First Flashcards
The concepts of defense mechanisms, transference and countertransference are derived from what theory?
Psychodynamic theory (Freud, Jung, Adler)
What is the basic premise of psychodynamic Theory?
There are conscious and unconscious mental processes that guide and influence a person’s thoughts and behaviors. The focus is the unconscious processes and how they relate to and affect a person’s behavior.
12 cranial nerves (on occasion our trusty truck acts funny, very good vehicle anyhow)
I- olfactory
II - optic
III- oculomotor
IV - trochlear
V- trigeminal
VI- abducens
VII - facial
VIII- vestibulocochlear
IX- glosopharyngeal
X- vagus
XI- accessory
XII- hypoglossal
Which class and which antidepressants block voltage sensitive Na+ channels in the — and — leading to —-
TCA
Clomipiramine (AnaFranil)
Heart and brain
Increases QT prolongation and Lowers seizure threshold
Mild serotonin syndrome syndrome symptoms
Tachycardia, flushing, fever, HTN, ocular oscillations, myoclonic jerks
Severe serotonin syndrome symptoms
Hyperthermia, coma, convulsions, autonomic instability, death
10 curative factors that differentiate group work from individual therapy. Who was the first to propose the theory.
Instillation of hope
University
Altruism
⬆️ socialization skills
Imitative behaviors
Interpersonal learning
Group cohesiveness
Catharsis
Existential factors
Corrective refocus
Yalom
“In university, all social skills, imitate, interpersonal, groups, catty existential, corrections”
Paired structure of DNA in nucleus cell
Chromosomes (structures of DNA)
Which medication is associated with retinal pigmentation, at what dose and what may it lead to even when stopped?
Thioridazine (mellaril), > 1000 mg. May lead to blindness.
Most central neurotransmitter in the neurophysiology of psychosis
Dopamine
Universal excitatory neurotransmitter and what has it been connected to?
Glutamate - bipolar disorder, seizures, mood imbalances and schizophrenia.
Which dopaminergic pathway is involved in addiction?
Ventral tegmental (reward pathway)
(Very addictive, heroin and meth work on this pathway).
Mnemonic- Very Tingling Addiction.
Nigo Strialtal Pathway
Involuntary movement, Stuttering, Parkinsonism
Meso limbic system
Transmits dopamine to prefrontal cortex and midbrain. = (+) symptoms of schizophrenia. {blocking dopamine decreases (+) symptoms of schizophrenia.
Frontal lobe reaches maturity at what age?
Mid to late 20’s
Frontal lobe begins to atrophy at age?
60’s
What does frontal lobe govern?
Controls voluntary movement, ability to project future consequences based on current actions, governs according to social cues, distinguishes similarities and differences.
What does frontal lobe dysfunction result in?
Incongruent affect, decreased motivation, impaired judgment and attention. Confabulation.
Internal validity
Independent variable causes a change in the dependent variable
External validity
when sample is representative of the population and the results can be generalized.
Variance
how the values are dispersed around the mean
Antecedants to lapse or relapse
accessability to substance, rationalization, and minimizing consequences
Example of an immediate determinant of lapse or relapse
coping skills
Symptoms of neurosyphillis
- wide based gait
- (+) romberg sign
- loss of vibratory and proprioceptive senses in lower extremities
- Decreased deep tendon reflex
- Pupil abnormalities
- Tremor
- Dyscoordination
- Spacitity in lower extremities
Risk factors for MDD
Genetic predisposition, first degree relative with MDD or dysthmymia
What factors affect distribution of a drug in the body
-Malnourished - protein deficit (< 16 mg/dl), toxicity can be achieved at low dose.
-fat to lean muscle ratio (as in elderly)
In terms of half-life, how are drugs typically dosed.
Once per half life
In terms of half-life, when is steady state achieved in the body?
Five half-lives
Typically, how many half-lives are needed before a drug is completely eliminated from the body.
Five Half-lives are needed to eliminate the drug from circulation completely.
What do CYP 450 inducers do to drugs
Increase metabolism thereby decreasing serum levels of the drug
What affect do CYP450 inhibitors have on drug
Slows metabolic rate thereby increasing the serum blood levels
Which drugs most commonly associated with Steven’s-Johnson syndrome?
Sulfa drugs, lamictal, carbamazepine
What elevates ammonia and which medication combination
Depakote, severe liver disease. Most common when depakote combined with amitryptyline and fluoxetine (inhibit metabolism of valpofic acid.
Advanced directive
Aka durable power of attorney. It’s a written document that’s legally binding in all 50 states appoints a person to make healthcare decisions on your behalf if you’re unable to.
HAM-A rating system
Hamilton anxiety score
Mild - 14-17
Moderate - 18-24
Severe - 25-30
Statistics regarding ADHD
- Rare to occur after age 35
- Mean age of onset is 19.5
- Males have earlier age of onset (25% before age 10)
- females are affected slightly more
- 12 month prevalence in the US is 1.2%
Schizoid personality traits
Lifelong pattern of emotional detachment, isolation, lack of interest in forming relationships
Schizophrenia negative cluster symptoms
Attention deficit, alogia or poverty of speech, affective flattening, avolition, apathy, anhedonia, difficulties with abstract thinking
Positive symptom cluster schizophrenia
Hallucinations, delusions, aggression, disorganized behaviors, grandiosity, mania, paranoia
Associated symptom cluster schizophrenia
Inappropriate affect, dysphoric mood, depersonalization, derealization, high anxiety
Immediate determinants of relapse
- High risk situations -negative emotional states (associated with highest risk of relapse) can be triggered by perceived peer pressure, lack of support
- Coping skills - response to high risk situations
- outcome expectancies - what the person expects to occur in response to substance use versus abstaining
Antecedents relapse and prevention
- lifestyle factors, alternative healthy behaviors, life balance, recreational activities, social connections
- Urges/cravings: environmental cues, accessability to substances, romanticizing use, mentally minimizing consequences, rationalization
PDQ-4
personality diagnostic questionnaire designed to assess personality traits and potentially personality disorder.
What population has highest rate of antisocial personality disorder?
Adult men with alcohol use disorder in a forensic setting
Tryptophan increases the risk of serotonin syndrome when taken with?
SSRI, MAOI. St john’s wart
What medications does melatonin interact with
Aspirin, NSAIDS, beta blockers, and steroids.
Which case determined competence to stand trial?
1960 Dusky vs. US
Which case is known for originating the insanity defense
Durham vs. US
Which case ruleds that harmlessly mental ill patients who can survive outside cannot be held against their will. Determined that the presence of a mental illness alone does not justify involuntary hospitalization.
1976 case of O’connor vs. Donaldson
Which case determined that the patients have the right to refuse any treatment and use an appeals process?
Rennie vs. Klein 1979
The reticular formation is part of what structure and regulates what?
Brain stem and regulates involuntary movement, muscle tone, BP and respiratory rate
Which neurotransmitter involves memory and sustained autonomic functions
acetylcholine and glutamate (primary excitatory neurotransmitter in CNS that regulates sympathetic function - increased HR and BP)
The general function of serotonin
regulation of sleep, pain perception, mood states, temperature, aggression and libido
Females with bipolar disorder are more likely to experience which features
rapid cycling and mixed states, depressive episodes, higher rates of comorbid alcohol use and eating disorders.
What values can be increased during treatment with lithium, thiazide diuretics, alkaline antacids or vitamin D
Calcium
What is the RAPS4
Rapid alcohol problem screen - 4 questions (remorse, amnesia, performance, and eye opener).
According to Erikson, which psychological stage if not resolved, develops delinquet behavior, borderline personality, gender-realted identity disorders
Identity vesus role confusion: adolescence to adulthood
Which theorist believed that child development is shaped by native endowment, biological and environemental factors
Jean Piaget
What are the barriers to interprofessional collaboration?
- Gender, power, socialization, education, status, cultural differences
- lack of a payment system and structure that rewards collaboration
- Misunderstanding of the scope and contribution to each profession
- Turf protection
Corrective refocusing
- Yalom - group work, one of the curative factors
- Occurs when participants reexperience family conflicts in the group. These experiences allow them to recognize and change their problematic behaviors.
According to Harry Stack Sullivan’s interpersonal theory, the primary motive of human behavior is?
- The satisfaction of interpersonal needs.
- The needs arise from early experiences and shape the development of personality.
Who published the 2010 report The Future of Nursing: Leading Change, advancing Health.
The Institute of Medicine
The Future of Nursing: Leading Change, Advancing Health report developed what 4 key messages?
- Nurses should practice to the full extent of their education
- Nurses should seek higher levels of education through seamless academic progression.
- Nurses should be full and equal partners with physicians.
- To improve the quality of health care, nurses need an improved information infrastructure.
What are the nurse practitioner’s standards of practice?
- Authoritative statements regarding the quality and type of practice that should be provided.
- Offer a way to judge the nature of care provided
- Reflect the expectation for the care that should be provided
- Professional agreement focused on the minimum level of acceptable performance.
- Can be used to legally describe the standard of care.
- May be either precise or general guidelines.
Nurse practitioners scope of practice
- Defines the NP role and actions
- Identifies competencies assumed to be held by al NP who function in a particular role.
- Has broad variations from state to state due to outdated legislation.
What % of US homeless population has coocurring substance and mental health disorders.
50%
Which sleep disorder falls asleep and wakes earlier
Advanced sleep cycle
Which sleep cycle falls asleep later and wakes later
Delayed sleep phase
Falling asleep usually and waking up progressively later
Non 24 hr sleep cycle
Decreased levels of what can cause renal failure
Calcium
What disorders are related to increased calcium
- Acidosis - (increases amount of calcium flowing out of bones, increased stimulation of parathyroid hormone, increased albumin bound calcium released into circulation)
- hyperthyroidism - (increase in thyroid hormone, increase bone turnover and lead to hypercalcemia)
- Addison disease- Adrenals doesnt produce enough hormones, specifically reduced cortisol leading to critically low blood pressure -may increase reabsorption of Ca into circulation and decreased removal from kidneys.
What specifier is used for a mood disorder with depressive and manic episodes
With mixed features
Regarding mood disorders, what does atypical features refer to
Excessive eating and weight gain, excessive sleeping, feeling sluggish or paralyzed, sensitive to rejection
Regarding mood disorders, what does with melancholic features specifier mean
Feeling worse upon wakening than in the afternoon, weight loss, decreased appetite, excessive guilt, agitation and are indecisive
What disorders does Sam-e treat
Depression, liver disease, osteoarthritis
Lethality in mental health means
The likelihood a person will commit suicide or homicidal violence.
Description of ODD including time frame
An enduring pattern of defiance, angry, irritable mood, argumentative and vindictive behavior for at least 6 months.
What is thought to be the etiology of ODD
Parents who express emotions in an extreme way, unresolved conflicts, trauma, PTSD, temperament
What is supplemental insurance from private insurance companies elderly can purchase to cover extra expenses Medicare doesn’t cover
Medi-gap
5 stages of group dynamics
- Forming
- Storming
- Norming
- Performing
- Adjourning
Hallmark presentation of delirium.
Impaired attention and memory. It’s an acute fluctuating disturbances in attention and awareness. Accompanied by changes in perception, cognition, behavior. Patients may also experience disturbances in sleep wake cycle, perceptual disturbances, hallucinations or delusions.
Humanistic therapy focuses on
Socratic questioning, CBT techniques focusing on self actualization, finding meaning in one’s life and its circumstances. Self-growth.
Which therapy targets finding meaning in one’s life and accepting reality and making responsible decisions.
Existential Therapy
Goals of family systems therapy
Murray Bowen- focuses on chronic anxiety in families with the goals of increasing self differentiation, which helps family members learn that their self worth is not dependent on external relationships, circumstances or occurrences.
id
Freud- primitive and instinctual part of the psyche driven by the pleasure principle seeking immediate gratification of basic needs and desires.
Ego
Rational and logical principle seeking balance the balance of the impulses of the id with the demands of reality.
Grassroots lobbying
nonpaid individuals contact legislators to influence policy
Special interest group
collection of individuals who coordinate lobbying efforts around a common interest and seek to influence policymakers.
caucus
group of members of congress or a political party created to support a defined political ideology.
continuing resolution
type of appropriations legislation that financially supports the Government.
Virtue of hope is associated to resolution fo which stage
erikson - trust vs mistrust
Virtue of will is associated with which resolution
erikson - autonomy versus shame and doubt
Virtue of purpose is associated with resolution of which stage
erikson - initiative versus guilt
Virtue of competence is associated with resolution of which stage
Erikson - industry versus inferiority
Virtue of fidelity is associated with the resolution of which stage
identity versus role confusion (forms a strong sense of self able to commit to values)
Virtue of love related to the resolution of which stage
Erikson - intimacy versus isolation
Virtue of **care **is related to resolution of which stage
erikson - generativity vs stagnation
Virtue of wisdom is related to resolution of which stage?
Erikson - ego integrity versus despair
What does the hippocampus play a role in
memory and spatial navigation
what is the basal ganglia involved in
motor control
what is the cerebellum involved in
coordination and balance
In patient interviewing clarification is what type of techinique
expanded psychiatric interview technique
Superego
Represents the moral and ethical standards of the individual striving for perfection and demanding adherence to social norms and values.
What is the Wisconsin card sorting test (WCST)
A test for executive function specifically looking at cognitive shifting, mental flexibility and problem solving. Abstract thinking.
Sort cards, rules change without notice, need to figure out rule and make correct choice.
What is the TRail making test (TMT)
Test for visual attention, cognitive flexibility, and processing speed.
What is the Stroop Color and Word Test (SCWT)
Assess cognitive control and response inhibition.
Giving two conflicting pieces of information - given the word blue with red font asking what color the word is in.
What is the WHODAS
World Health Organization disability assessment schedule. Assess 6 domains.
1 -cognition
2- mobility
3- self care
4 -getting along with people
5 -life activities
6 -participation in society
According to Piaget, children between the age of 6-11 are in what cognitive development stage
Cognitive-spatial concepts
-hierarchy classification
-reversibility
-conservation
-decentration
-spatial operations
-horizontal decelage
-transitive inference
What year was first nurse practitioner program developed
1965
What is the cerebral cortex responsible for
Receiving sensory incoming sensory information from the thalamus
What structure converts short term memory into long-term memory
Hippocampus (of the limbic system)
3 examples of how different cultures describe panic attacks
Hit by the wind - Vietnamese
Soul lost- Cambodia
Attack of the nerves -Latin America
What is ARRA
American recovery and reinvestment act. 2009 Obama aimed at saving and creating jobs and establishing infrastructure, education and healthcare. It included the HITECH act which attempts to update American infrastructure including electronic health records.
Which type of dementia manifests as a progressive cognitive decline in a step wise fashion.
Vascular dementia
What are extrapyramidal side effects associated with
Drug effects that affect motor activity and muscle movement. They occur in the nigostriatal tract where there is deficiency in dopamine and excess acetylcholine.
What does muscaranic 1 antagonist medications do
**anticholinergics **- Reduce effects of excessive acetylcholine relieving extrapyramidal symptoms.
Ethical duty doing what’s fair
Justice
Ethical duty veracity
Telling the truth, honest and to provide accurate information. Requires nurses to be truthful in all aspects of a patient’s care, including diagnosis and treatment goals. Helps patients make informed decisions and builds trust.
Which ethical duty means treating everyone with dignity
Respect
Lethality
The liklihood that a person will commit suicidal or homicidal focused violence
Biological preventative factors for developing a psychiatric disorder
- without a history of mental illness
- Healthy nutritional status
- good general health
Psychological preventative factors
- Good self esteem
- Good self concept
- Internal locus of control
- Healthy ego defenses
Social preventative factors for developing a psychiatric disorder
- Low stress occupation
- higher socioeconomic status
- Higher level of education
What is the drug of choice for managing an agitated or confused patient with delirium
Haldol
Name some things that can cause an increase in calcium
vitamin D, lithium, alkaline antacids
Clozapine induced agranulocytosis symptoms
High fever, pharyngitis, oral and peri-anal ulcerations
Ataque de nervios
Latinos from carribean - sense of being out of control, uncontrollable shouting, breaking things, trembling, crying, fainting. Usually occurs after a stressful event relating to family.
Which medications can cause depression
Beta blockers, progesterone, interferon, retroviral drugs, neoplastic drugs, isotretinoin
Which medications induce mania
Steroids, disulifuram (Antabuse), antidepressants, isoniazid
Prevalence of bipolar disorder including which folks have higher rates of
Higher in high income countries 1.4% compared to 0.7 % low income. Those who are separated, divorced, or widowed have higher rates. 12 month prevalence of bipolar disorder in US is 1.8%. Lifetime male to female ratio is 1:1.
What is the reticular formation part of and what dies it regulate.
Brain stem- regulates involuntary movement, muscle tone, blood pressure, and respiratory rate.
Ziprasidone (key points to remember)
Geodon - taking with food increases absorption two fold, monitor QTc, caution in CHF, hypothermia, hypomagnesia, recent MI.
Beneficence
The duty to help a patient by doing what’s best for them.
Barriers to meaningful use include
Staff training, workflow, usability, altered patient provider interaction, clinician resistance to change.
What medical conditions is panic disorder associated with
IBS, dizziness, cardiac arrhythmia, hyperthyroidism, asthma, COPD
Phallic stage
Age 3-5/6, identify with same sex parent, penis object of interest to both genders during this stage
Internal validity
When an independent variable causes a change in the dependent variable.
Serotonin dopamine antagonist
2nd generation antipsychotic
Examples of healthcare informatics tools
Clinical guidelines, EHR, patient care technology devices, database of healthcare guidelines
Black box warnings carbamazepine
Agranulocytosis, aplastic anemia
When there is a disruption in this pathway, ADHD, addiction, and schizophrenia can result.
Mesocorticolimbic
Timeline Criteria for GAD
More days than not for at least 6 months
What % of incarcerated population has severe mental illness
15-24%
Examples of nursing sensitive adverse events
Failure to rescue
Nosocomial infection
Pressure ulcers
Falls
Medication errors
Transfusion errors
(Events that can be directly related to quality of nursing care and could be improved upon with improved nursing practices)
Gag rule
In managed care NP are prohibited from discussing alternative treatments not covered by the plan and discussing limitations of the plan or speaking negatively about the plan.
Contraindications for seclusion and restraint.
- Overtly suicidal patients
-Unstable psychiatric or medical conditions
-For punishment
Delirious or demented patient that cannot tolerate decreased stimulation - patient with severe drug reactions or overdose
Alzheimer’s (DAT) characteristics
- usually occurs in 6th decade of life (onset in 4th/5th) most likely familial.
- most prevalent type
- gradual onset & progressive decline
- without focal neurological deficits
- definitive diagnosis by autopsy only with amyloid deposits and neurofibrillary tangles.
Lewy Body Dementia
-Characterized by abnormal clumps of proteins causing neuronal malfunction
- commonly occurring in patients with Alzheimer’s and Parkinson’s disease.
- characterized by visual hallucinations of small creatures
*exacerbated by antipsychotic medication!
Picks disease
-Frontotemporal dementia
-onset 5th and 6th decade of life
- marked by personality change
-cognitive decline occurs later in the disease process
Kluver Bucy syndrome
- Type of frontotemporal dementia
-uninhibited, cheery, hypersexual, hyperorality (esp carbs)
Creutzfeldt -Jakob disease
- precipitous onset (rapid) prion (mis wrapped proteins)
-sometimes referred to as mad cow disease
- rapid decline that results in death within 6 months
- middle aged adults presenting with fatigue, flu-like symptoms, cognitive impairment
-later symptoms aphasia, apraxia, emotional lability, and psychosis
Huntingtons disease
- Subcortical dementia characterized by motor abnormalities including psychomotor slowing, choreoathetoid movements, and executive dysfunction
-complicated by impaired language, memory and insight later in disease
Vascular dementia
- formerly known as as multi infarct dementia
-rare under age 65
-more sudden onset than Alzheimer’s - Progressive decline in a stepwise fashion
- rapid episodic deterioration with intermittent plateaus
- previously lost function is not regained
Dementia in HIV
- poor prognosis death within 6 months
- in late stages may experience psychosis
-decline is progressive with motor and behavioral abnormalities - secondary disorders may develop such as OCD, PTSD, GAD, depression and mania
- accompanying symptoms such as mania, mutism, global cognitive impairment, seizures disorder, delusions, hallucinations, apathy and self neglect may raise suspicion for organic etiology
What’s a more severe form of HIV associated neurocognitive (HAND) syndrome and characteristics of HAND
- HIV dementia
- subcortical dementia with parenchymal abnormalities visualized on MRI
Most prominent symptom of dementia
Impaired immediate and intermediate memory
Delirium neurological findings
Psychomotor agitation, restlessness, purposeless, random actions, uncoordinated, tremor, myoclonus, nystagmus, asterixis (flapping tremor)
Asterixis
Flapping tremor
Comparing dementia to delirium regarding orientation
- dementia impaired late phase
- delirium acutely impaired due to LOC
Part of brain responsible for orientation
Temporal, frontal, cingulate cortex
In delirium what does immediate recall look like
Acutely impaired inattentive
Part of brain responsible for immediate recall
- Wernicke (part of temportal lobe, responsibe for language comprehension)
- **Broca **(part of frontal lobe, responsible for expressive speech)
Language, naming, repetition, reading and comprehension, writing associated with which parts of brain
Left temporal, left parietal, wernicke m, Broca
Abstract thinking, proverb interpretation, and conceptualization portion of brain
Frontal and prefrontal
Portion of brain visual processing and what symptom associated with this area.
Occipital - hallucinations
Etiologies for delirium
-nutrition deficiency
- anemia significant enough to cause poor perfusion
- electrolyte abnormalities
- fever
- dehydration
- infection
- constipation
- toxicity
- poor perfusion
Cholinesterase inhibitors function
Slow loss of function and reduce agitated behaviors (do not prevent progression of disease
Side effects of cholinesterase inhibitors
Nausea, diarrhea, vomiting, weight loss, insomnia, vertigo
(increase the level of acetylcholine (ACh) in the nervous system by preventing the breakdown of ACh)
Examples of cholinesterase inhibitors
- donepezil (aricept) 5-23 mg per day
- ruvastigmine (Exelon) 1.5- 6 mg bid or 4.5- 13.3 mg daily transdermal patch
N methyl d aspartame glutamate receptor antagonist (NMDA receptor antagonist)
Believed to enhance cognition preventing over excitement glutamate receptors. Stalking neuro degenerative process and promote synaptic plasticity {ketamine, dextromethorphan, amatadine, phencyclidine, methadone}
Name a n methyl d aspartame glutamate receptor antagonist
Memanatine (Namenda) 10- 20 mg
Medical foods
Believed to provide esssential nutrients ( medium chain fatty acids) high concentration of ketones, to cross blood brain barrier
Mild TBi recovery
Recover fully in 3 months, residual symptoms on 6 months
What techniques are used in strategic therapy
- straightforward directives are tasks in anticipation of family members compliance.
-paradoxical directive is negative in nature, assigned when family members are non compliant
-** reframing belief system** is when problematic behaviors are relabeled to have a more positive meaning.
An exception finding question is used in what type of therapy
- used in solution focused therapy
Miracle question is in what type of therapy
Solution based therapy
Miracle question is in what type of therapy
Solution based therapy
What type of therapy is structural mapping used in?
Structural family therapy
Reaction formation
Defense mechanism in which individual expresses feelings or behaviors that are opposite of their true feelings to deny their own feelings which they feel are morally or socially unacceptable
Which type of aphasia difficulty comprehending meaning and what are some additional characteristics
- Wernicke’s aphasia also known as receptive aphasia
- May produce fluent speech devoid of content and may have difficulty understanding spoken or written language
When in excess which neurotransmitter results in disorganized thinking, loose associations, tics, and stereotypic behavior
Dopamine
A decrease in this neurotransmitter results in symptoms of parkinson’s, endocrine alterations, poor spatiality, lack of abstract thought.
Dopamine
Excess of this transmitter results in restlessness, agitation, myoclonus, VS abnormailities,
Serotonin
Excess of this neurotransmitter results in over-inhibition, anxiety, somatic complaints, self-conciousness and drooling.
Acetylcholine
Excess of this neurotransmitter results in hyperalertness, paranoia, and decreased appetite.
Norepinephrine
Services not covered under Medicare
- Vision care
- eyeglasses
- dental care
- dentures
- hearing exams
- hearing aids
- routine physical exams
- inpatient psychiatric hospitalizations
suicidal patients usually are extremely hopeless and believe that through suicide they will experience
secondary gain
selective abstraction
when individuals take things out of context
Circular reasoning
logical fallacy where a person begins with what they think they want to end with when making a statement. An arguements conclusion is assumed to be true without providing any evidence. (X is true because X is true)
Regarding sodium levels which is more associated with confusion
hyponatremia
Age trust vs mistrust
Erikson - birth to 12 months
Age autonomy vs shame and doubt
Erikson - 12-18 months to 3 years
age initiative versus guilt
erikson 3 to 5-6 years
Age industry vs inferiority
Erikson 5-6 years to adolescence
Age Identity vs role confusion
Erikson - Adolescence to adulthood
Age - intimacy vs isolation
Erikson - adulthood
Age intamacy vs. isolation
Erikson - adulthood
Age generativity vs. stagnation
Erikson - middle adulthood (40-65)
1981 Roger’s vs Oken
Patient has the absolute right to refuse treatment but a guardian may authorize it.
Characteristics of complex partial seizures
- includes sensory aura and automatic behavior
-during seizure may fiddle with clothing, blink eyes or lip smack - usually result in impaired consciousness
What medication can be added to correct neutropenia caused by clozapine and how much does it increase?
Lithium - increase by about 2000, not dose related
What does intersecting pentagon drawing assess for
Assesses visiospatial impairment- function of right parietal lobe, prefrontal cortex, basal ganglia.
Orientation to person place and time effects what part of brain
Temporal lobe, frontal lobe, and cingulate cortex. Impaired in late phase of dementia.
Delayed recall reflects what portion of brain
Function of hippocampus, and medial temporal lobe. More common in Alzheimer’s type dementia.
What portion of brain affects abstract thinking
Frontal and prefrontal regions of the brain.
Primary distinguishing factor between delirium and dementia
Disturbance of consciousness
Mixed delirium characteristics
Cyclical manifestation of psychomotor retardation and agitation with disturbance in consciousness. Risk factors include infections, fever and relocation.
What is a subtype of frontotemporal dementia (Picks) characterized by uninhibited cheerfulness and hypersexuality..
Kulver Bucey Syndrome- subtype of frontotemporal dementia.
Creutzfeldt Jakob disease characterized
Precipitous onset cognitive decline that rapidly progresses to death. Symptoms include fatigue, cognitive impairment and eventually aphasia, apraxia, emotional lability, and psychosis.
Hyperactive delirium
Characterized by psychomotor agitation and restlessness, hyper vigilance.
Definition of psychosis
Disorganized behavior with one of three following
-delusions
-hallucinations
-disorganized speech
Marked by frequent derailment or incoherence.
Brief psychotic disorder
Lasting 1 day to < 1 month
with at least one of the following
* delusions
* hallucinations
* disorganized speech (derailment or incoherence)
* grossly disorganized or catatonic behavior
Schizophreniform disorder
Lasting greater than one month but less than 6 months
Schizophrenia time frame
Lasting greater than 6 months
Neurotransmitter characteristics associated with schizophrenia
- Decreased serotonin, gamma aminobutryic acid (GABA), dopamine in mesocortical pathway
-excess glutamate, dopamine in Mesolimbic pathway
Characteristics of schizophrenia in females
Age onset 25-35, more associated dysphoria and paranoid delusions with comorbid hallucinations, less prodromal symptoms than men
Characteristic of schizophrenia in men
Age onset 18-25, more prevalent negative symptoms than women, worse prognosis, more hospitalizations, less responsive to medications.
Delusional disorder (including time frame)
A deeply held belief despite evidence of the contrary, or a lack of evidence to support the deeply held belief. Without prominent hallucinations. Lasting at least one month.
Schizoaffective disorder characterized by
Characteristics of schizophrenia (hallucinations, delusions, disorganization) > 2 weeks without prominent mood symptoms. , AND manic or depressive features are present most of the time when not in psychosis.
Which SGA least likely to prolong QTc?
Aripiprazole (Abilify)
Which SGA least likely to cause EPSE
Quetiapine - (seroquel)
How does smoking affect antipsychotic treatment?
Inducer CYP450 pathway reducing antipsychotic efficacy requiring increased dosages.
What is ACT?
Assertive community treatment - intensive care management with multidisciplinary team includes home visits and long acting injections. Best for med noncompliance, frequent recidivism and failure to go to outpatient appointments.
TD
Abnormal involuntary movements in a rhythmic pattern affecting face, mouth, tongue (potentially irreversible)
When does NMS most often occur
More common typical antipsychotic within first two weeks of starting treatment, rapid dose escalation, parental route of administration
Treatment NMS
bromocriptine, Benzodiazepines, Dantrium (dantrolene) interferes with calcium release from muscle cells- reduces muscle rigidity
What causes EPS of antipsychotic
When dopamine is blocked from the receptor site, acetylcholine (ACH) is increased
Which anticholinergic medications treat akinesia, akathisia, dystonia, pseudo-Parkinson’s
Anticholinergics - cogentin (benzotropine), Artane (trihexphenidyl)
Which antihistamine used to treat akinesia (inability to perform a voluntary movement), dystonia, pseudoparkinsons
Benadryl
Dopamine agonist used in akinesia and pseudo-Parkinson’s
Symmetrel (amanatadine)
BB used in akathisia
Inderal (propranolol)
Alpha blocker used in akathisia
Catapres (Clonidine)
Benzos used in akathisia and dystonia
Klonopin or Ativan (lorazepam)
Dendrites
Receive information to conduct toward cell body.
Axon
Sends information away from cell body
Depolarization
Initial phase - excitatory response. Calcium and sodium flow into cell.
Repolarization
Restoration phase (inhibitory response) potassium leaves and chloride enters the cell.
Categories of neurotransmitters
Monoamines, amino acids, cholinergics, neuropeptides
Where is dopamine produced, precursor, how is it removed from synaptic cleft
Substantial nigra and Ventral tegmental area, precursor is tyrosine. Removed from cleft by monoamine oxidase (MAO) enzymatic action.
Norepinephrine produced where, precursor, how removed. What is it implicated in.
Locus ceruleus of the pons. Precursor tyrosine, removed from synaptic cleft via an active reuptake process. Implicated in mood, anxiety, and concentration.
Where is epinephrine produced and what system is it also referred to as
Adrenal glands adrenergic system.
Serotonin is produced in, precursor, how removed from cleft,
Raphe nuclei of brain stem, tryptophan, active reuptake process.
Major amino acids
Glutamate, aspartate, y-aminobutyric acid (GABA), glycine
Glutamate, is universal, involved in the process of, implicated in which diseases processes
Excitatory neurotransmitter, involved in process of kindling, which is implicated in seizure disorder and bipolar disorder
And imbalance implicated in mood disorders and schizophrenia.
{kindling - theoretical concept where repeated episodes of a condition, like a seizure or a mood swing in bipolar disorder, can gradually lower the threshold for future episodes to occur, potentially making them more frequent and severe over time, even with seemingly smaller triggers; essentially, the brain becomes increasingly sensitive to stimuli that might initially have had little effect, similar to how repeatedly applying a small electrical stimulus to a brain region in animal studies can eventually trigger a full-blown seizure}
Aspartate
Excitatory neurotransmitter (and amino acid)works with glutamate.
GABA is universal, site of action of
y-aminobutyric acid, site of action of benzodiazepines, alcohol, barbiturates and other CNS depressants
Glycine
Inhibitor neurotransmitter works with GABA
Acetylcholine - what is it and where is it synthesized
Cholinergic - synthesized in nucleus of Meynert
Norepinephrine receptors and its basic function in body
a1. a2
Attention
Focused alertness, orientation, fight or flight, learning memory
Acetylcholine receptors
Nicotinic receptors, muscarnic
Acetylcholine receptors
Nicotinic receptors, muscarnic
Acetylcholine general function
Attention, memory, thirst, mood regulation, REM sleep, sexual behavior, muscle tone
Which neurotransmitter is implicated in Extra pyramidal movement, drooling, self- consciousness, somatic complaints, depression, over-inhibition
Acetylcholine excess
Which neurotransmitter has AMPA, MNDA receptors
Glutamate
Neurotransmitter implicated in kindling, seizures, anxiety panic
Glutamate - in excess
Which neurotransmitter is implicated in lack of inhibition, decreased memory, euphoria, antisocial behavior, decreased speech, dry mouth, blurred vision constipation
Acetylcholine deficit
Which medication requires testing for HLA-B gene for which population?
Asian, carbamazepine due to risk of Steven’s Johnson syndrome and toxic epidermal necrolysis (TEN)
Common side effects of serotonergic medication side effects
*SPAROW-tonin
-Sleep - involved in regulating sleep. Differs from one to the other, activating or sedating
-Platelet dysfunction 10% serotonin is found in platelets where it’s involved with blood clotting. Increases risk for bleeding.
-Abdominal upset 90% of serotonin is found in gut. Causing nausea, diarrhea, stomach discomfort
-Reproductive sexual side effects
-Overdose. Potential to cause overdose.
-Weight gain
Common side effects of serotonergic medication side effects
*SPAROW-tonin
-Sleep - involved in regulating sleep. Differs from one to the other, activating or sedating
-Platelet dysfunction 10% serotonin is found in platelets where it’s involved with blood clotting. Increases risk for bleeding.
-Abdominal upset 90% of serotonin is found in gut. Causing nausea, diarrhea, stomach discomfort
-Reproductive sexual side effects
-Overdose. Potential to cause overdose.
-Weight gain
Where is serotonin produced
Raphe nuclei in brain stem
“Ray-phe nuclei brings rays of light to depression”
Where is norepinephrine produced
Locus ceruleus
“Being cerounded makes your locus ceruleus jump”
Where are a-1 adrenergic receptors found and what are main effects?
Primarily found in vascular smooth muscle. But also in GU and nervous system. Vasoconstriction.
What part of brain is responsible for sleep-wake cycles
Hypothalamus
What part of brain is responsible for sleep-wake cycles
Hypothalamus
Which neurotransmitters are associated with sleep wake cycles
Serotonin, norepinephrine, acetylcholine
Which neurotransmitters are responsible for wakefulness
- HISTAMINE strong contributor to wakefullness. Histamine is produced in the posterior hypothalmus.
- **norepineprhine **works on locus coeruleus of the brainstem to promote wakefullness (releases norepinephrine)
- orexin AKA hypocretin orexin producing neurons are located in the lateral hypothalmic region. projects signals to various other parts of the brain to regulate wakefulness, appetite and energy metabolism.
- sertotonin promotes wakefullnesss and supresses REM sleep
- **acetylcholine **promotes wakefulness
Two phases of sleep cycle
Nonrapid eye movement (NREM)
Rapid eye movement (REM)
How many stages NREM sleep
3
Stage 1 NREM
Lightest sleep stage, lasts up to 15 minutes, drowsiness easily disrupted, muscle tone begins to relax, Hypnic jerks (head nods, sensations of falling)
Stage 2 NREM
Accounts for 40-60% of total sleep time, more difficult to Strouse, eye movement slows, activity busts (sleep spindles) and K complexes on ECG. Body temperature and heart rate decrease.
Stage 3 NREM
5-15% total sleep time (higher during periods of rapid growth and development) deep restorative sleep, delta waves ECG, most difficult to arouse, parasomnias (sleep walking, sleep terrors. Somniloquy (sleep talking) occur
When does REM sleep occur
Stage 4, 90 minutes after sleep onset and can last 10-15 minutes.
Characteristics of REM sleep
Eyes move side to side, more active brain waves than 2 and 3. Arousal can occur more easily. Feel most groggy in this stage.
Which questionnaire is used to assess excessive daytime sleepiness (EDS)
EPworth sleep scale. 0-24 points. > 10 warrants further investigation.
Sleep latency
Time it takes to fall asleep
Sleep efficiency
Time spent asleep while in bed
Sleep maintenance
The ability to stay asleep for desired amount of time.
Disorder- Wake in the middle of the night and inability to go back to sleep (includes early morning insomnia)
Polysomnography
Standard for evaluation sleep disorders- records brain waves, O2, HR, IM leg movements
Multiple sleep latency test (MLST)
Monitor daytime napping to determine sleep latency
Narcolepsy criteria
2 or > episodes of sleep latency less than 8 minutes and or 2 or more episodes with REM periods.
What CSF test can be used when assessing for narcolepsy
Hypocretin (Orexin) less than 109
Criteria for chronic versus short- term insomnia
Chronic - present at least 3 times per week for 3 months
Short-term 3 times per week for less than 3 months.
Hypersomnolence
Dx of exclusion, persistent sleepiness despite getting 7 hrs sleep. Sx includes strong drive to sleep, difficulty waking from sleep accompanied by feelings of confusion, combativeness, or irritability.
Risk factors for hypersomnolence disorder
- acute and daily persistent stress
- excessive alcohol
- remote history of viral infection
- hx of head trauma in previous 2 years
- family hx
- dementia
- Parkinson’s disease
When is RLS usually triggered and where else can it occur,
At the moment of falling asleep that disrupts initiation of sleep. Symptoms may also arise in upper extremities.
What is rate of onset of RLS in people before age of 20
30%
Diagnostic work up
- iron deficiency
- CMP
- magnesium
-TSH and free T4 - methylmalonic acid (rule out B12 deficiency)
- Homocysteine (rule out folate deficiency)
Dopaminergic agents used to treat RLS
- pramexiprole (Mirapex)
- bromocriptine
-levodopa/carbidopa
Antileptic drugs to treat RLS
- gabapentine
-pregablin
Besides dopaminergic agents and antileptic agents, what are other treatments for RLS
- Alpha blocker - clonidine
- nutritional supplement with ferrous sulfate or ferrous gluconate, magnesium oxide
Shortest half life and less residual sleepiness sedative hypnotic
Zolpidem (ambien)
Intermediate half-life sedative hypnotic, residual drowsiness
Eszopiclone (lunesta) “lunar easy pic”
Melatonin receptor agonist
Ramelton (Rozerm) low bioavailability, variable efficacy, low SE, Low incidence of drowsiness
Orexin receptor antagonist
Suvorexant (Belsomra) - suppress wakefulness, very long half-life, residual drowsiness
What stimulants are prescribed for OSA
Armodafinil (Nuvigil)
Modafinil (Provigil)
*reduce excessive daytime sleep symptoms, don’t give within 6 hrs of sleep
OSA symptoms include
Irritability, cognitive impairment, excessive daytime sleepiness. May also worsen glycemic control
Narcolepsy is characterized by the tetrad
- hypersomnia (excessive daytime sleepiness)
- cataplexy (transient loss of muscle tone in the presence of strong emotions-fear, embarrassment)
- sleep paralysis ( partial or total loss of muscle during sleep-wake transition)
Hypersomnia is characterized by
Excessive daytime sleepiness not due to an environmental disturbance, underlying medical condition, substance induced disorder, mood disorder and is not associated with sleep paralysis, cataplexy
Atypical depressive symptoms
-increased appetite
-increased sleep > 10 hours
-Physical sensation of heaviness (like walking through quicksand)
-increased interpersonal sensitivity to rejection leading to social or occupational impairment
Time criteria for MDD
At least 2 weeks
How long is treatment recommended after remission of symptoms in MDD
one year (patients with 2 or more episodes may require lifelong medication)
Psychopharmacology in MDD usually targets symptoms. Which symptoms is usually targeted first if there are multiple symptoms
Sleep
Most common side effect with SNRI medication
HTN
Name most common SNRI medications
Venlafaxine (effexor)
duloxetine (Cymbalta)
Most important to know about Effexor
At higher doses causes HTN, very short half-life severe withdrawal symptoms.
What type of medication is bupropion major side effect and absolute contraindication
- NDRI (norepineprine, dopamine reuptake inhibitor)
- Lowers seizure threshold
- Absolutely contraindicated in Bulimia due to electrolyte abnormalites that further increase risk for seizures.
most common electrolyte side effect with SSRI
hyponatremia
Name most common TCA’s
- Imipramine (tofranil)
- Clopiramine (anafranil)
- Amitryptyline (elavil)
- Nortriptyline (pamelor)
- Doxepin (Sinequan)
“Candi”
TCA’s mechanism of action
TCA
* Transmitters - inhibit reuptake of serotonin and norepineprhine
* Channel - calcium and sodium channel inhibitor
* Antagonize acetylcholine and histamine (anticholinergic effects)
Widened QRS is highly specific to what class of medications
TÇA’s overdose
What is antidote for TÇA overdose
bicarbonate
(**car **runs over tricycle)
Therapeutic index of TCA
7= most deadly toxicity in overdose
what is imapramine used 2nd line in
enuresis - prevents bladder contraction (I am pee ramine)
clomipramine (anafranil (is gold standard for treating ___ after SSRI
OCD - most sertonin reuptake blocking med.
(O** ClomipramiD**e)
nortriptyline is associated with less of which side effects when compared to other TCA’s
less sedation and orthostatic hypotension
(elderly no triptyline)
name 4 most common MAOI’s and mechanism of action
- Phenelzine (nardil)
- tranylcypromide (Parnate)
- isocarboxazid (Marplan)
- selegeline (Emsam)
- 1-3 work on MAO-A and MAO- B = increase norepinephrine, serotonin, dopamine)
- Selegeline is specific to MAO-B = increases dopamine only which is why it is sometimes used in Parkinsons
What are MAOIs most effective at treating
Atypical depresssion (mood reactivity, leaden paralysis, etc.)
two lethal side effects of MAOIs
- Hypertensive crisis (consuming foods containing tryamine, aged cheese, wine) causes widespread vasoconstriction
- Serotonin syndrom**e - when prescribed with other serotogen meds, requires 2 week wash out when transitioning except for fluoxetine requries 5 weeks due to long half-life.
Symptoms of HTN crisis
- Sudden onset worse headache ever
- facial flushing
- palpitations
- pupillary dilation,
- fever
- diaphoresis
Treatment of HTN crisis
phentolamine 5 to 15 mg IV push
Contraindications for ECT
cardiac disease, aortic stenosis, pulmonary insufficiency
Dysthymia
Persistent depressive disorder - a depressed mood a majority of the days for at least 2 years.
disruptive mood dysregulation disorder characteristics
severe and recurrent temper outbursts verbally or behaviorally that are grossly out of proportion to the provocation with irritable angry mood most of the days between outbursts.
Bipolar two disorder characterisitics/criteria
- at least one hypomanic episode and one MDD episode
- hypomanic episode must be a distinct period of elevated mood or irritablility lasting 4 days plus at least 3 manic symptoms.
- Change in mood is observable but not so severe to require hospitalization
cyclothymic disorder characteristics
periods of hypomanic symptoms that do not exceed full criteria and depressive symptoms that do not meet full criteria for MDD. Must have characteristic pattern for at least 2 years (like dysthymia)
Bipolars version of dysthymia
Acute intermittent porphyria
Commonly occurs after excessive heme demand after alcohol consumption, recreational drug use, stress and fasting. Manifests as manic or psychotic sx, abdominal pain, nausea, vomiting, muscle pain, numbness, tingling, hallucinations, paranoia.
- test urinary porphoblinogen
Capras syndrome
Delusional belief people have been replaced by imposters and is associated with psychosis.
