Mental Health Flashcards
What is a dangerous side effect to consider when prescribing trazodone monotherapy?
Priapism
Trazodone mechanism of action
Prevents serotonin reuptake
Which SSRI is most sedating?
Paroxetine (Paxil)
Lithium drug interactions
Diuretics
Side effects of lithium toxicity
Diarrhea, decreased LOC, weakness,
What labs need to be monitored when treating bipolar with lithium?
Lithium levels, kidney function, chemistry, thyroid
Side effects of SSRI
QTc prolongation, serotonin syndrome, angle-closure glaucoma, hyponatremia, sexual dysfunction, GI upset, diarrhea, headaches, blurred vision
Side effects of Tricyclic Antidepressants
Anticholinergic side effects: dry mouth, constipation, blurry vision, urinary retention
Side effects of SNRIs
Hypertension, QTc prolongation, serotonin syndrome, sexual dysfunction, GI upset
Which serotonin receptor do most antidepressants affect?
5-1T1A
Length of time for buspirone to reach peak efficacy?
4-6 weeks
Which drug class are the first therapy choices for depression, GAD, PTSD, and OCD?
SSRIs
A patient displays mania symptoms after initiating an SSRI for depression. What is the new diagnosis?
Bipolar Disorder
Lithium side effects
Polydipsia, polyuria
What are bupropion (Wellbutrin) indications, drug class, and side effects?
MDD, Seasonal depression, smoking cessation, ADHD*
Norepinephrine-dopamine reuptake inhibitor (NDRI)
Xerostomia, nausea, constipation, insomnia
What is the diagnosis?
Individual experiences stress out of proportion to stressor.
Stressors: employment, family, financial, life-transitions, death, relationships
May display mood or behavioral symptoms
Occurs within 3 months of identifiable stressor and resolves within 6 months
Adjustment Disorder
Treatment for Adjustment Disorder
-Supportive psychotherapy to strengthen existing coping mechanism and strengthen resiliency
- Trazodone 12.5-25mg tid prn (anxiety)
- Hydroxyzine 50mg prn (anxiety)
- Lorazepam 0.5mg bid prn for short time (anxiety)
- SSRI (short term use)
What is the diagnosis?
Exposure to a traumatic or life-threatening event
Experiencing flashbacks, nightmares, intrusive images, increased vigilance and avoidance symptoms
Symptoms present for at least 1 month and impair functioning
Post-Traumatic Stress Disorder
If symptoms present for only 3 days to 1 month following trauma, the diagnosis is Acute Stress Disorder
PTSD Psychotherapy Treatment Options
Cognitive processing therapy
Prolonged exposure therapy
Eye-movement Desensitization Reprocessing(*EMDR); 8-12 sessions ASAP
Psychological debriefing (single session)
PTSD Pharmacotherapy Options
Sertraline, paroxetine (FDA) (depression, panic attacks, sleep disruption, startle responses)
Beta-blockers Propranolol 80-160mg daily (tremors, palpitations)
Clonidine 0.1mg hs-0.2mg tid (hyperarrousal)
Prazosin 2-10mg hs (nightmares and sleep)
Trazodone 25-100mg hs (hypnotic)
Essentials of Anxiety Disorder Diagnoses
Persistent and excessive worry, anxiety, or fear with associated behavioral disturbances
Difficulty concentration, apprehension, tension, fear
Somatic symptoms: Autonomic NS symptoms; dyspnea, palpitations, paresthesia, tachycardia, hyperventilation, SOB
What is the diagnosis?
Cardiac, GI, neuro, and anxiety present for 6 months or longer?
Generalized Anxiety Disorder
What is the diagnosis?
Recurrent, unpredictable episodes of intense surges in anxiety with marked physiologic response (Impending doom, chest pain sweating, tachycardia, etc)
Panic Disorder
What is the diagnosis?
Social phobias and simple phobias
Phobic Disorder
What does the GAD-2 and GAD-7 screen for?
Anxiety
GAD-2
Over the last 2 weeks how often have you been bothered by (0-3)
1-Feeling nervous, anxious, or on edge
2-Not being able to stop or control worrying
Treatments for GAD
SSRI, SNRI, (benzo for brief acute management only), Buspar, Gabapentin, BB (avoid alcohol as self treatment), clonidine
CBT, relaxation, emotive imagery
Treatments for Panic Disorder
SSRI, SNRI (may use benzo for bridge until SSRI/SNRI becomes effective), trazodone
CBT, relaxation, emotive imagery
Treatments for Phobic Disorder
SSRI, SNRI, gabapentin
Propranolol 20-40mg 1 hr. prior to exposure
Relaxation techniques, Desensitization, Emotive imagery, CBT
What is the diagnosis?
Preoccupations or rituals that are distressing to individual.
Symptoms are excessive or persistent beyond developmentally normal periods
Anxiety relieved by ritualistic performance
Obsessive-Compulsive Disorder
Screening: Yale Brown Obsessive Compulsive Screening (YBOCS)
Treatments for OCD
SSRI (may take 12 weeks for response)
Topamax
Antipsychotics
Gradual exposure
CBT
Transmagnetic Stimulation (FDA approved)
What are the essentials for diagnosing Anorexia Nervosa?
Symptoms present for at least 3 months
Disturbance of body image or fear of becoming fat
Weight loss; Severity classified by BMI
Extremely severe: body weight 15% below expected
Absence of 3 consecutive menstrual cycles
What are the essentials for diagnosing Bulimia Nervosa?
Symptoms present for at least 3 months
Overly concerned with weight and food
Binge-eating and purging type: Engaged in recurrent episodes of binge-eating or purging behavior at least 2x/wk
Recurrent inappropriate weight gain compensations: self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Potential lab findings in anorexia nervosa?
Anemia, leukopenia, electrolyte imbalances, elevated BUN and creatinine, increased cholesterol, depressed LH and FSH
Differentials: TB, Crohn disease, gluten enteropathy, Addison disease, DM, pan-hypopituitarism
Potential complications of bulimia nervosa?
Gastric dilation, pancreatitis, poor dentition, pharyngitis, esophagitis, aspiration, dehydration, electrolyte imbalances
What is the SCOFF questionnaire?
Screens for eating disorders
In the past 3 months have you:
Sick because uncomfortably full? Controlling eating: Loss of control One Stone/14 lb weight loss? Fat self-image? Food dominates life?
Anorexia Nervosa Management
Co-managed by PMHNP or Psychiatrist
Include family, supportive care = most important
CBT, intensive psychotherapy, family therapy
TCA, SSRI, lithium
Parenteral nutrition?
Hospital admit if signs of hypovolemia, major electrolyte imbalances, and severe protein-energy malnutrition
Bulimia Nervosa Management
Co-managed by PMHNP or Psychiatrist
Psychotherapy, CBT, individual, group, SSRI
What is the diagnosis?
Persistent patterns of inability to sustain attention, excessive motor activity/restlessness/impulsivity or both
Symptoms interfere with daily functioning
Symptoms began prior to age 12 or in at least two settings (school, work, home, with friends/family)
Attention Deficit Hyperactivity Disorder
What does the Vanderbilt Assessment Scale screen for?
ADHD
ADHD Treatments
Stimulants: Methylphenidate, amphetamine
Non-stimulants: Atomoxetine, burpropion, desipramine, clonidine
Start CBT after symptoms managed
What is the diagnosis?
Persistent issues with social communication and interactions
Repetitive behaviors, interests or activities
Symptoms interfere with functioning
May or may not have accompanying language or intellectual impairment
Autism Spectrum Disorders
Needs comprehensive and multidisciplinary approach to assessment and management
No treatment for core symptoms, supportive
What does the M-CHAT-R screen for?
Autism Spectrum Disorders
What is the diagnosis?
Prominent physical symptoms involving one or more organ systems and associated with distress and/or impairment
Occasionally able to correlate symptom development with psychosocial stress
Combination of biogenetic and developmental patterns
Somatic Symptom Disorders
What is the diagnosis?
Functional neurologic symptoms with no identifiable pathology
Conversion Disorder
What is the diagnosis?
One or more somatic symptoms associated with significant distress or disability with no identifiable pathology
Somatic Symptom Disorder
What is the diagnosis?
Displays intentional symptoms that can be self-induced or fabricated
Factitious Disorders (Munchausen Syndrome or by proxy)
Management of Somatoform Disorders
Building a therapeutic clinician-patient relationship is mainstay of treatment
Regular, frequent, short appointments that are not symptom-contingent may be helpful
Medications should not replace appointments
Empathetic, realistic, optimistic approach
Hypnosis
Group Therapy
Psych referral
Biofeedback (Immediate feedback after learning to recognize symptoms)
What is the diagnosis?
Chronic complaints of pain Symptoms frequently exceed signs Minimal relief with standard treatment History of seeing many clinicians Frequent use of several nonspecific medications
Chronic Pain Disorders
What is the diagnosis?
Anatomic changes, chronic anxiety, depression, anger, and changed lifestyle
Possible secondary gains: sick role, financial compensation
May become more dependent on family/friends and less active
Chronic Pain Syndrome
Management of Chronic Pain Disorders
Intensive behavioral program Decrease medication use Positive reinforcement Partner with patient Encourage only discussing pain with provider to stabilize home life Biofeedback and hypnosis Self-rating chart
Sees only one provider for management No referrals No opioids APAP or NSAIDs SNRI, TCA, gabapentin, pregabalin, anticonvulsants Physical therapy Acupuncture
What are the three main types of psychosexual disorders?
Paraphilia, gender dysphoria, sexual dysfunction
Management of Sexual Dysfunction
Social engineering - eliminate close proximity of others
Sildenafil, vardenafil - ED
SSRI - premature ejaculation
What is the diagnosis?
Long history dating back to childhood
Recurrent maladaptive behavior
Difficulties with interpersonal relationships or society
Depression with anxiety when maladaptive behavior fails
Personality Disorders
What is the cluster?
Paranoid, schizoid, schizotypal
Cluster A
What is the cluster?
Avoidant, dependent, obsessive-compulsive
Cluster C
What is the cluster?
Antisocial, borderline, histrionic, narcissistic
Cluster B
Personality Disorder Mangement
Self-help
Peer pressure to modify self-destructive behaviors
CBT
Dialectal behavior therapy (DBT) for chronic suicidality and borderline
Maintain boundaries
Medications directed at symptom clusters (schizo, anxiety/depression, etc)
What personality disorders have the most guarded prognosis?
Antisocial (Cluster B)
Borderline (Cluster B)
What is the diagnosis?
Social withdrawal, slowly progressive with decrease in emotional expression and/or motivation
Deterioration in personal care with disorganized behaviors and/or decreased reactivity to the environment
Disorganized thinking, often inferred from speech that switches topics oddly or is incoherent
Hallucinations, delusions
Schizophrenia Spectrum Disorders
What are delusions?
Fixed false beliefs despite conflicting evidence, frequently of a persecutory nature
What are hallucinations in schizophrenia?
Usually auditory
Commands
What are positive symptoms in schizophrenia?
Hallucinations and delusions
What are negative symptoms in schizophrenia?
Disorganized speech, poor hygiene, lack of pleasure, withdrawal, anhedonia
Schizoaffective disorder
Schizoaffective symptoms without psychotic symptoms lasting >6 months
Brief psychotic disorder
Psychotic symptoms lasting <1m, causing psychological stress, may be precursor to schizophrenia
What must you order with first episode of psychosis?
MRI or CT
Schizophreniform disorder
Schizoaffective symptoms but lasting>1m but <6mo
Management of schizophrenia
CBT, cognitive remediation, family therapy, positive reinforcement
Psych referral
Pharmacologic:
1st Gen antipsychotics
2nd Gen antipsychotics
Close monitoring of labs
Side effects of first generation (typical) antipsychotics
EPS (dystonia, akathisia, pseudoparkinsonism, tardive dyskinesia)
Less likely to have metabolic abnormalities
Side effects of second generation (atypical) antipsychotics
Metabolic abnormalities: weight gain, elevated glucose, elevated lipid
Prolonged QTc
What must you monitor monthly if a patient is taking clozaril?
Atypical antipsychotic
CBC monthly - r/f agranulocytosis
What does the AIMS Scale screen for?
Movement disorders with antipsychotic treatments
What is the diagnosis?
Chronic mood disturbance with episodes of subsyndromal depression and hypomania >2 yrs.
Cyclothymic Disorder
What is the diagnosis?
Persistent depressed or low mood most days for 2 years
Dysthymic Disorder
How does bipolar 1 differ from bipolar 2?
Bipolar 1: Experienced 1 episode of mania or mixed episode
Bipolar 2: Experienced at least 1 episode of hypomania and 1 episode of MDD; never manic
What do these tools screen for?
PHQ-2, PHQ-9, SIGECAPS, MDQ
Mood Disorders
SIGECAPS
Sleep, Interest, Guilt, Energy, Cognition/Concentration, Appetite, Psychomotor, Suicide
Once depression stabilizes, how long should medications continue before considering discontinuation?
6-12 months
After starting an SSRI, when is lethality risk greatest?
Beginning at 1-2 weeks for 28 days
Management of Bipolar Disorders
Antipsychotics (Glucose, Lipids, Weight)
First or Second Generation
Mood stabilizers (blood levels) Valproic acid Tegretol Lamotrigine Lithium (monitor levels, TSH)
Caution with use of antidepressants and stimulants in patients with mood disorders
Management of Sleep-Wake Disorders
Psychological
Insomnia-CBT, education re: sleep hygiene, avoid alcohol
Pharmacologic
Insomnia-may add medications if above are insufficient. If appropriate use for short course of 1-2 weeks.
-Benzodiazepines and Barbiturates: Caution—habit forming, cognitive slowing, increased risk for falls, increased somnolence
-Zolpidem caution in elderly,
-Antihistamines, Trazadone, Remeron-non-habit forming
Narcolepsy-Dextroamphetamine, modofinil
Medical Sleep study and treatment, if indicated
Management of aggression
Violence Risk Screen
Seriously violent or psychotic-antipsychotics q 1-2 hours until sx relief
Acute agitation: atypical antipsychotics
Chronic aggressive states: risperidone, tegretol, Depakote
Lithium, SSRI, and Buspar helpful
