Mental Health Flashcards
Antipsychotic meds-how to screen for and manage side effects, complications, and sequela
Meds for Anxiety: continue for 6-12mos after resolution of sx. May take 6 weeks w/ titration for effect
Typical and Atypical antipsychotics-Tardive dyskinesia- AIMS tool to screen
Sense of risk or harm, disturbing thoughts and images
RF: Strong familial and genetic pattern, Subgroup will have tourettes
Repetitive behaviors high level of discomfort if unable to complete behavior
OCD
Tx for OCD in kids
CBT first line, Pharm SSRI-safest
Screen by identifying TRAUMA symptoms:
Trauma-know traumatic experience
Re-experience- includes flashbacks and nightmares
Avoidance- avoid stimuli associated with the event
Unable to function
Month or longer
Arousal-hypervigilant, sleep disturbances, concentration difficulties, or exaggerated startle response
PTSD
TX for PTSD
Psychotherapy is core for PTSD w/trauma-focused CBT, EDMR. B-blocker-propranolol could be used for somatic symptoms-not well studied in children.
BPD
What potential concerns to screen for with anti psych meds?
ESP/ TD, sedation . blurred vision, dizziness, urinary retention, confusion, hallucinations, tachycardia, dry mouth, prolonged QT, gynecomastia, galactorrhea, increased or decreased prolactin level
What potential concerns to screen for with SSRI meds?
can exacerbate depression, suicidality, dry mouth, sexual dysfunction, headache, night sweats, fatigue, weight gain
Lexapro, zoloft, prozac. BBW in kids (SI)
What potential concerns to screen for with Benzos?
controlled medication- risk for addiction, tolerance/ dependence, withdrawal if abruptly d/c, short term- use as needed (sparingly), CSA, PMP review, resp depression
How to screen for tardive dyskinesia ( facial tics like lip-smacking, tongue thrusting and rapid blinking)
AIMES scale - usually caused as side effect of antipsychotic med (ex. Olanzapine)
What to do if AIMS screening is positive?
notify the pts mental health specialist and discuss/ send copy of AIMS evaluation
not recommended for bipolar disorder; avoid in OSA
Benzos
Extreme irritability- aggressive outbursts
Violent behavior
Borderline personality disorder
Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms and rules are violated
Onset Toddlerhood… diagnosed from 4 to 6 years old, and a formal diagnosis is typically made when the child is 7 years old or older.
frequently associated with a history of harsh discipline, abuse, or neglect.
Most commonly, referrals for clinical treatment are for aggressive behavior patterns
Conduct Disorder
pattern of problems with rules and authority figures. ODD symptoms emerge during the preschool years and persist for a minimum of 6 months
Usually dx at school age
Most commonly, referrals for clinical treatment are for aggressive behavior patterns
Oppositional Defiant Disorder
diagnosed >4yo, inattention, hyperactivity, impulsivity inappropriate for developmental age should exist in at least 2 settings, ADD: attention issues more common adulthood (less hyperactive), poor work performance, failed relationships, frequent MVC,
ADHD
Dx and screenings for ADHD
Diagnostics: BP, EKG not necessary
Screening: Vanderbilt ADHD Scales, ADHD rating scale, obtain from two domains (home/school)
Tx for ADHD
Behavior management alone if <6yo; over age 6 combine behavioral therapy with meds
Amphetamines: ex. Vyvanse 70mg/day; others 0.3-1.0 mg/kg/day
Methylphenidate (ritalin): less emotional lability
Alpha agonist: clonidine
Strattera
School accommodations may be needed (Section 504 service plan)- requires 60-day evaluation in most states
difficulty with social communication and restricted, repetitive patterns of behavior, interest, or activities.
Persistent deficits in social communication and social interaction across multiple contexts
restricted , repetitive patterns of behavior, interests, or activities
Intellectual disability or global developmental delay
School age-inability to build friendships, difficulty transitioning, isolation
Adolescence- rote learning
ASD
Screenings for ASD
MCHAT-under 2,
CAST -over age of 3
validated screening tool at 18 and 24 months of age for early identification
Routine developmental screening is suggested at nine-, 18-, and 24- or 30-month well-child visits
Dx for ASD
Comprehensive assessment by interdisciplinary team or child psychologist, developmental pediatrician
Dx confirm with DSM-5 for ASD
Tx for ASD
Early intensive behavioral intervention- 25 hours per week recommended for preschool to early school aged children with ASD
Cognitive behavior therapy- decreases anxiety symptoms in older children with ASD who has average to above average ASD
Aripiprazole (Abilify) and risperidone (Risperdal)- approved for ASD-associated irritability, explosive outburst, aggression, and self injury
aripiprazole - children 6-17 yrs
risperidone - children 5-16 years
s/e: weight gain, tremor, sedation, and extrapyramidal symptoms
Melatonin- insomnia
Ritalin- ADHD
mood instability irritable, chronic sleep problems, risky behaviors, racing thoughts, talk fast, psychotic symptoms, Hallmark: don’t feel like they need to sleep and feel rested after 1-2 hours
Bipolar Type 1
hypomania (depression followed by periods of feeling well and emotionally healthy) and major depression
Bipolar Type 2
Dx for Bipolar
CBC, CMP, Lipid panel, TFT, urine drug screen, mood disorder questionnaire (MDQ), patient health questionnaire PHQ, Columbia suicide severity rating scale
Tx for Bipolar
Lithium carbonate, valproate (depakote), carbamazepine/oxcarbazepine, lamotrigine,
Atypical antipsychotic ex. Abilify, zyprexa, risperdal, seroquel, geodon SE: hyperlipidemia, wt gain, EPS, nipple discharge
Psychotherapy
Partial hospitalization program/intensive outpatient program
ECT
Abstaining from caffeine, alcohol, and illicit drugs
12-step programs as appropriate
Encourage structure
Exercise, social interaction
Stable living environment
Refer to psychologist for maximized tx
restriction of food intake resulting in low body weight, intense fear of gaining weight or becoming fat, and disturbance of body image
Restrictive type
Binge eating/purging type
Define: loss of control and the feelings of guilt, shame, and embarrassment
Overweight or obese
Highest mortality rate of any mental health disorder
Anorexia
uncontrolled eating of an abnormally large amount of food in a short period, followed by compensatory behaviors such as self induced vomiting, laxative abuse, or excessive exercise
Bulimia
Dx criteria for anorexia
- Refusal to maintain bodyweight at or above minimally normal weight for height/age (less than 85th percentile). Or failure to gain weight during growth periods so that weight drops below 85%
- intense fear of “being fat”
- body dysmorphia
- binge eating/ purging subtype
Dx criteria for bulimia
- consuming large quantities of food in a short period of time (w/in 2 hours)
- loss of control during binge episodes
- engaging in repeated behavior to lose weight, including purging, excessive exercise or fasting
- binging or purging behaviors that occur at least once a week for at least 3 min
what should eval include for eating disorder
thorough H&P
Assess cormobidities
Dx for eating disorder
TSH, CBC, CMP, FBS, FSH (amenorrhea), U/A, ECG, possible bone density
eating disorder differentials
IBS, PUD< hyperthyroidism, CNS lesions, hormonal and metabolic diseases, immune disorders, OCD, SUD, Major depression
How to do refeeding plan for pts with an eating disorder
1.1 pounds (0.5 kg) per week goal
the primary role of PCP in eating disorder
Screening and early ID- EAT 26
Sequelae and co-morbids for eating disorder
death= arrhythmias, hypokalemia alcohol/ drug addictions osteoporosis - get DEXA scan GI disturbances Gynecological/ fertility probs
Pharm tx for OCD
SSRI and SNRI first line
1st line RX for PTSD
SSRI or SNRI
Long term SE: weight gain and sexual dysfunction
Benzos shortest length of time possible; caution in elderly.
CI current or previous substance abuse
Can cause rebound insomnia
Onset 16-30 years old; men earlier than women. Rare in children
RF: genetics and environment
Born during winter, advanced paternal age, parental stressors, OB complications, severe childhood abuse, cannabis use
schizophrenia
50-day prodromal period during which pt may experience changes in grades, sleep, mood, reduced concentration, attention, drive, and motivation\
schizophrenia
(sx added)- auditory hallucinations (voices, whispers; can be profane, critical, and derogatory or command); Visual hallucinations, tactile hallucinations; delusions
+ schizophrenia sx
(decrease or loss of normal functions): strong predictor of long term disability; deficit syndrome (disorganized behavior, progression of negative sx, and sx less responsive to meds and tx)
- schizophrenia sx
problems focusing, monitoring and evaluating performance, problem solving, setting and maintaining goals, serial learning, immparied verbal fluency.
cognitive sx
tests for appearance, attitude, speech, behavior, mood/affect, perceptions, thought process, sensorium, insight, judgment
Mental Status Exam (MSE):
Dx for schizophrenia
Labs and CT or MRI to r/o structural or traumatic conditions
Min 1 mo of positive sx and 6 mos of social disruption
TX of schizophrenia
assertive community treatment programs; skills training, CBT (individual or group for 4-9 mos)
antipsychotics:
(sometimes irreversible: chewing, tongue protrusion, facial grimacing, jerking extremities), extrapyramidal sx; hyperprolactinemia affecting BMD and sexual performance. Muscarinic and cholinergic (dry mouth, blurred vision, constipations, drowsiness, weight gain), and alpha-1 (orthostatic hypotension)
Tardive dyskinesia- SE of antipsychotics:
TX of tardive dyskinesia or EPS
Tx tardive dyskinesia w/ clozapine
Tx EPS sx w/ benztropine 2mg IM or diphenhydramine 50mg
also improve negative sx w/ lower risk of EPSs→ increased CV risk (weight gain, dyslipidemia, DM, accelerated cardiovascular disease) and premature death.
Med trials should last 2-6 weeks. Continue tx for 1 yr after relief is obtained
Second-generation/atypical antipsychotics
most often caused by an adverse reaction to neuroleptic or antipsychotic drugs
Medical emergency → elevated core body temp and modest-severe muscle rigidity + 2 or more:
Diaphoresis, tachycardia, elevated or labile BP, dysphagia, incontinence, tremor, changes in LOC, mutism, leukocytosis, lab evidence of muscle injury and hepatic enzyme elevations
Neuroleptic malignant syndrome (NMS)
Pt preoccupied with bodily sx and feel they have a serious illness; highly anxious (HAs, sure they have a brian tumor)
Somatic symptom disorder and illness anxiety disorder are two different diagnoses that replaced hypochondriac
Screening: Somatic symptom scale-8;
Somatic Symptom Disorder
Tx of Somatic Symptom Disorder
Tx: schedule short frequent visits (2-4 weeks) treat underlying anxiety/depression w/ ssri or snri. Try to get into mental health tx, often resistant; empathy, stress coping; limit diagnostic testing
CBT
Substance Use disorders
Screening:
Adults: AUDIT (14 +; alcohol only)
Kids: CRAFFT (car, relax, alone, forget, friends, trouble), s2bibi
Drugs: DAST-10
5-100mg; up to 300mg daily. Metabolized by liver w/ long half-life (caution liver)- for Alcohol withdrawal
Chlordiazepoxide (Libirum)
1-4mg q2-4hrs; less concern for liver injury- Alcohol withdrawal
Lorazepam (Ativan)
long half-life; ease of tapering
- Alcohol withdrawal
Diazepam (Valium)
opioid antagonist. once daily PO (50mg) or once monthly IM (380mg).
CI: cirrhosis, patients needing opioids.
SE: GI, HA, dizziness, lightheadedness, weakness. More common early in tx
50mg po once daily OR IM 380 mg monthly. Avoid w/ opioids or if used in last week. CI Cirrhosis
SE: lightheaded, dizzy, weak, GI sx; usually resolve after early tx. Alcohol can be consumed
- for alcohol cravings
Naltrexone (Revia or Vivitrol)
FDA approved; Do not have to stop drinking alcohol. Helps reduce amount consumed.
2 tabs 3x/day If pts weigh <132 lbs reduce to bid. SE: minor GI Better for a patient who may want to continue drinking and slowly decrease consumption Renally cleared; CI GFR <30 Teratogenic
Acamprosate (Campral)
alcohol deterrent; abstinence only- no OTC meds with alcohol
Can remain in body for 2 wks
- for alcohol cravings
Disulfiram (Antabuse)
Vitamin Replacement for Alcohol
Thiamine 100-200 mg daily
B12 IM 1000 mg monthly or 100 mg daily
Multivitamin with folic acid
who should be screened for alcohol and substance abuse?
screen everyone age 18 or older in primary care incl. pregnant women
- AUDIT, CRAFFT, CAGE
DX for substance abuse?
drug screen, LFTs, renal fx, STD, hepatitis, HCG, TSH, other nutrients
management plan for alcohol use disorder
trusting relationship
refer to support groups, psychotherapy/ CBT, rehab, pain mgmt specialist when indicated
Tx for opioid use dosrder
titrated for opioid withdrawal by specialist
Full opioid agonist
Eventually will need maintenance therapy, watch for QT prolonging drugs and drugs that accelerate/slow methadone metabolism
Methadone
Wait to give until withdrawal symptoms present
Partial opioid agonist which can precipitate withdrawal symptoms but utilized inpatient when clinical opiate withdrawal score is high 8 to 10 or greater then tapered over minimum of 5 days
Tx for opioid use dosrder
Buprenorphine/ naloxone (Suboxone)
Suppresses hyperactivity- Tx for opioid use dosrder
Clonidine
Augmenting agents:Tx for opioid use dosrder
NSAIDS/tylenol, muscle relaxers,n/v meds, anti diarrhea meds
Nicotine replacement therapy (NRT)
gum, lozenge, nasal spray, dermal patches. Careful during pregnancy takes 14-30 days
antidepressant approved for smoking cessation in a person who smokes 10 more cigarettes/day. Can be used in conjunction with NRT
Taper up dose, Start 1 week before quit date, continue for 7-12 weeks
Bupropion (Wellbutrin or Zyban)
start tx 1 week before quitting nicotine. Minimum 12 week tx.
Not recommended to use with NRT
SE: nausea
Varenicline tartrate (Chantix)
Substance use disorder:
At least 2 of the following in a 12 month period
Substance taken in larger amounts over longer period of time than intended
Persistent desire or unsuccessful effort to cut down or control use
Great amount of time spent to obtain substance
craving/ strong desire/urge
Recurrent use resulting in failure to fulfill major role obligations at work, school home
Continued use despite social interpersonal problems caused by substance affects
Social occupational or recreational activities are given up or reduced due to use
Recurrent use in situations in which it is physically hazardous
Use continued despite knowledge of having a physical or psychological problems due to substance
Tolerance or withdrawal
“Chronic relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences”
addiction
patient exhibits drug seeking behavior and appears aggressive but they in fact have untreated actual pain
Pseudoaddiction
TX for ADD/ ADHD tx
Amphetamines, methylphenidate, psychostimulants.
strattera is non stimulant and will not provoke anxiety
Stimulants increase risk for PVD or Raynauds
age group PTSD sx- infants
feeding problems, failure to thrive, sleep probs, irritability
age group PTSD sx- preschool
sleep probs, nightmares, developmental regression, aggression, extreme tamper tantrums, anxiety sx, sudden worsening fears, irritability, avoidance of sx
age group PTSD sx- school age
sleep probs, nightmares, developmental regression, repetitive themes in play and social withdrawal, may have partial amnesia of events, new onset anxiety or fears, panic attacks, impaired concentration ,impaired school performance, avoidance sx or hypervigilance, somatic complaints `
age group PTSD sx- adolescents
acting out , sleep probs/ nightmares, extreme startling, social withdrawal, fears, anxiety, panic attacks, depression, anger or rage, internalizing, suicidal ideation, impaired concentration, impaired school performance, hypervigilance
evaulation of trauma sx
careful direct clinical interview including child
avoid prompting leading questions
invasion of privacy, how trauma occurred, sx pattern
Trauma, re-experience, avoidance, unable to fx, month or longer, arousal
factors influencing the severity of PTSD response
severity of the trauma exposure
parental distress related to the trauma
temporal proximity to the event
management for PTSD
referral to behavioral health, CBT, report social services, medication mgmt
