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Nursing 661 Study Guide Exam 1
- Know different types of anxiety disorder s and be able to distinguish between them a. panic disorder: neurotransmitters; serotonin, norepinephrine and GABA. Increased sympathetic tone in the peripheral as well as central NS. Post-synaptic serotonin hypersensitivity; local inhibitory GABA transmission to amygdala, midbrain and hypothalamus. p.
- Anxiogenic effects of yohimbine, exaggerated MHPG cortisol and cardiovascular responses. Panicogens: respiratory panicogens: carbon dioxide, sodium lactate, bicarbonate. psychosocial theories: unsuccessful defense against anxiety- provoking impulses=physiological response. Higher incidence of stressful life events: abuse, separation anxiety first-degree relatives of patients with panic disorder have a four- to eight-fold higher risk for panic disorder than first- degree relatives of other psychiatric patients. From Sadock (2014) p. 393 includes the DSM-V criteria.
- Recurrent unexpected panic attacks: abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time 4 or more of the follow occur
- palpitations, pounding heart or elevated HR
- sweating
- trembling or shaking
- sensation of SOB or smothering
- feelings of choking
- chest pain or discomfort
- nausea or abdominal distress
- dizzy, unsteady, light-headed or faint
- chills or heat sensation
- paresthesia (numbness or tingling)
- derealization (feelings of unreality) or depersonalization (being detached from one’s self)
- Fear of losing control or going crazy
- fear of dying
- Culture specific sx: tinnitus, neck soreness, headache, uncontrollable screaming or crying. shouldn’t count as one of the four sx
- At least one of the attacks has been followed by 1 mo or more of a. persistent concern or worry about another panic attack or consequences like losing control b. significant maladaptive change in behavior as a results of attack: avoidance of perceived stimulus 3. Disturbance not better explained by another mental disorders: social anxiety, phobia, OCD, separation b. separation anxiety disorder: Bowlby’s theory of anxiety: child’s sense of distress during separation is perceived and experienced as anxiety and is prototype of anxiety. Mother’s ability ot relieve fear is fundamental to attack with child. Tearfulness and/or irritability; emerges and peeks usually around 9-18mo/old, generally disappears by 3rd year. Crying is the primary signal. (Sadock p. 99). P. 1253: with children-- highly comorbid with GAD and social anxiety disorder. 30% have all three and 60% having one will have one of the others. 15% of children display intense persistent fear, shyness and social withdrawal when faced with unfamiliar settings and people. Higher than average resting heart rate, higher morning cortisol, low heart rate variability. DSM-V: a level of fear or anxiety regarding separation from parents or primary caregiver which is beyond developmental expectations. At least 3 sx of excessive worry for at least 4 weeks: refusal to attend school, repeated physical complaints (headaches, stomach aches) with anticipated separation, nightmares related to separation. get remained DSM V criteria. DSM-V--DEvelopmentally inappropriate or excessive fear or anxiety concerning separation for those to whom the individual is attacked: p. 191 DSM-V a. 3 of the following:
- recurrent excessive distress when anticipation or experiencing separation from home or major attachment figures.
- persistent excessive worry about losing, harm to them, injury, disasters or death to major attachment figures
- persistent excessive worry about an untoward event to person that will separate them from major attachment figure (MAF): get lost, kidnapped, accident become ill
- persistent excessive reluctance to sleep away from home
- Repeated nightmares about separation
- repeated physical symptoms when separated from MAF: headaches, stomachaches, N/V b. The fear, anxiety, or avoidance is persistent lasting at least 4 weeks in children and 6 mo in adults c. Causes clinically significant impairment in social academic, occupational, or other important area of functioning c. Not better explained by other mental disorder: austism, delusions, hallucinations, agoraphobia, GAD, having an illness anxiety disorder. . c. Generalized anxiety disorder is characterized by a pattern of frequent, persistent worry and anxiety that is out of proportion to the impact of the event or circumstance that is the focus of the worry. The distinction between generalized anxiety disorder and normal anxiety is emphasized by the use of the word “excessive” in the criteria and by the specification that the symptoms cause significant impairment or distress. DSM-5 diagnostic criteria for generalized anxiety disorder are listed in Table 9.6-2. Has the oldest median age of onset.
- most often coexists with other mental disorder: usually social or specific phobia, panic d/o or depressed d/o. p. 407 50-75% have another mental disorder.
- 25 % of anxiety pts have GAD. usually late adolescence/early adult onset, but oldest median age onset.
- basal ganglia, limbic system, frontal cortex. occipital lobe has the highest concentration of benzo receptors. p. 408
- DSM-V for GAD
- Excessive anxiety and worry (apprehensive expectation) more days than not for 6 mo bout a number of events or activities.
- Difficult to control the worry
- Anxiety/worry are associated with 3 or more of the following (only 1 sx required in children)
- restlessness, feeling keyed up or on edge
- being easily fatigued
- difficulty concentrating, mind goes blank
- irritability
- muscles tension
- sleep disturbance: falling asleep, staying asleep; or restless, unsatisfying sleep
a. Illusions - Perceptual misinterpretation of a real external stimulus.
b. Delusions - False belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief c. Hallucinations - False sensory perception occurring in the absence of any relevant external stimulation of the sensory modality involved. d. Paranoid ideation - Thinking dominated by suspicious, persecutory, or grandiose content of less than delusional proportions
- Transference : The thoughts, feelings and behaviors that are associated with early important relationships with caretakers and significant others and that are felt toward the therapist. Reflects state- dependent memories of specific psychological states of consciousness from the past. It is ubiquitous and reflected in the way the patient acts, talks and feels about the therapist. Wheeler p. 186
- Countertransference: Reflects the feelings that the therapist has toward the patient. Is similar to transference. Involves past significant relationships and includes attitudes feelings and thoughts about another person. It can be sued to understand the patient. Serves as s barometer in the relations with the patients for the self-aware therapist. Can be useful but often represents a boundary violation or problem in the relationship. Involves state-dependent memories in the relationship with the patient. Wheeler p. 195; see chart p. 196 for signs of CT 5. Know what substance-induced depressive disorder is a. Causes: One example: Withdrawal from amphetamines such as dextroamphetamine can lead to depression. When taking dextroamphetamine, there is a surge of dopamine in the brain, so overtime the brain stops making its own. When the medication is stopped, the brain is not making dopamine on its own, leading to a depletion, ultimately resulting in depression. p. 297 sadock: psychoactive subs cause intox and w/d syndrome and induce psychiatric disorders like bipolar and related, OCD and related, sleep disorders, sexual dysfunction, delirium and neurocognitive disorders. p. 621 Sadock
or markedly diminished interest or pleasure in all or almost all activities. B. Evidence from the history, physical exam, lab finding of both 1 and 2
- Criteria A (above) developed during or soon after substance intox or withdrawal or exposure to medication
- INvolved substance is capable of producing the sx in criteria A C. Disturbance isn’t better explained by depressive disorder that is not sub/med induced. Would include the following: depressive sx preceded exposure to the substance; sx persist for a substantial time like a month after acute w/d or severe intoxication; or there is evidence of hx of depressive disorder not related to sub use D. Disturbance doesn’t occur substantially during course of delirium E. disturbance causes clinically significant distress, impairment in social, occupational, or other important areas of functioning. Substances: alcohol, phencyclidine, other hallucinogen, inhalant, opioid, sedative, hypnotic or anxiolytic amphetamine or other stimulant., cocaine, other or unknown substance Suicide risk is high. marked change in thoughts from baseline Treatment: Pharmacologic and Other Treatment Considerations When substance-induced mood disorder (SIMD) is suspected, immediately discontinue the offending agent (when possible). Consider the possibility of depressive or manic symptoms worsening if the drug is continued. However, if the patient truly has a medical or psychiatric need for the drug, consider similarly efficacious, but less toxic, alternative medications. If no alternatives are available, lower the dose of the offending agent and/or shorten the duration of treatment—as medically indicated. Also consider a retrial of the medication under close supervision. If the mood symptoms do not subside within 4 weeks, consider other etiologies for the mood symptoms. No consensus has been reached on the initiation of treatment with medications. Watchful waiting is usually sufficient. TAken from Medscape due to not being able to find anything in our
texts about tx
- Know DSM criteria for bipolar I disorder a. Hypomania is an episode of manic symptoms that does not meet the criteria for manic episode. A hypomanic episode lasts at least 4 days and
require hospitalization to prevent harm to self or others or there are psychotic features
D. episode is not attributable to physiological effects of substance (drug abuse, meidations, or other tx) or to a medical conditions. A full manic episode tat emerges during antidepressant treatment (meds, ECT) but persists at a fully syndromla level beyond the physiological effect of that tx is sufficient evidence for a manic episode and therefore a bipolar I dx. b
- Know the FDA warnings for the following antidepressants : a. bupropion: dose dependent Increased seizure threshold, EEG changes (sharp waves), higher for women than men; increased risk with hx of sz, use of ETOH, recent benzo w/d, organic brain disease, head trauma, pretreatment epileptiform discharges on EEG. Non-teratogenic p. 954- 955 sadock. Activation of SI esp adolescents and children Stahls b. sertraline: Black box warning for suicide for pediatrics and young adults; may also cause it may also cause birth defects, suicidal thoughts, autism and withdrawal symptoms. From drugwatch.com c. citalopram: for lexapro and celexa the drugs’ labels included a black box warning for an increased risk of suicide. Other side effects include birth defects from drugwatch.com d. fluoxetine: The antidepressant side effects include birth defects and suicidal thoughts and actions. drugwatch.com
- Know the following and be able to distinguish between them: INFO about AIMs (ab invol movements): p. 94 Stahl psychopharm: nigrostriatal dopamine pathway is a part of the extrapyramidal nervous system, and controls motor movements. Deficiencies in dopamine in this pathway cause movement disorders including Parkinson’s disease, characterized by rigidity, akinesia/bradykinesia (i.e., lack of movement or slowing of movement), and tremor. Dopamine deficiency in the basal ganglia also can produce akathisia (a type of restlessness), and dystonia (twisting movements especially of the face and neck). These movement disorders can be replicated by drugs that block D2 receptors in this pathway. Hyperactivity of dopamine in the nigrostriatal pathway is thought to underlie various
a. myoclonus: a symptom and not a diagnosis of a disease. It refers to sudden, involuntary jerking of a muscle or group of muscles. Myoclonic twitches or jerks usually are caused by sudden muscle contractions, called positive myoclonus, or by muscle relaxation, called negative myoclonus. Myoclonic jerks may occur alone or in sequence, in a pattern or without pattern. They may occur infrequently or many times each minute. Myoclonus sometimes occurs in response to an external event or when a person attempts to make a movement. The twitching cannot be controlled by the person experiencing it. a hiccup is an example. from NIH neurological disorders. May develop in response to infection, head or spinal cord injury, stroke, brain tumors, kidney or liver failure, lipid storage disease, chemical or drug poisoning, or other disorders https://www.ninds.nih.gov/Disorders/Patient- Caregiver- Education/Fact-Sheets/Myoclonus-Fact-Sheet b. Dystonia: brief or prolonged contractions of muscles that result in obviously abnormal movements or postures, including oculogyric crises, tongue protrusion, trismus, torticollis, laryngeal–pharyngeal dystonias, and dystonic postures of the limbs and trunk. Other dystonias include blepharospasm and glossopharyngeal dystonia; the latter results in dysarthria, dysphagia, and even difficulty in breathing, which can cause cyanosis. Children are particularly likely to evidence opisthotonos, scoliosis, lordosis, and writhing movements. Dystonia can be painful and frightening and often results in noncompliance with future drug treatment regimens. Increased risk with high potency IM in men <30y/o May be caused by dopaminergic hyperactivity in the basal ganglia that occurs when CNS levels of the antipsychotic drug begin to fall between doses. Can be prevented by prophylaxis with anticholinergics Treatment: IM or IV Benadryl, IV diazepam (Valium), amobarbital (Amytal), caffeine sodium benzoate Extrapyramidal motor disturbance consisting of slow, sustained contractions of the axial or appendicular musculature; one movement often predominates, leading to relatively sustained postural deviations; acute dystonic reactions (facial grimacing and torticollis) are occasionally seen with the initiation of antipsychotic drug therapy. From Sadock glossary
c. chorea: Chorea is an abnormal involuntary movement derived from the Greek word “dance”. It is characterized by brief, abrupt, irregular, unpredictable, non-stereotyped movements. In milder cases, they may appear purposeful; the patient often appears fidgety and clumsy. They can affect various body parts, and interfere with speech, swallowing, posture and gait. got from the movement disorders website as I couldn't find it in the book. From SAdock glossary: Movement disorder characterized by random and involuntary quick, jerky, purposeless movements. Seen in Huntington’s disease. Sadock p. https://www.movementdisorders.org/MDS/About/Movement- Disorder-Overviews/Chorea--Huntingtons-Disease.htm d. Akathisia is subjective feelings of restlessness, objective signs of restlessness, or both. Examples include a sense of anxiety, inability to relax, jitteriness, pacing, rocking motions while sitting, and rapid alternation of sitting and standing. Akathisia has been associated with the use of a wide range of psychiatric drugs, including antipsychotics, antidepressants, and sympathomimetics. Once akathisia is recognized and diagnosed, the antipsychotic dose should be reduced to the minimal effective level. Akathisia may be associated with a poor treatment outcome. Sadock page
- SAdock glossary 1411.
- Know DSM criteria for major depression disorder A. If you have been experiencing 5 or more of the following signs and symptoms most of the day, nearly every day, during the same two week period, you may be suffering from depression; at least one of the two sx is either 1: depressed mood or 2: loss of interest or pleasure: a. Depressed mood most of the day; nearly everyday: subjective report (feels sad empty, hopeless) or observation b. Marked diminished interest or pleasure in all or almost all activities; subjective or observation c. significant weight loss when not dieting or weight gain: more than 5% of body weight in a month or decrease/increase in appetite nearly everyday (children: failure to make weight gain) d. insomnia or hypersomnia nearly every day e. psychomotor agitation or retardation nearly every day (not merely subjective feeling but observed by others)
g. feelings of worthlessness, or excessive or inappropriate guilt (which may be delusional) nearly every day. not merely self- reproach or guilt about being sick h. diminished ability to think or concentrate, or indecisiveness nearly every day i. recurrent thoughts of death (not just fear of dying) recurrent suicidal ideation without a plan, or SA or specific plan for suicide B. cause clinically significant distress or impairment in social, work, or other important areas of functioning C. there has never been a manic episode and not better explained by other mental disorders or response to a significant loss. These are from medscape which I thought were concise and useful j. Persistent sad, anxious, or “empty” mood j. Feelings of hopelessness, or pessimism j. Irritability j. Feelings of guilt, worthlessness, or helplessness j. Loss of interest or pleasure in hobbies and activities j. Decreased energy or fatigue j. Moving or talking more slowly j. Feeling restless or having trouble sitting still j. Difficulty concentrating, remembering, or making decisions j. Difficulty sleeping, early-morning awakening, or oversleeping j. Appetite and/or weight changes j. Thoughts of death or suicide, or suicide attempts j. Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment
- Know the following and be able to distinguish between them: a. echolalia, Psychopathological repeating of words or phrases of one person by another; tends to be repetitive and persistent. Seen in certain kinds of schizophrenia, particularly the catatonic types. From sadock glossary b. dysarthria , Difficulty in articulation, the motor activity of shaping phonated sounds into speech, not in word finding or in grammar. SAdock glossary
c. stuttering, Frequent repetition or prolongation of a sound or syllable, leading to markedly impaired speech fluency. sadock glossary d. aprosodia : From one of the study guides; not in the glossary. A neurological condition characterized by the inability of a person to properly convey or interpret emotional prosody. Prosody in language refers to the ranges of rhythm, pitch, stress, intonation, etc. These neurological deficits can be the result of damage of some form to the non-dominant hemisphere areas of language production. The loss of ability to express and understand emotions is debilitating to those experiencing aprosodia. It has a large impact on their lives and affects their day-to-day interactions with others. While it is often overlooked, affective prosody is as integral to communication as the ability to form and understand correct words. Patients exhibiting extreme cases of aprosodia speak in a monotone fashion and are barely able or unable to distinguish changes in stress or intonation.
- Know how to test : sadock p 203. A complete assessment of memory usually involves a number of specialized tests that sample intellectual functions, new learning capacity, remote memory, and memory self-report. Sadock 118 a. Short-term memory - Reproduction, recognition, or recall of perceived material within minutes after the initial presentation. TEST (p. 203 Sadock) repeat these numbers tests immediate memory. short-term memory: , what did you have for breakfast? Remember 3 things, repeat after me then retest in 5 minutes. b. Long-term memory - Reproduction, recognition, or recall of experiences or information that was experienced in the distant past (Wheeler). Evaluations of retrograde memory loss should attempt to determine the severity of any memory loss and the time period that it covers. Most quantitative tests of remote memory are composed of material in the public domain that can be corroborated (Sadock, 121). Sadock p 203: Also called remote memory: TEST Address in the 3rd grade, who was your teacher, what did you do the summer between high school and college. Who was the president before last?
- Know what are and what they indicated for
