PMHNP Certification Exam Study Guide Verified Question Latest Update 2024/2025 100% Correc, Exams of Nursing

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PPIs; ranitidine, famotidine, omeprazole Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:06 / 0:15 Full screen Brainpower 5 ODD diagnostic criteria: Argumentative, defiant for at least 6 months and with 4 sx Treatment of ODD: Focused on family therapy, child management skills, teaching parents reinforcement/boundaries/problem solving DMDD diagnostic criteria: Childhood depressive d/o between ages 6-17; chronic dysregulated mood, frequent tantrums, severe irritability; typically DMDD rather than bipolar d/o in children Neurotransmitters implicated in ASD: Glutamate, GABA, 5HT - GGS Echolalia Meaningless repetition of words; often seen in ASD Broken mirror theory Dysfunction of the mirror neuron system results in poor social interaction and cognition in ASD patients Parallel play is developmentally appropriate at which ages? 1-3 years old 6 Parallel play continuing beyond the age of 3 years old may be indicative of... ASD dx d/t social deficits M-CHAT Modified Checklist for Autism in Toddlers; ASD scale ADOS-G Autism Diagnostic Observation Schedule - Generic; ASD scale ASQ Ages and Stages Questionnaire; development and social/emotional screening Pharmacological treatment of ASD: Stimulants (increase DA to help with impulsivity, hyperactivity, inattention; Antipsychotics (target aggressive bx, tantrums, self-injury, stereotyped bx) Nightmares in children can be the result of: Genetic factors; assess family patterns of nightmares Features of children diagnosed with Fragile X 7 LARGE features: large head, elongated face, hyperextensible joints, abnormally large testes, short stature Features of children diagnosed with fetal alcohol syndrome small features: small head, small eye opening, low nasal bridge, flat midface, smooth philtrum, thin upper lip Clock drawing test assesses function of which brain lobe? Parietal What does the clock drawing test assess for? Executive/cognitive fx, impairments associated w/ damage to right parietal lobe, constructional apraxia (inability to draw or assemble objects) Important labs to draw for patients presenting with dementia? B12, folic acid Dementia presents with mental decline that is ___ Chronic; if acute sx, consider other dx Symptoms of subcortical dementia: Motor sx, lack of coordination, tremors, depression, irritability, apathy 10 BNZ Anytime a patient presents with delirium, what labs should you order? UA with culture and specificity d/t infx being a potential cause for delirium, esp in older adults What is pseudodementia? Cognitive sx r/t depression in older adults Dementia vs. pseudodementia Dementia: premorbid hx of slowly declining cognition Pseudodementia: acute onset of significant cognitive changes How would someone with dementia vs. pseudodementia answer a question? Dementia: confabulates, lacks answer Pseudodementia: "I don't know" How can depression present in older adults? Cognitive deficits - irritability, agitation, hallucinations, delusions What neurotransmitters are implicated in mood disorders? DA, NE, 5HT (DNS), GABA, glutamate 11 What neurotransmitters are implicated in depression? DA, NE, 5HT - DNS How does depression present in children/adolescents? Irritability/anger What cerebral changes are noted in depression? Increased amygdala, decreased hippocampus/thalamus First line pharmacological tx of depression SSRIs What medication is best for a patient who is depressed and prescribed Tamoxifen for cancer treatment? SSRI (especially sertraline, citalopram, escitalopram) Best pharmacological treatment for comorbid depression and fibromyalgia SNRI (duloxetine), TCAs, alpha 2 delta ligand (gabapentin, pregabalin); always choose SNRI over TCA if possible d/t safety What major side effect of SNRIs should you monitor for? Increased blood pressure 12 Which depression medications are least likely to cause sexual dysfx? Bupropion, mirtazapine Best treatment for depression with low energy and fatigue? Bupropion; contraindicated in those with seizures or ED hx If a patient has a suicide attempt while prescribed an antidepressant, what is your next step? Discontinue antidepressant, switch medication to SGA or mood stabilizer When should fluoxetine be dosed? AM because of potential to cause insomnia; if patient experiencing insomnia and taking at night, switch to AM dosing instead of adding addtl med to sleep Which antidepressants are helpful for insomnia? Trazodone, mirtazapine Why is there more evidence for efficacy of antidepressants with adults than children? Children have lower placebo rates What happens if you have a 5HT2C genetic dysfunction? Experience decreased medication efficacy 15 Sx of beta-blocker induced bronchospasm Pain, chest tightness, SOB, wheezing, coughing, dizziness Panic d/o Recurrent, unexpected panic attacks that appear out of nowhere; impacts ability to go places for fear of experiencing panic attack in place can't escape from Tx for panic d/o SSRIs, SNRIs Hallmark sx of schizophrenia Impaired proverb interpretation Why are stimulants contraindicated in those dx with schizophrenia? Increase DA release -> increased psychotic sx What metabolic effects are associated with schizophrenia? Low HDL, increased triglycerides What medications do individuals with schizophrenia have a low tolerability to? Alpha 2 adrenergic agonists 16 What level of prevention is social skills training? Tertiary Benefits of referring those with schizophrenia to an exercise program Metabolic benefits; improves cognition, brain fx, quality of life Average age of onset for schizophrenia in men and women Men: 18-25 Women: 25-35 Neurobiological changes in schizophrenia Enlarged ventricles; decreased: cerebral cortex, frontal/temporal lobes, symmetry between lobes, cerebral blood flow, hippocampus, amygdala What sx of schizophrenia is indicative of cerebral cortex abnormalities? Aggression What is the formula for switching from PO to IM haldol? 20 * total daily oral dose = IM dose; give no more than 100 mg at a time, give rest 7 days later ACT treatment 17 Assertive community treatment for patients with SMI; intensive integrated approach to community mental health services; post-hospitalization, less restrictive than residential; holistic approach to improve all aspects of patient life Schizophreniform Similar sx to schizophrenia but last between 1-6 months; if sx last longer than 6 months, consider schizophrenia Cluster A personality d/o Schizoid, schizotypal, paranoid Schizoid personality d/o Voluntary social isolation; cold, detached, no interest in social support Schizotypal personality d/o Similar to schizophrenia but no hallucinations/delusions; social difficulties, few/no friends; ideas of reference, magical thinking, "off beliefs"; bx overtly odd, inappropriate affect Paranoid personality d/o Longtime distrust, suspiciousness of others; thinks everyone is out to get them Cluster B personality d/o BPD, histrionic, narcissistic, antisocial 20 SGAs: Haldol, Pimozide, Aripiprazole Alpha agonists: control bx sx, impulse control, rage attacks Acute stress d/o sx Stress response within 4 weeks of traumatic event, lasts less than 1 month. If lasts greater than 1 month likely PTSD. Sx: anxiety, insomnia, poor concentration, helplessness, fear Hallmark of PTSD Re-experiencing of trauma PTSD dx criteria Intrusive re-experiencing of trauma, increased arousal, avoidance of stimuli associated w/ trauma Pharmacologic tx for PTSD SSRIs, TCAs, prazosin for nightmares Nonpharm tx for PTSD EMDR, CBT, ERP, group therapy, relaxation Phases of EMDR DIB - desensitization, installation, body scan Desensitization: bilateral stimulation while thinking about event 21 Installation: strengthen positive belief to associate with target event Body scan: hold target event and positive belief while scanning body and processing any disturbances Factitious d/o Px or mental sx induced purposely (drinking contaminated substances, injecting fecal material, etc.) in the absence of any obvious external rewards Malingering Similar to factitious d/o but motive is secondary gain (i.e. getting out of jail) Factitious d/o imposed on another Causing sx in another w/ the intention of deceiving others, in absence of any external reward; report to CPS if a child is involved What group may you need to use yes/no with rather than open ended questions? Those with intellectual/developmental disabilities; also use if patient unable to construct chronological narrative Enmeshment Relationship btwn 2+ people where personal boundaries are unclear Parentification Lack of healthy boundaries; unclear, diffuse, enmeshed 22 Cognitive distortions Inaccurate and irrational automatic thoughts or ideas that lead to false assumptions and misinterpretations; usually generalized; ex: catastrophizing, all or nothing thinking, should statements, labeling Cognitive therapy Beck; focus to change irrational beliefs/cognitive distortions Behavioral therapy Change maladaptive bx; participate in active bx techniques: exposure, relaxation, skills training, problem-solving, role-playing, modeling CBT Replace irrational beliefs and change bx; journaling, cognitive restructuring, cognitive rehearsal What is the better option for patient tx: cognitive therapy or CBT? CBT Interpersonal therapy Focus on interpersonal issues; identify/modify interpersonal problems in context of relationships Psychodynamic therapy 25 Structural family therapy Clearly defined boundaries and hierarchies; genograms; enactment: family member asked to play out relationship patterns during session; map, track, modify family structure Key elements of mindfulness Awareness of breath, body sensations, thoughts How do self-esteem exercises benefit children? Promote resilience, improve relationships and social anxiety Benefits of body massage Decrease stress by lowering cortisol levels, reduce pain by improving circulation If you are conducting a joint session with multiple people and only 1 shows up, what is the priority action? Must reschedule for a time when all participants can be there If a child experiences sexual assault from a sibling, what are your next steps? 1. Insist mom not leave child with sibling 2. Report to CPS 3. Arrange crisis therapy for family 26 Freud psychosexual stages of development Birth-1: oral - sucking, swallowing 1-3: Anal - witholding/expelling feces 3-6: Phallic - penis or clitoris, masturbation 6-puberty: Latent - little/no sexual motivation Puberty to adulthood: Genital - penis or vagina, sexual intercourse A mother tells you her 3 year old child has been touching their genitals. What do you advise her to do? Nothing, this is normal for children this age; may explore genitals, ask questions, masturbate Yalom characteristics of group therapy -Instillation of hope: seeing others cope with similar problems and achieving goals can inspire peers -Universality: feel understood and similar to others -Information giving: increase knowledge/understanding -Altruism: selflessly helping other group members -Increased development of social skills: new skills learned, maladaptive bx corrected -Imitative bx: increase skills by imitating bx of others -Interpersonal learning: intxt with others increases adaptive interpersonal relationships -Group cohesiveness: participants develop attraction to group/other members, sense of belonging 27 -Catharsis: catharsis experienced as members express feelings that were suppressed -Existential factors: deal w/ meaning of own existence -Corrective refocusing: reexperience family conflicts in group, recognize/change bx that may be problematic Yalom group phases -Pregroup: consider direction/framework of group including inclusion/exclusion criteria -Forming: orientation phase; leader most active; norms discussed (confidentiality, attendance, etc.); discuss time frame/termination of group -Storming: transition phase; anxiety, ambiguity, conflict; group acts out, test bx to define self/group -Norming: cohesive phase; develop cohesion and therapeutic alliance forms (i.e. disapproving late members) -Working: performing phase; individual growth/team productivity; experiment with new ideas/bx -Adjourning: termination phase; discuss/review outcomes, explore what worked/didn't; not time to introduce new concerns/initiatives Recovery model Tx doesn't focus on full sx resolution; ephasis on resilience, control over sx; goal: recognize, foster abilities/interests; individualized, person-centered, self-directed; non-linear; ongoing support crucial for recovery 30 When does behavioral management begin? As soon as patient is admitted (not upon dc) Piaget Stages of Cognitive Development Birth-2 years: Sensorimotor (object permanence) 2-7: Preoperational (magical thinking, egocentric) 7-11: Concrete (conservation; concrete beliefs, rigid) 12+: Formal (abstract logic, reasoning; hypothesis testing) Erikson's Stages of Development +Trust vs. Mistrust: birth-1 yo (hope) +Autonomy vs. Shame: 1-3 yo (will) +Initiative vs. Guilt: 3-6 yo (purpose) +Industry vs. Inferiority: 6-12 yo (confidence) +Identity vs. Role Confusion: 12-20 yo (fidelity) +Intimacy vs. Isolation: 20-35 yo (love) +Generativity vs. Stagnation: 35-65 yo (care) +Ego Integrity vs. Despair: 65+ (wisdom) Children's understanding of illness - 2-7 yo Magical thinking, think immediate experiences are related to illness (e.g. if sunny, think sun made them sick); may think it's because of something they got in trouble for (e.g. hitting dog); experience guilt/shame - important to tell them it isn't their fault Children's understanding of illness - 8-12 yo 31 Logical, understand factors that influence illness; good to discuss health dangers (i.e. consequences of smoking) Mnemonic for Erikson's stages TAG I RISE (trust, autonomy, guilt, inferiority, role confusion, intimacy, stagnation, ego integrity) Ages to remember for Erikson's stages 1, 3, 6, 12, 20, 35, 65 What birth defect can depakote cause? Spina bifida S/s hepatotoxicity RUQ pain, nausea, red urine, yellow skin/scleara, fatigue A patient is exhibiting signs of hepatotoxicity. What is your priority action? d/c offending agent, order LFTs Normal range for ALT/AST 5-40 Depakote therapeutic range 32 50-125 At what level is depakote toxic? >150 S/s depakote toxicity Disorientation, lethargy, respiratory depression, N/V Interventions for depakote toxicity d/c med; labs: VPA, LFT, ammonia What psychotropics are contraindicated for use in combination with metoprolol? Paroxetine, fluoxetine, bupropion because hypotension, bradycardia What psychotropic can cause pancreatitis? Depakote Which psychotropics can prolong QTc? Ziprasidone, haldol, citalopram - ZHC Which psychotropics should you not rx for those with cardiac hx d/t potential to prolong QTc? Ziprasidone, haldol, citalopram - ZHC 35 What is a sign that a patient prescribed carbamezapine or cloazaril is experiencing agranulocytosis? Sudden s/s infx (fever, chills, sore throat, etc.) In carbamazepine or clozaril, what ANC and WBC would you discontinue meds at> ANC <1000; WBC <3000 What is the only know antipsychotic show to reduce risk of suicide in patients with schizophrenia? Clozaril Therapeutic range for lithium level 0.6-1.2 At what level is lithium toxic? 1.5 What is the neuroprotective psychotropic treatment of choice for bipolar d/o? Lithium What is the gold standard psychotropic tx for mania? Lithium Which psychotropic has been associated with decreased suicide in those with bipolar d/o? 36 Lithium What labs should you order when prescribing lithium? TSH, BUN/Cr, UA (check proteins for kidney damage), Hcg Lithium side effects Hypothyroidism, fine hand tremors, rash, GI upset, diabetes insipidus (polyruia/polydipsia), t-wave inversion, leukocytosis, kidney disease Normal range for creatinine 0.6-1.2 Normal range for BUN 10-20 Lithium can cause which birth defect? Ebstein anomaly (congenital heart defect); avoid in pregnancy esp 1st trimester Which mood stabilizer is safest in pregnancy? Lamotrigine What should you do if patient has hx of thyroid issues or experiences hypothyroidism while rx'd lithium? 37 Refer to endo - don't need to dc med S/s lithium toxicity Severe nausea/vomiting/diarrhea, confusion, muscle weakness, heart palpitations, ocarse hand tremors, unsteadiness What should you do if you suspect lithium toxicity? d/c med, check lithium levels What medications should you avoid in patients prescribed lithium and why? Those that reduce renal clearance because they will increase lithium levels; ex: NSAIDs, thiazides, ACE inhibitors, lisinopril Dehydration can cause _____ lithium levels Increased; encourage proper hydration Hyponatremia can cause _____ lithium levels Increased If a patient experiencing tics is diagnosed with ADHD, what psychotropic should you prescribe to tx the ADHD? Non-stimulants; avoid stimulants b/c worsen tics 40 Increased ACh, decreased DA What psychotropic is used to treat EPS? benztropine What antiemetic can cause EPS? Metoclopramide (reglan) If a patient presents with TD, how would you proceed? Lower current dose or switch to SGA What medications are FDA approved for tx of TD? Deutetrabenezine, valbenazine Sx of NMS FEVER/HYPERTHERMIA, tachy, diaphoretic, muscle rigidity, mutism, immobility, myoglobinuria, elevated CPK If an antipsychotic is causing SE, the sx are likely r/t ___ or ___; if an antidepressant is causing SE, the sx are likely r/t ___ antipsychotic: NMS or EPS; antidepressant: SSRI 41 Hallmark sx of NMS Hyperthermia, extreme muscle rigidity Psychopharm tx for NMS overall sx Bromocriptine (D2 agonist) Psychopharm tx for NMS muscle rigidity Dantrolene (muscle relaxant) Halmark of serotonin syndrome Hyperreflexia, myoclonic jerks If a patient is exhibiting s/s serotonin syndrome, what is your course of action? d/c offending agent, administer cyproheptadine SE of St. John's Wort Elevated serotonin, impaired glucose tolerance, decreased insulin response How long should you wait to wash out from SSRI to MAOI? 2 weeks How long should you wait to wash out from fluoxetine to MAOI? 42 5 weeks How long should you wait to wash out from MAOI to fluoxetine? 2 weeks How long is washout period when switching between psychotropics? 5 half-lives; waiting for degeneration Why are triptans contraindicated with antidepressants? Can cause serotonin syndrome MMSE (Folstein Scale) - what does it test for? Screen for dementia, monitor severity/progression over time; monitors concentration, ability to learn new material, recall, fund of knowledge MMSE (Folstein Scale) scores 0-9: severe impairment 10-20: moderate impairment 21-24: mild impairment 25-30: normal SLUMS Scale - what does it test for? Cognitive impairments 45 *15+: Scheduled meds and PRN Which benzo for alcohol withdrawal has the longer half life? Diazepam Which benzo for alcohol withdrawal has the shorter half life? Why would you want to use this instead of one with a longer half life? Lorazepam; use in patients with compromised hepatic fx What non-benzo psychotropic can be used for tx alcohol withdrawal? Librium What setting is appropriate for tx alcohol withdrawal - outpatient or inpatient? Inpatient AUDIT screens for what? Alcohol consumption DAST-10 screens for what? Drug use not including alcohol/tobacco What is included on COWS scale? 46 HR, sweating, restless, pupil size, bone aches, runny nose/tearing, GI upset, yawning, tremors, anxiety, goosebumps What is included on CIWA scale? N/V, tremor, sweats, anxiety, agitation, tactile disturbances, auditory disturbances, headaches, orientation What does the CRAFFT scale measure for? Alcohol/drug use in kids <21 What does CRAFFT stand for? *Car (ridden in car driven by someone drunk/high) *Relax (use substance to relax) *Alone (use substance alone) *Forget (forget what you did while using) *Friends (friends say you need to cut back) *Trouble (gotten in trouble while using) What score on CRAFFT requires further assesment? 2+ What does CAGE screen for? Drug and alcohol use 47 If screening for alcohol use, should you use AUDIT or CAGE and why? Audit b/c specific to alcohol use - CAGE assesses both drug and alcohol, less sensitive/specific What psychotropics can be used to tx alcohol use d/o? Which is best for those w/ liver dysfx d/t not being metabolized by liver? Acamprosate, disulfiram, naltrexone; acamprosate not metabolized by liver S/s PCP intoxication Hallucinations, delusions, aggression/agitation, nystagmus, sweating, elevated body temp, increased BP/HR What enzyme metabolizes alcohol? Alcohol dehydrogenase Why are women more likely to get drunk than men? They have less alcohol dehydrogenase to metabolize alcohol S/s stimulant abuse Insomnia, tremors, inc BP/HR, agitation/anxiety, irritable, mood swings Which lab is elevated in autoimmune dz? Cytokines 50 Landau reflex 3 mos-2 years; hold baby face down, will extend legs and head like looking up Grasp/palmar reflex Birth-6 months; stroke palm of hand, grasp Moro/startle reflex Birth-6 mos; baby startled, throws head back, extends arms/legs, brings back in Babinski reflex Birth-2 yrs; sole of foot stroked, toes fan out Tolerance Diminshed effect of med @ same dose over time Cranial nerves 1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens 51 7. Facial 8. Vestibular 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal How do you test cranial nerve 7? Have patient smile, puff out cheeks, raise eybrows, wrinkle forehead, close eyes - tests for facial paralysis What are phosphodiesterase type 5 (PED5) medications used for? Tx sexual dysfx; know they are rapidly absorbed after admin What would you do if FDA releases a new black box warning about a med your patient is on? Research risks/benefits of continued use - don't automatically dc How would you document off-label use of a medication in your patient's chart? Full disclosure/documentation of risks/benefits, include evidence that supports off-label use Apoptosis Neuronal loss/cell death 52 Normal TSH range 0.5-5 Hypothyroidism lab trends TSH high, T3/T4 low Hyperthyroidism lab trends TSH low, T3/T4 high S/s hyperthyroidism Mimics mania; heat intolerance, sweating, agitation, anxiety, tachycardia, mood swings, wt loss S/s hypothyroidism Cold intolerance, lethargy, wt gain, decreased libido What does the trendelenberg test look for and what are +/- findings? Assesses hip dysfx; patient stands on both feet, raises one foot off the ground without support; - indicates adequate abductor strength, hips remain level; + indicates hip abductor weakness, hips don't remain level, refer out S/s lead poisoning Especially assess if live in homes built before 1970, rural areas; developmental delay, learning difficulty, irritability, loss of appetite, wt loss, sluggish/fatigue, abdominal pain, vomiting, constipation, hearing loss, seizures, pica 55 Just culture Organization held accountable while focusing on risk, systems design, human bx, patient safety Case management model Considers patient and provider satisfaction, cost consideration to help manage overall health Benefits of case management approach Optimize client self-care; reduce fragmentation of care; provide quality care across continuum; improve QOL; improve care/outcomes; reduce LOS, increase patient/provider satisfaction; promote cost- effective use of scarce resources Care coordination Deliberately organizing patient care activities, sharing info among all participants in patient's care; safer and more effective Primary goal of care coordination Meet patient needs, deliver high quality/value care Integrated healthcare Coordination of general and bx healthcare Caring Theory 56 Jean Watson; caring is essence of nursing and essential for health promotion/healing; holistic and goes beyond px aspects of care; recognizes importance of nurturing mind, body, spirit What is your initial action when a patient discloses abuse? Provide safe environment, reassure them of personal safety (even before intervention) Should safety/no-harm contracts be used? No! What is your intervention if a child reports abuse in presence of parents? Separate child/parents and interview separately, then report to CPS A child comes into the office and is presenting sexually. What do you do? Suspect sexual abuse; suspicion is enough to report, call CPS What diagnoses increase thoughts of HI? Antisocial personality d/o, then psychotic d/o Tarasoff principle You have duty to warn potential victims of imminent danger/homicidal clients What are quality improvement projects? 57 Those projects designed to improve systems, decrease cost, improve productivity (such as chart review) What is PDSA? Quality improvement momdel; plan, do, study, act How do you assess barriers and facilitators to EBP? Assess baseline knowledge/beliefs/practices among HCPs with a survey Aspects of MSE Consciousness, orientation, appearance, attitude, attention/concentration, psychomotor, eye contact, speech, mood, affect, memory, intelligence, thought, perception, insight/judgment, SI/HI Delusion firm belief maintained despite evidence to the contrary; don't try to challenge delusion/provide reality reorientation; can result in harm to others d/t beliefs How should you interview a preschooler? Listen and observe cues; based on clinical observation What is the purpose of the thought process portion of the MSE? Assess organization of a patient's thoughts and ideas 60 Determine need for info outweighs principle of confidentiality; harm to self/others; answering court orders (subpoenas, summonses); info give to attorneys; releasing records to insurance; meet state requirements for mandatory reporting of dz/conditions Perjury lying under oath Informed consent Patient able to give informed consent for tx if can repeat risks/benefits of medication What if a patient cannot give informed consent? Assess for need for involuntary tx Justice doing what is fair Nonmaleficence doing no harm (e.g. stopping a med causing harmful SE; duty to warn if imminent risk) Beneficence doing good 61 Fidelity being true/loyal; integrity/honesty; meet patient's reasonable expectations (courteous, competent, respectful) Veracity telling the truth Autonomy right to self-determination Renni v. Klein an involuntarily committed patient who is not found to be incompetent has a right to refuse psychotropics, unless emergency What are the rights of psychiatric patients? Least restrictive tx, informed consent, confidentiality How can you engage in client advocacy? Ensure autonomy, self-determination; support patients' best interests while respecting family's important role; reduce stigma of mental illness; help clients receive services When advocating for psychiatric population, what is the best way to reduce stigma? Speaking to largest group possible; choose speaking via media vs. speaking to small group 62 What conditions are covered under the individuals with disability education act? Autism, ADHD, Tourette's, CP Kickback illegal compensation to encourage patient to ome to their office/encourage another provider to refer to their office 4 components of health policy Process, policy reform, policy environment, policy makers How do you make policy change? Assess/address organizational barriers/facilitators; brainstorm w/ stakeholders Mental Health Parity and Addiction Equity Act Insurers required to provide same level of benefits for mental health/substance use tx as they would medical dx Donaldson v. O'Connor It is unconstitutional to commit a person involuntarily who is not an imminent danger to self/others What role does serotonin play in SGAs? 5HT2a receptor antagonists 65 Which histamine receptor is implicated in insomnia? H1 (histamine receptor) What brain waves are implicated in insomnia? Alpha waves NE location of production Locus coeruleus, reticular formation 5HT location of production Raphe nuclei DA location of formation Nucleus accumbens, substantia nigra, VTA (ventral tegmental area) ACh location of production Nucleus of Meynert Dorsolateral prefrontal cortex purpose Executive fx; cog processes; problem solving; direct/maintain attention to task 66 Orbitofrontal cortex Learning, reward, punishment Tuberoinfundibular pathway implicated in prolactin levels; D2 blockade -> increased prolactin What is the result of increased prolactin in tuberoinfundibular pathway? Amenorrhea, galactorrhea, sexual dysfx, gynecomastia Which psychotropic is most likely to increase prolactin levels? Risperdal What should you do if patient is experiencing inc prolactin while rx'd risperdal? Switch to aripiprazole or quetiapine (less likely to cause galactorrhea) Galactorrhea milk production from breast not r/t lactation/pregnancy What is a consequence of prolonged hyperprolactinemia? Osteoporosis Normal prolactin levels in men and women 67 Men <20 Women <25 Structures of limbic system Amygdala, hypothalamus, hippocampus, anterior cingulate; involved in bx/emotional responses Amygdala fx Survival; Aggression, fear, anxiety, emotions Hypothalamus fx Maintains homeostasis; Appetite/hunger/thirst/satiety, water balance, circadian rhythm, body temp, libido, emotional regulation Hippocampus Memory, learning, emotions, stress Anterior cingulate Cognitive fx/decision making; empathy, impulse control, emotions Brain areas implicated in addiction Hippocampus, basal ganglia, amygdala, PFC, orbitofrontal cortex, cingulate gyrus, nucleus acumbens 70 tai chi, qigong (combine px movement w/ meditation/breathwork); reduce stress, improve mental well- being biofeedback learn how to control physiological fx, reduce anx/stress Is a culturally expected response to a stressor considered a mental illness? NO! What should you tx a cultural syndrome with? Brief supportive therapy; don't need rx Cultural formulation interview Clarify meaning of illness/predicament; contextualize situation to local world; empower patient If serving a multicultural population, what should your intervention be? multicultural teaching/education Keys of culturally competent care Respectful, nonconfrontational, nonjudgmental What do native americans believe mental health d/o are caused by? 71 Imbalance between an individual's relationship with the world Which ethnic group in the US has the highest rate of suicide/suicide attempts? Native americans What do native americans believe can help to heal their sx? Healing stick A native american patient comes to the inpatient unit with a healing stick. The staff nurse tries to take it away d/t unit policy. What do you do? Teach the nurse about cultural competency, let patient keep it What is susto? What are its sx? Hispanic illness believed to be d/t a shocking/unpleasant/frightening experience that results in the soul leaving the body; appetite and sleep disturbance, troubled sleep/dreams, amotivation, muscle aches, headache, stomachache, diarrhea Mal de pelea Puerto Rican cultural syndrome; hyperkenetic seizure, become violent and attack others If a patient requests their traditional healer to be a part of their care, what do you do? Allow it, get ROI signed 72 Khyal attacks Wind attacks; Cambodian syndrome w/ dizziness/tinnitus/neck soreness Trung gio Wind attacks; Vietnamese syndrome, headaches Mal de ojo evil eye; Mexican cultural syndrome, believed to cause sickness If a test question mentions culture, what is the answer going to be? Culture-specific Ataque de nervios Hispanic cultural syndrome; out of consciousness state resulting from evil spirits