspending: if you start to be careless with your money, buying things you normally wouldn’t, or making huge purchases without talking to someone else about it, it could be a sign that you are transitioning into or experiencing a manic episode. 8. Inflated self-esteem or grandiosity: while it’s important for everyone to have a healthy self-esteem and love themselves, people who are experiencing mania have an elevated self-esteem that is more like overly confident and arrogant to the point they feel like they’re on top of the world or invincible. Knowing your baseline level of self-esteem can help you determine if what you are experiencing is healthy self-love and self-esteem or if it’s mania. 9. Risk-taking: are you engaging in risky behaviors that you normally wouldn’t do? This can include driving fast, increased promiscuity, substance abuse, or other thrill-seeking behaviors. 10. Feeling euphoric: when people come out of a prolonged depressive episode, mania can seem enjoyable because of the feelings of euphoria that often accompany it. This feeling on its own is not dangerous, but is a good indicator that mania is setting in. 11. Be able to describe the role of the neurotransmitters involved in obsessive compulsive disorder and if there are deficiencies or abundances of the neurotransmitters, or dysregulations of the neurotransmitters involved. a. Obsessive-compulsive disorder (OCD) is associated with abnormalities in the cortico-striatal– thalamic–cortical (CSTC) circuitry, and may be associated with dysregulation of neurotransmitters within this network. The major neurotransmitters of the CSTC are serotonin, dopamine, glutamate and γ-aminobutyric acid (GABA. It concludes that the neurotransmitter model of OCD involves dopaminergic and glutamatergic overactivity in frontostriatal pathways, along with diminished serotonergic and GABAergic neurotransmission in frontolimbic systems. These neurotransmitter imbalances may explain frontostriatal hyperactivity and impaired frontolimbic emotion regulation. b. The hypothesis that an abnormality in serotonergic neurotransmission underlies OCD arose out of the observation that clomipramine, which inhibits both serotonin and norepinephrine reuptake, relieved symptoms, whereas noradrenergic reuptake inhibitors did not. c. Genetic and neurochemical studies implicate glutamate and monoamine neurotransmitters, especially serotonin and dopamine.[2] 17 d. More specifically, reports indicate that the neurotransmitters serotonin and dopamine are associated with the pathophysiology of OCD. Scientists show that patients with OCD may experience an increase in dopamine in the prefrontal cortex and/or a decrease in serotonin in the basal ganglia. 12. What types of symptoms might you see in patients who present with conversion disorder or somatic disorders? a. Conversion disorder (functional neurologic disorder): Functional neurologic disorder — a newer and broader term that includes what some people call conversion disorder — features nervous system (neurological) symptoms that can't be explained by a neurological disease or other medical condition. However, the symptoms are real and cause significant distress or problems functioning. i. Symptoms Signs and symptoms of functional neurologic disorder may vary, depending on the type of functional neurological symptoms, and they're significant enough to cause impairment and warrant medical evaluation. Symptoms can affect body movement and function and the senses. Signs and symptoms that affect body movement and function may include:  Weakness or paralysis  Abnormal movement, such as tremors or difficulty walking  Loss of balance  Difficulty swallowing or feeling "a lump in the throat"  Seizures or episodes of shaking and apparent loss of consciousness (nonepileptic seizures)  Episodes of unresponsiveness Signs and symptoms that affect the senses may include:  Numbness or loss of the touch sensation  Speech problems, such as the inability to speak or slurred speech  Vision problems, such as double vision or blindness  Hearing problems or deafness  Cognitive difficulties involving memory and concentration b. Somatic disorder: Somatic symptom disorder is a disorder in which individuals feel excessively distressed about their health and also have abnormal thoughts, feelings, and behaviors in response to their symptoms i. Pain. This is the most commonly reported symptom. Areas of reported pain can include chest, arms, legs, joints, back, abdomen, and other areas. ii. Neurological symptoms such as headaches, movement disorders, weakness, dizziness, fainting iii. Digestive symptoms such as abdominal pain or bowel problems, diarrhea, incontinence, and constipation iv. Sexual symptoms such as pain during sexual activity or painful periods v. Usually, patients report experiencing more than one symptom. Symptoms can range from mild to severe. Approximately 30 to 60 percent of patients with somatic symptom disorder also have anxiety and/or depression. 13. Be able to describe some treatment outcomes for a patient with depression and anxiety. TableTen key statistics about the treatment of depression* 20 Medication (Brand Name) Usual Daily Dose (mg) Efficacya Tolerabilityb Anxietyc Desvenlafaxine (Pristiq) 50-100 ✓ ✓ Duloxetine (Cymbalta) 60-120 ✓ Venlafaxine-XR (Effexor) 75-225 ✓ ✓ Other medication Buproprion-SR (Wellbutrin) 150-300 ✓ Mirtazapine (Remeron) 30-60 ✓ Trazodone (Desyrel) 200-400 Vortioxetine (Trintellix) 5-20 b. Anxiety Medication Generalized Anxiety Disorder Panic Disorder Social Anxiety Disorder SSRI Citalopram First-line (A) Second-line (B) Escitalopram First-line (A) First-line (B) First-line (A) Fluoxetine First-line (A) Fluvoxamine First-line (A) First-line (A) Fluvoxamine CR First-line (A) Paroxetine First-line (A) First-line (A) First-line (A) Paroxetine CR First-line (C) First-line (B) First-line (B) Sertraline First-line (A) First-line (A) First-line (A) SNRI Duloxetine First-line (A) Venlafaxine XR First-line (A) First-line (A) First-line (A) TCA Clomipramine Second-line (A) Imipramine Second-line (A) Second-line (A) MAOI Phenelzine Second-line (A) Other antidepressant Agomelatinea First-line (A) Bupropion SR/XL Second-line (B) Mirtazapine Second-line (B) Reboxetine Second-line (A) Vortioxetine Second-line(A b) Anxiolytic Alprazolam Second-line (A)! Second-line (A)! Second-line (B)! Bromazepam Second-line (A)! Second-line (B)! 21 Medication Generalized Anxiety Disorder Panic Disorder Social Anxiety Disorder Clonazepam Second-line (A)! Second-line (A)! Diazepam Second-line (A)! Second-line (A)! Lorazepam Second-line (A)! Second-line (A)! Anticonvulsant Pregabalin First-line (A) First-line (A) Antipsychotic Quetiapine XR Second-line (A)! Other Buspirone Second-line (A) Hydroxyzine Second-line (A) Gabapentin Second-line (B) c. Bipolar disorder Lithium Lithium (Lithobid, Eskalith) is effective at stabilizing mood and preventing the extreme highs and lows of bipolar disorder. Periodic blood tests are required because lithium can cause thyroid and kidney problems. Common side effects include restlessness, dry mouth and digestive issues. Lithium levels should be monitored carefully to ensure the best dosage and watch for toxicity. Lithium is used for continued treatment of bipolar depression and for preventing relapse. There is evidence that lithium can lower the risk of suicide but the FDA has not granted approval specifically for this purpose. Anticonvulsants Many medications used to treat seizures are also used as mood stabilizers. They are often recommended for treating bipolar disorder. Common side effects include weight gain, dizziness and drowsiness. But sometimes, certain anticonvulsants cause more serious problems, such as skin rashes, blood disorders or liver problems. Valproic acid and carbamazepine are used to treat mania. These drugs, also used to treat epilepsy, were found to be as effective as lithium for treating acute mania. They may be better than lithium in treating the more complex bipolar subtypes of rapid cycling and dysphoric mania. Lamotrigine is used to delay occurrences of bipolar I disorder. Lamotrigine does not have FDA approval for treatment of the acute episodes of depression or mania. Studies of lamotrigine for treatment of acute bipolar depression have produced inconsistent results. Second-Generation Antipsychotics (SGAs) SGAs are commonly used to treat the symptoms of bipolar disorder and are often paired with other medications, including mood stabilizers. They are generally used for treating manic or mixed episodes. SGAs are often prescribed to help control acute episodes of mania or depression. Finding the right medication is not an exact science; it is specific to each person. Currently, 22 only quetiapine and the combination of olanzepine and fluoxetine (Symbax) are approved for treating bipolar depression. Regularly check with your doctor and the FDA website, as side effects can change over time. Standard Antidepressants Antidepressants present special concerns when used in treating bipolar disorder, as they can trigger mania in some people. A National Institute of Mental Health study showed that taking an antidepressant also to a mood stabilizer is no more effective that using a mood stabilizer alone for bipolar I. This is an essential area to review treatment risks and benefits. d. Schizophrenia Second-generation antipsychotics These newer, second-generation medications are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics. Second-generation antipsychotics include:  Aripiprazole (Abilify)  Asenapine (Saphris)  Brexpiprazole (Rexulti)  Cariprazine (Vraylar)  Clozapine (Clozaril, Versacloz)  Iloperidone (Fanapt)  Lurasidone (Latuda)  Olanzapine (Zyprexa)  Paliperidone (Invega)  Quetiapine (Seroquel)  Risperidone (Risperdal)  Ziprasidone (Geodon) First-generation antipsychotics These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible. First-generation antipsychotics include:  Chlorpromazine  Fluphenazine  Haloperidol  Perphenazine These antipsychotics are often cheaper than second-generation antipsychotics, especially the generic versions, which can be an important consideration when long-term treatment is necessary. Long-acting injectable antipsychotics Some antipsychotics may be given as an intramuscular or subcutaneous injection. They are usually given every two to four weeks, depending on the medication. Ask your doctor about 25 26. Disorganised thought – difficulties in goal direction such that daily life is impaired. 27. Catatonic behaviour – decrease in reactivity to environment (e.g., immobility, peculiar posturing, motiveless resistance to all instructions, absence of speech, flattened affect). 28. Rapid or extreme mood swings or behaviour that is unpredictable or erratic (often in response todelusions or hallucinations; e.g., shouting in response to voices, whispering). 18. Know the positive and negative symptoms of Schizophrenia. What observations might you see on the mental status exam of a patient with psychosis; general appearance, mood, affect, cognition, and speech. Know the difference between schizophrenia, brief psychotic disorder, substance induced psychosis, and delusional disorder. Positive symptoms include:  Hallucinations: When a person sees, hears, smells, tastes, or feels things that are not actually there. Hearing voices is common for people with schizophrenia. People who hear voices may hear them for a long time before family or friends notice a problem.  Delusions: When a person has strong beliefs that are not true and may seem irrational to others. For example, individuals experiencing delusions may believe that people on the radio and television are sending special messages that require a certain response, or they may believe that they are in danger or that others are trying to hurt them.  Thought disorder: When a person has ways of thinking that are unusual or illogical. People with thought disorder may have trouble organizing their thoughts and speech. Sometimes a person will stop talking in the middle of a thought, jump from topic to topic, or make up words that have no meaning.  Movement disorder: When a person exhibits abnormal body movements. People with movement disorder may repeat certain motions over and over. Negative symptoms include loss of motivation, loss of interest or enjoyment in daily activities, withdrawal from social life, difficulty showing emotions, and difficulty functioning normally. Negative symptoms include:  Having trouble planning and sticking with activities, such as grocery shopping  Having trouble anticipating and feeling pleasure in everyday life  Talking in a dull voice and showing limited facial expression  Avoiding social interaction or interacting in socially awkward ways  Having very low energy and spending a lot of time in passive activities. In extreme cases, a person might stop moving or talking for a while, which is a rare condition called catatonia. a. Schizophrenia: Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling. People with schizophrenia require lifelong treatment b. brief psychotic disorder: Brief psychotic disorder (BPD) according to DSM-5 is the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses. It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis. c. substance induced psychosis: A substance-induced psychotic disorder is a mental health condition in which the onset of your psychotic episodes or psychotic disorder symptoms can be traced to starting or stopping using alcohol or a drug (onset during intoxication or 26 onset during withdrawal). You could experience psychotic episodes just when you’re using, or just when you are not using. You may even develop this disorder when you’re in recovery from a substance use disorder . d. delusional disorder: Delusional disorder, previously called paranoid disorder, is a type of serious mental illness — called a “psychosis”— in which a person cannot tell what is real from what is imagined. The main feature of this disorder is the presence of delusions, which are unshakable beliefs in something untrue. People with delusional disorder experience non-bizarre delusions, which involve situations that could occur in real life, such as being followed, poisoned, deceived, conspired against, or loved from a distance. These delusions usually involve the misinterpretation of perceptions or experiences. In reality, however, the situations are either not true at all or highly exaggerated. People with delusional disorder often can continue to socialize and function quite normally, apart from the subject of their delusion, and generally do not behave in an obviously odd or bizarre manner. This is unlike people with other psychotic disorders, who also might have delusions as a symptom of their disorder. In some cases, however, people with delusional disorder might become so preoccupied with their delusions that their lives are disrupted. 19. Know the DSM 5 criteria for schizophrenia, prodrome symptoms of psychosis, and what are symptoms to recognize in relapsing schizophrenia? 1) Schizophrenia a) Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): i) Delusions. ii) Hallucinations. iii) Disorganized speech (e.g., frequent derailment or incoherence). iv) Grossly disorganized or catatonic behavior. v) Negative symptoms (i.e., diminished emotional expression or avolition). vi) For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). vii) Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). viii) Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. ix) The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. x) If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). 27 2) Prodromal phase i) Marked social isolation or withdrawal ii) Marked impairment in role functioning iii) Markedly peculiar behavior iv) Marked impairment in personal hygiene and grooming v) Blunted or inappropriate affect vi) Digressive, vague, overelaborate or circumstantial speech, or poverty of speech, or poverty of content of speech vii) Odd beliefs or magical thinking viii) Unusual perceptual experiences ix) Marked lack of initiative, interests, or energy. 3) Relapsing schizophrenia Early Warning Signs of a Relapse Be alert to these early signs:  Trouble sleeping  Eating less  Trouble concentrating or being disorganized  Staying away from other people or disappearing unexpectedly  Mood changes, nervousness, or irritability  Having strange ideas or disorganized thinking  Poor personal hygiene  Speech that doesn't make sense  Hearing voices  Delusions, suspiciousness, or increased paranoia  Aggressive talk  Suicidal thoughts Some later signs may include:  Physical aggression against yourself or others  Smiling for no reason  Strange thoughts  Breaking things a) Common warning signs of a schizophrenia relapse include insomnia, social withdrawal, difficulty concentrating, loss of interest, increasing paranoia, and hallucinations. Knowing these symptoms is important, but knowing the symptoms that are specific to each person with schizophrenia — called “relapse signatures” — is more important. Up to 70 percent of people with schizophrenia will experience these early symptoms before a full relapse sets in. "The first sign of a relapse is repeating symptoms of a previous episode,” Frangou says. 20. What is dissociation? What diagnoses are common for dissociative symptoms. What usually causes dissociation and are there any treatment recommendations?