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NURS-5461 PSYCHIATRIC STUDY GUIDE, Study Guides, Projects, Research of Psychotherapy

A.T. Still University of Health Sciences (ATSU)Psychotherapy

NURS-5461 PSYCHIATRIC STUDY GUIDE

Typology: Study Guides, Projects, Research

2023/2024

Available from 11/22/2023

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NURS-5461 PSYCH STUDY GUIDE
The Brain:
Limbic (amygdala) – emotions, thoughts of death, guilt
Limbic (hippocampus)- memory, concentration
Frontal cortex- depressed mood, concentration
Basal Ganglia - psychomotor
agitation/retardation
Hypothalamus – loss of appetite, weight loss, anhedonia
- Sleep problems: delayed onset, shortened REM, lack of sleep or hypersomnia
- Antidepressants tx circadian dysregulation and restore sleep
architecture Prefrontal cortex – decision making, planning, judgement – 30% of
brain
Neurotransmitters
-Dec. Serotonin: mood, sleep, impulsive
-Dec. dopamine: pleasure, fatigue, low energy
-Dec. norepi: mood, arousal, appetite, planning, concentration
-Dec. GABA: anxiety, agitation of depression
-Inc. Glutamate – Inc in neuronal cell death
GLIAL Cells – protect neurons by stabilizing glutamate, releases BDNF to repair neurons
-Antidepressants increase BDNF
Excess glutamate- loss of neuron function, progressive depression, damage to neurons, twice
the risk of dementia with depression
DEPRESSION
•
USPSTF recommends screening for adults & older
adults when staff assisted depression care
supports are in place (e.g. case management)
H&P
•
Do full interview if screening indicates symptoms
•
Assess target symptoms: sleep, appetite, anhedonia,
mood ,
suicidal thinking, guilt, concentration, low energy, etc
•
Objective Assessment: thyroid, CBC (anemia), CMP
(nutritional deficiency, UTI
Major Depressive Disorder criteria
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NURS-5461 PSYCH STUDY GUIDE

The Brain: Limbic (amygdala) – emotions, thoughts of death, guilt Limbic (hippocampus)- memory, concentration Frontal cortex- depressed mood, concentration Basal Ganglia - psychomotor agitation/retardation Hypothalamus – loss of appetite, weight loss, anhedonia

  • Sleep problems: delayed onset, shortened REM, lack of sleep or hypersomnia
  • Antidepressants tx circadian dysregulation and restore sleep architecture Prefrontal cortex – decision making, planning, judgement – 30% of brain Neurotransmitters
  • Dec. Serotonin: mood, sleep, impulsive
  • Dec. dopamine: pleasure, fatigue, low energy
  • Dec. norepi: mood, arousal, appetite, planning, concentration
  • Dec. GABA: anxiety, agitation of depression
  • Inc. Glutamate – Inc in neuronal cell death GLIAL Cells – protect neurons by stabilizing glutamate, releases BDNF to repair neurons
  • Antidepressants increase BDNF Excess glutamate- loss of neuron function, progressive depression, damage to neurons, twice the risk of dementia with depression DEPRESSION
  • USPSTF recommends screening for adults & older

adults when staff assisted depression care

supports are in place (e.g. case management)

H&P
  • Do full interview if screening indicates symptoms
  • Assess target symptoms: sleep, appetite, anhedonia,

mood ,

suicidal thinking, guilt, concentration, low energy, etc

  • Objective Assessment: thyroid, CBC (anemia), CMP

(nutritional deficiency, UTI

Major Depressive Disorder criteria

  • At least one major depressive episode and no

manic or hypomanic episode (ever)

  • Depressed mood or anhedonia every day for 2 weeks

or

longer

  • Change from previous functioning
  • Significant distress or impairment in social or

occupational or

other area of functioning

  • Not schizophrenia or other psychosis
  • R/O substance abuse, medication, medical conditions to

make diagnosis

MDD S/S

  • Depressed mood
  • Anhedonia

PLUS THESE 4 of these Symptoms X 2

Weeks

  • Neuro-veg symptoms: sleep, appetite
  • weight loss (5% in month)
  • insomnia/hypersomnia every day
  • psychomotor agitation/retardation

every

day

  • Fatigue
  • Worthlessness feeling
  • Loss of concentration
  • Recurrent thoughts of deathj

MDD Specifiers: anxious distress +

(tension, restless, probs concentrating,

impending doom, afraid to lose control).

Moderate: 3 symptoms

Moderate-severe; 4-5 symptoms

Specifiers for MDD cont’d.

• If meet criteria for mania or hypomania- then

bipolar diagnosis

With psychotic features (mood congruent or mood incongruent) •

With catatonia

• With peri-partum onset

• During pregnancy or

• During 4 weeks post partum

• With psychosis or without (risk of infanticide if commanding

hallucinations) 188

• With seasonal pattern

• not linked to stressors

• 2 year pattern

• Onset and remission same time x 2 years • Mild moderate,

severe

• In partial remission or full remission

PHARM MGMT OF MDD

▪ Medications

▪ Lifestyle changes

- ▪ Exercise, diet, stress management, spiritual - ▪ Adequate sleep - ▪ Mild to moderate depression benefit from exercise: walking fast for 35 min

5x a week or 60 min 3 times a week)

- ▪ Folate (vitamin B9), Omega 3 fatty acids )650 to 1200 mg combination

EPA and DHA)

GROUP Therapy:

- Helpful for individuals who are having difficulties with relationships

with others.

- ▪ Unites the goals of the individual with others in the group making it

a helpful environment where one feels included.

  • ▪ Helpful to be in a group with other people who are having similar

struggles. Members can sometimes provide validation and support for an

individual who's coping with similar issues and who is struggling to get

over depression with a similar cause, such as loss of a loved one, or a

new diagnosis.

Family Therapy:

  • Illness in one family member may be a symptom of a larger family

problem. A change in one family affects both the family structure

and each member individually.

- ▪ Teaches family members about how families function in general;

helps the family focus less on the member who has been identified as ill

and focus more on the family as a whole; helps to identify conflicts and

anxieties and helps the family develop strategies to resolve them;

strengthens all family members so they can work on their problems

together; teaches ways to handle conflicts and changes within the

family differently.

▪ Cognitive Behavioral Therapy: The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. Medications PLUS Cognitive Therapy more effective than meds or therapy alone in adults, Medications PLUS Cognitive Behavioral Therapy better for adolescent depression than either by themselves

▪ Psychosis or bipolar disorder

▪ OCD, eating disorder, substance abuse ▪ Lack of time

to see regularly

ANTIDEPRESSANTS

▪ MAOI: discovered through TB drug

▪ Can cause hypertensive crises from release of

NE & vasaoconstriction and stimulation of the

heart.

▪ Selegiline (EMSAM patch); less hypertensive

issues. 20 mg patch delivers 6 mg of selegeline.

Should only be used by psychiatric providers at this

time.

▪ older ones, rarely used. Hypertensive crisis with food

rich in tyramine, caffeine, chocolate, and other drugs

(SSRIs, TCAs, atypicals, decongestants, asthma meds,

Ritalin.

rd

line treatment due to dietary requirements

▪ TCAs: Discovered in search for antipsychotics ▪ THIRD to FOURTH line treatments now ▪ Side effects: ▪ Muscarinic (anticholinergic) ▪ Alpha 1: postural hypotention ▪ H1: weight gain, sedation ▪ Toxicity: ▪ Prolongs QTc on EKG (cardiac toxicity) ▪ > 1000 mg overdose can cause death (risk of death if OD –give only 1 week at a time)

▪ SSRIs: Selective blocks reuptake of 5HT- first line ▪ Fluoxetine (Prozac), paroxetine (Paxil and Paxil CR), sertraline (Zoloft); fluvoxamine (Luvox and Luvox CR); citalopram (Celexa), escitalopram oxalate (Lexapro); brintellix (vortioxetine); Viibryd (vilazodone) SSRI’s ▪ First line treatment for depression ▪ Safer in suicide attempt than tricyclic antidepressants ▪ Less cardiac toxicity ▪ Start low in patients with anxiety disorder ▪ Immediate blockade of serotonin transporter on axon terminals in areas of serontonergic neuron ▪ Delayed down regulation/desensitization of serotonin receptors ▪ Delayed “turning off” of serotonin release from axon terminals SSRI SIDE EFFECTS – ASSESS AT EACH VISIT

▪ Nausea/Vomiting/Diarrhea, especially Zoloft;

▪ Sexual Dysfunction ranging from problems with

libido to problems with ejaculation/ anorgasmia; less c

Viibryd

▪ Mild akathisia (restless); sweating, tremor

▪ Weight gain over time except for Prozac

▪ Lethargy and fatigue especially Celexa; Paxil

▪ Discontinuation syndrome – especially Paxil; less with

Prozac; same as

▪ Tryptophan

▪ Buspirone

▪ Lithium?

▪ Methylphenidate? ▪ Tramadol

▪ Amphetamine ▪ Ecstasy

▪ Other antidepressants: NaSSA: Noradrenergic and specific serotonergic antidepressants; serotonin antagonist and reuptake inhibitor (SARI):

SNRI MEDICATIONS

▪ Venlafaxine and venlafaxine ER and Effexor XR ), duloxetine (Cymbalta), Pristiq (desvenlafaxine), Savella (milnaciprin) (for fibromyalgia at 50 mg bid), Fetzima (levomilnacipran): for MDD in adults only ▪ Watch for hypertension side effects ▪ Some risk for qtc prolongation ▪ Discontinuation syndrome-taper off very slowly. ▪ Note liver enzyme increase with Cymbalta ▪ Check creatinine in Fetzima at onset and as needed; metabolized by liver but excreted by kidneys. ▪ Atypical: Selective antagonism of Dopamine & Norepinephrine (bupropion) ▪ Quetiapine (Seroquel); FDA approved adjunct. XR take 12 hours before pt wants to awaken; or 3 hours before wants to fall asleep; take on an empty stomach. SE: rapid weight gain, hyperglycemia; TD, neutropenia, agranulocytosis.

▪ aripiprazole (Abilify)—partial dopamine agonists se: akathesia, restlessness, nausea; weight gain, metabolic issues ▪ Approved for Treatment Resistant Depression ▪ Use after 2 failed trials with antidepressants ▪ S/E weight gain, increased appetite, dry mouth, somnolence, fatigue ▪ Risk of hyperglycemia, increased triglycerides, diabetes (from olanzapine) ▪ Monitor CMP; lipids, weight and BMI Psych-Mental Health Issues in Adult Health Anxiety— Separation Anxiety; Panic Disorder, Agoraphobia, Social Anxiety Disorder, Generalized Anxiety Disorder [GAD]

  • Differ from each other in the types of objects or situations that induce fear, anxiety, or avoidance behavior, and associated cognitive ideation [DMS-5]
  • Excessive—overestimate the danger
  • Persistent, most develop in childhood—need to assess and treat in childhood
  • More in females than males [2:1]
  • Need to ask or they may not report In Geriatrics
  • Difficult to diagnose due to somatic symptoms and multiple medical issues
  • 2x more prevalent than dementia; 4-8x more prevalent than MDD
PANIC DISORDER
  • Prevalence—females 2:1 (5.1% women; 1.9% men); lower in children (<0.4%); highly genetic
  • Median age of onset 20-24 (adolescent onset can occur); co- occurring anxiety, depression
  • Chronic, waxing and waning (without treatment), serious but treatable illness
  • Older adults may have dampened autonomic response
  • R/O cardiac cause of symptoms; refer for treatment if ends up in ED Panic Attacks
  • Recurrent unexpected panic attacks
  • Panic attack—abrupt surge of intense fear or intense discomfort, reaches peak within minutes
  • 4 or more symptoms:
  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating, trembling or shaking
  • Sensation of SOB or smothering; feeling of choking; chest pain or discomfort • Paresthesias
  • Nausea or abdominal distress S/S of Panic Attacks
  • At least 1 panic attack followed by 1 month of
  • Persistent concern about having additional attacks

(anticipatory anxiety)

  • Worry about the implications of the attack or its

consequences— losing control, going crazy, having MI

  • Behavior to avoid future attacks—avoidance Screening Panic Attacks
    • Ask for symptoms of the panic attack (must have at least 4 documented)
    • Ask how often do they occur? Ever out of the blue, for no apparent reason? Ever wake you from sleep? How long do they last? Anxious

about having another attack? Do you avoid certain activities to keep from having another attack?

  • Does caffeine increase panic attacks? Genetic Component of Panic Disorder
  • 48% genetic, 52% environmental factors—stress, perinatal factors, substance misuse and life events (violence, social isolation, loss)
  • Genetic regions chromosome 4q32-q34; 5q21, 9q31; 13q
  • 80% have comorbid disorders as well
  • 64% with PD have agoraphobia; 25% have ETOH use disorder
  • 3.76 OR risk of PD with migraines ALSO: May be associated with Asthma – CO2 hypersensitivity can provoke attack Panic Disorder Management
  • Outpatient management for most
  • Hospitalization when
  • MDD and suicidal ideation
  • Substance abuse needing treatment
  • Therapy—panic focused CBT 12 weeks + SSRIs • Breathing and progressive relaxation
  • Mindfulness based stress reduction
  • SSRIs—start with 1⁄2 of starting dose to minimize hypersensitivity, ↑ dose over several weeks until no panic attacks
  • FDA approved (increase dose after 3-5 days) • Zoloft—start 25 mg
  • Paxil—start 10 mg
  • Paxil CR—start 12.
  • All other SSRIs used off label for PD
  • Benzos - Xanax XR (alprazolam) approved for PD
  • Enhances action of GABA
  • Withdrawal reaction if dependent
  • Toxicity if ETOH used and ↑ risk of seizure; taper slowly to prevent seizures
  • Dose 0.5,1,2,3 mg once a day
  • Side effects—sedation, somnolence, memory impairment, dysarthria, abnormal coordination, ataxia, ↓ libido
  • NOT EVER FIRST LINE TREATMENT and is $$$ AGORAPHOBIA
  • • Helpful in up to 75%
    • Recognize and change negative thoughts about yourself • Exposure therapy—gradually face situations you fear
    • Skills training
    • Role playing to gain comfort and confidence

    • Relaxation and stress management techniques

  • SSRI’s Treatment of choice
  • SSRIs—may need high doses; start low for all anxiety

disorders to minimize side effects [may need to use liquid

if small doses are needed to start]

  • Prozac—start 10 mg [may need up to 80 mg]
  • Paxil—start 10 mg [may need to 60 mg; FDA approved]
  • Zoloft—start 25 mg [may need up to 200 mg; FDA

approved]

  • Luvox—start 50 mg [may need up to 300 mg]
  • Celexa—start 10 mg [may need up to 40 mg; consider

cardiac side effects]; Lexapro—start 10 mg [may need

up to 20 mg in the nongeriatric]

  • Viibryd—start 10 mg [may need up to 40 mg] SE’s of Med TX
  • Start low and go slow—discuss the potential SE before you start the patient on the med
  • GI
  • Insomnia or Hypersomnia
  • Headaches / Diaphoresis
  • Weight gain / Sexual side effects
  • Activation—agitation, tremor, anxiety
  • Those with anxiety disorders sensitive to s. e. GENERALIZED ANXIETY DISORDER
  • Ask about all of these
  • Excessive anxiety and worry about events or

activities most days for 6 months [job, household

chores, late for appointments, finances, health of

family members]

  • Difficult to control the worry
  • Associated with 3 of 6 symptoms
    • Easily fatigued, restlessness, being keyed up or on

edge

  • Muscle tension, difficulty concentrating or mind goes

blank

  • Irritability, sleep disturbance ↓ Serotonin ↑ Norepinephrine , AND ↓GABA GAD TREATMENT
  • SSRIs—first line
  • Lexapro 10 mg to start (FDA+) • Paxil10mg(FDA+)
  • All SSRIs can be used
  • SNRI
  • Effexor XR (start 37.5mg) (FDA approved) • Cymbalta 30 mg
  • Pristiq 50 mg
  • Anxiolytic
  • Buspirone (Buspar) 15 mg
  • Other meds used in GAD—gabapentin, gabitril AVOID BENZOS if possible! Dependence, withdrawal, ETOH interactions! BUSPAR- not addicrtive, helps mild s/s OCD and Related Disorders— OCD, Trichotillomania, Hoarding, Excoriation Disorder OCD:
  • Obsessions—recurrent and persistent thoughts or images, that are intrusive and inappropriate and cause anxiety or distress
  • Recognize they are products of one’s own mind (children may not have insight)
  • Attempt to ignore or suppress them or neutralize with some other thought or activity
  • Examples—contamination, doubt, harm, symmetry, somatic, religious, sexual images, hoarding
  • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or due to rules they must abide by
  • Behaviors or mental acts aimed at preventing or reducing distress or preventing some dread event
  • Goal of treatment is to reduce TIME spent, reduce urge to perform compulsions & reduce frequency of thoughts (cool down the brain)
  • Cognitive Behavior Therapy
  • Exposure and response prevention of rituals
  • Stay in presence of feared situation (e.g. germy things) and NOT perform the ritual (response prevention) for 25-30” • Think the thoughts— don’t resist them
  • Perform at site where worse symptoms
  • Identify fear hierarchy—rate discomfort 1-10 • LEARN NOT TO NEUTRALIZE
  • “It is not me it is my OCD”
  • Remove shame & guilt
  • Decrease anxiety by desensitizing the amygdala
  • Learn to respond to the obsessive threat & not try to escape it Trauma Disorders— PTSD, ASD, Adjustment Disorder PTSD – Follows severe stress event – RAPE, incest, war, MVA ➢ Than 1 month PTSD Brain IMPACTS
  • Exaggerated amygdala activation
  • Hyporesponsive anterior cingulate—involved in

memory, emotion

and selective attention

  • Decreased hippocampal volume—encodes memories CLUES TO DX PTSD
    • Office patients who make frequent visits or are frequently hospitalized
    • Somatizisers [multiple unexplained symptoms]
    • Those who have high emotional distress
  • Those you are treating for depression or anxiety & are not getting better
  • Those who use drugs to forget & numb out