Psych

Question 1

Danger Signals

S_____ Risk Factors

Acute S_____ Syndrome

Malignant ______ Syndrome

Answer 1

Suicide Risk Factors

Acute Serotonin Syndrome (Serotonin Toxicity)

Malignant Neuroleptic Syndrome

Question 2

Suicide Risk Factors

1. Older people who have recently lost a _____ (due to death or divorce)
2. Plan involving a g___ or other lethal weapon
3. H_____ of attempted suicide and/or family history of suicide
4. M____ illness such as depression, bipolar disorder
5. History of sexual, emotional, and/or physical ____
6. T_____ illness, chronic illness, chronic p____
7. Al____ abuse, s______ abuse
8. Age 1__ to 2__ years or over age ___

Answer 2

1. Older people who have recently lost a spouse (due to death or divorce)
2. Plan involving a gun or other lethal weapon
3. History of attempted suicide and/or family history of suicide
4. Mental illness such as depression, bipolar disorder
5. History of sexual, emotional, and/or physical abuse
6. Terminal illness, chronic illness, chronic pain
7. Alcohol abuse, substance abuse
8. Age 15 to 24 years or over age 60

Question 3

Suicide Risk Factors Cont.

Demographic subgroups: American I_____ and A_____ Native youth and middle-age persons have the highest rate of suicide; _____ Americans have the lowest suicide rate

Significant l____ (divorce, breakup with boyfriend/girlfriend, job loss, death of a loved one)

(1) gender make more attempts compared with (1) gender, but (1) gender are more likely to die by suicide

Elderly (1) gender who recently lost a partner are at highest risk of suicide

Answer 3

Demographic subgroups: American Indian and Alaska Native youth and middle-age persons have the highest rate of suicide; African Americans have the lowest suicide rate

Significant loss (divorce, breakup with boyfriend/girlfriend, job loss, death of a loved one)

Females make more attempts compared with males, but males are more likely to die by suicide

Elderly males who recently lost a partner are at highest risk of suicide

Question 4

(1)

Occurs from high levels of serotonin accumulating in the body due to the introduction of a new drug (drug interaction) and an increase in the dose. Has acute onset with rapid progression.

Answer 4

Acute Serotonin Syndrome (Serotonin Toxicity)

Question 5

Acute Serotonin Syndrome (Serotonin Toxicity)

The Hunter Toxicity Criteria Decision Rules

A patient must have taken a serotonergic agent and meet one of the following conditions:

• spontaneous cl_____
• inducible clonus plus ag_____ and di______
• o_____ clonus plus agitation or diaphoresis
• tr____ plus h____reflexia
• or h____tonia plus temperature >___C plus ocular clonus or inducible clonus.

Answer 5

The Hunter Toxicity Criteria Decision Rules

A patient must have taken a serotonergic agent and meet one of the following conditions:

• spontaneous clonus
• inducible clonus plus agitation and diaphoresis
• ocular clonus plus agitation or diaphoresis
• tremor plus hyperreflexia
• or hypertonia plus temperature >100.4°F (38°C) plus ocular clonus or inducible clonus.

Question 6

Acute Serotonin Syndrome (Serotonin Toxicity)

Look for ____ pupils (mydriasis).

Higher risk if combining two drugs that both block serotonin (i.e., S____, M____, T____, tr____, tryptophan).

If switching to another drug affecting serotonin, wait a minimum of __ weeks.

Acute serotonin syndrome is a potentially life-threatening reaction. Refer to ___.

Answer 6

Look for dilated pupils (mydriasis).

Higher risk if combining two drugs that both block serotonin (i.e., SSRIs, MAOIs, TCAs, triptans, tryptophan).

If switching to another drug affecting serotonin, wait a minimum of 2 weeks.

Acute serotonin syndrome is a potentially life-threatening reaction. Refer to ED.

Question 7

Malignant Neuroleptic Syndrome

=

Answer 7

Rare life-threatening idiopathic reaction from typical and atypical antipsychotics

Question 8

Malignant Neuroleptic Syndrome Causes

It is most often seen with ____-potency, ____-generation antipsychotics (e.g., chlorpromazine, haloperidol).

It can also be seen in _____ disease (parkinsonism hyperpyrexia syndrome) due to ______ of l-dopa or dopamine agonist therapy, dose reduction, or switching medications.

Syndrome usually develops following in_____ or a rapid in_____ in dose.

Answer 8

It is most often seen with high-potency, first-generation antipsychotics (e.g., chlorpromazine, haloperidol).

It can also be seen in Parkinson disease (parkinsonism hyperpyrexia syndrome) due to withdrawal of l-dopa or dopamine agonist therapy, dose reduction, or switching medications.

Syndrome usually develops following initiation or a rapid increase in dose.

Question 9

Malignant Neuroleptic Syndrome S/S

Sudden onset of high f____, muscular r_____, m_____status changes, dysautonomia (fluctuating (1) VS), and urinary ______.

Look for a history of mental illness and prescription of an (1)(s).

This is a potentially ___-threatening reaction. Mortality rate of 10% to 20%. Refer to ___ or call ____.

Answer 9

Sudden onset of high fever, muscular rigidity, mental status changes, dysautonomia (fluctuating blood pressure [BP]), and urinary incontinence.

Look for a history of mental illness and prescription of an antipsychotic(s).

This is a potentially life-threatening reaction. Mortality rate of 10% to 20%. Refer to ED or call 911.

Question 10

(1)

This Act allows 72 hours (3 days) of involuntary detention for evaluation and treatment of persons who are considered at very high risk for suicide and/or hurting others

Answer 10

The Baker Act

Question 11

Common Mental Health Questionnaires

• (1) Depression Inventory-II:* A multiple-choice self-report inventory for evaluating depression. Based on the theory that negative cognitions about the self and world in general can cause depression.
• (1):* The diagnostic manual for mental and emotional disorders created and used by the APA.
• (1):* A questionnaire used to evaluate an individual for confusion and dementia (e.g., Alzheimer’s, stroke)

Answer 11

• Beck Depression Inventory-II:* A multiple-choice self-report inventory for evaluating depression. Based on the theory that negative cognitions about the self and world in general can cause depression.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5;* The diagnostic manual for mental and emotional disorders created and used by the APA.
• Folstein Mini-Mental State Exam* (MMSE): A questionnaire used to evaluate an individual for confusion and dementia (e.g., Alzheimer’s, stroke); see

Question 12

Common Mental Health Questionnaires

• (1):* A 30-item (yes/no response) questionnaire. Shorter version contains 15 items. Used to assess depression in the elderly. Self-assessment format.
• (1):* A 7-item screening tool for helping to identify patients with anxiety. Is a valid and efficient tool (89% sensitivity and 82% specificity). The higher the score, the higher the anxiety level. Severe anxiety (15 or higher), moderate anxiety (10 points), and mild anxiety (5 points).

Answer 12

• Geriatric Depression Scale (GDS):* A 30-item (yes/no response) questionnaire. Shorter version contains 15 items. Used to assess depression in the elderly. Self-assessment format.
• Generalized Anxiety Disorder 7-Item (GAD 7) Scale:* A 7-item screening tool for helping to identify patients with anxiety. The GAD 7 is a valid and efficient tool (89% sensitivity and 82% specificity). The higher the score, the higher the anxiety level. Severe anxiety (15 or higher), moderate anxiety (10 points), and mild anxiety (5 points).

Question 13

Folstein Mini-Mental State Exam

(1) : What is the date today? (current day, month, year) Location? (name of the city, county, state)
(1) : Instruct patient that you will be testing their memory; say three unrelated words (pencil, apple, ball); ask patient to repeat words
(1) : Say “Starting at 100, count backward and keep subtracting 7.” Say “Spell the word world backward.”

(1): Give person one blank piece of paper and ask them to write a sentence
Draw intersecting pentagons; ask patient to copy the pentagons

Answer 13

Orientation: What is the date today? (current day, month, year) Location? (name of the city, county, state)

Immediate Recall: Instruct patient that you will be testing their memory; say three unrelated words (pencil, apple, ball); ask patient to repeat words

Attention and Calculation: Say “Starting at 100, count backward and keep subtracting 7.” Say “Spell the word world backward.”

Writing and Copying: Give person one blank piece of paper and ask them to write a sentence
Draw intersecting pentagons; ask patient to copy the pentagons

Question 14

Folstein Mini-Mental State Exam Scoring

Max Score =

Score indicating impairment

Answer 14

Maximum score is 30 correctly done

Score of <19 indicates impairment

Question 15

(1)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Quetiapine (Seroquel)

Answer 15

Atypical Antipsychotics

Second-generation antipsychotics are serotonin-dopamine antagonists and are also known as atypical antipsychotics.

Question 16

Atypical Antipsychotics AE

Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel)

O_____

D_____ type 2

Answer 16

Obesity

Diabetes type 2

Question 17

Atypical Antipsychotics Monitoring

Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel)

All can cause ____ gain

Check B _ _

Check weight every __ months

Answer 17

All can cause weight gain

Check BMI

Check weight every 3 months

Question 18

(1)

Haloperidol (Haldol), chlorpromazine

Answer 18

Typical Antipsychotics

First-generation antipsychotics are dopamine receptor antagonists (DRA) and are known as typical antipsychotics

Question 19

Typical Antipsychotics AE

Haloperidol (Haldol), Chlorpromazine

Elevates l_____/tr______

E _ _ effects*

T_____ dyskinesia*

___ prolongation

Sudden _____

(1) syndrome (rare)

Answer 19

Elevates lipids/triglycerides

Extrapyramidal effects*

Tardive dyskinesia*

QT prolongation

Sudden death

Malignant neuroleptic syndrome (rare)

Question 20

Typical Antipsychotics Monitoring

Haloperidol (Haldol), Chlorpromazine

Labs: Fasting blood g____ and l____ profile

Black Box Warning: Frail elderly are at higher risk of ____ from antipsychotics

Look for E_____ symptoms such as dys____, p_____sonism, ak____ (inability to stay still), t_____ dyskinesia

Answer 20

Labs: Fasting blood glucose and lipid profile

Black Box Warning: Frail elderly are at higher risk of death from antipsychotics

Look for extrapyramidal symptoms such as dystonia, parkinsonism, akathisia (inability to stay still), tardive dyskinesia

Question 21

(1)

Lamotrigine (Lamictal)

Carbamazepine (Tegretol)

Valproate (Depakote)

Answer 21

Anticonvulsants

Question 22

Anticonvulsants AE
(1)

Answer 22

Stevens–Johnson syndrome (Lamictal)

Question 23

Anticonvulsants Monitoring

Advise patient to report r____ (Stevens–Johnson); some anticonvulsants are also used as a ____ stabilizer for ____disorder

Monitor serum (1) concentration

Check serum (1) acid concentration

Answer 23

Advise patient to report rashes (Stevens–Johnson); some anticonvulsants are also used as a mood stabilizer for bipolar disorder

Monitor serum carbamezapine concentration

Check serum valproic acid concentration

Question 24

(1)

Sertraline (Zoloft)

Paroxetine (Paxil)

Citalopram (Celexa)

Escitalopram (Lexapro)*

Answer 24

SSRIs

Question 25

SSRIs AE Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa), Escitalopram (Lexapro)**_\*_** All SSRIs can cause s\_\_\_\_\_ dysfunction Highest risk of er\_\_\_\_\_\_ dysfunction (ED) El\_\_\_\_\_ on multiple drugs, less risk of drug interactions

Answer 25

All SSRIs can cause sexual dysfunction Highest risk of erectile dysfunction (ED) Elderly on multiple drugs, less risk of drug interactions

Question 26

SSRI's Monitoring *Black Box Warning:* Do not discontinue _____ abruptly; wean gradually

Answer 26

*Black Box Warning:* All SSRIs may cause suicidal ideation/plans (\<24 years of age) Do not discontinue Paxil abruptly; wean gradually

Question 27

(1) Bupropion (Wellbutrin) Buproprion (Zyban)

Answer 27

Atypical Antidepressants

Question 28

Atypical Antidepressants AE, Monitoring Bupropion (Wellbutrin), Buproprion (Zyban) AE (1) Monitoring = CI in (1) disorders, an\_\_\_\_, bu\_\_\_\_\_, can be used for (1) cessation

Answer 28

AE = Seizures Monitoring = Contraindicated with seizures disorder, anorexia, or bulimia, For smoking cessation

Question 29

(1) Venlafaxine (Effexor) Duloxetine (Cymbalta**_\*\*_**)

Answer 29

SNRIs

Question 30

SNRIs AE Venlafaxine (Effexor), Duloxetine (Cymbalta**_\*\*_**) Can precipitate acute narrow-angle \_\_\_\_\_\_\_ Bio\_\_\_\_\_\_reduced by 33% in smokers

Answer 30

Can precipitate acute narrow-angle glaucoma Bioavailability reduced by 33% in smokers

Question 31

SNRIs Monitoring Venlafaxine (Effexor), Duloxetine (Cymbalta**_\*\*_**) Avoid with uncontrolled (1) Do not take 5 days before or 14 days after M\_\_\_\_, lin\_\_\_\_, sel\_\_\_\_\_, IV methylene \_\_\_\_

Answer 31

Avoid with uncontrolled narrow-angle glaucoma Do not take 5 days before or 14 days after MAOI, linezolid, selegiline, IV methylene blue

Question 32

(1) Amitriptyline (Elavil) Nortriptyline (Pamelor) Doxepin (Sinequan)

Answer 32

TCAs

Question 33

TCAs AE Amitriptyline (Elavil), Nortriptyline (Pamelor), Doxepin (Sinequan) Anti\_\_\_\_\_\_ effects Category \_\_\_

Answer 33

Anticholinergic effects Category X

Question 34

TCAs Monitoring Amitriptyline (Elavil), Nortriptyline (Pamelor), Doxepin (Sinequan) Do not combine with (1) or (1), as they will increase risk of serotonin syndrome

Answer 34

Do not combine with SSRIs or MAOIs, as they will increase risk of serotonin syndrome

Question 35

**Lithium** Lithium carbonate (Eskalith) Indication (1) **AE (1)\*** Contraindicated if sodium de\_\_\_\_\_, **de\_\_\_\_\_,** significant **r\_\_\_\_** or cardiovascular disease Check serum trough level when?

Answer 35

Used for bipolar disorder; **“Ebstein’s anomaly”** is congenital heart defect caused by lithium Contraindicated if sodium depletion, **dehydration**, significant renal or cardiovascular disease Check serum trough level 12 hours after last dose

Question 36

**Selective Serotonin Reuptake Inhibitors** First line treatment for (4)

Answer 36

**Major depression**, obsessive-compulsive disorder **Generalized anxiety disorder**, panic disorder, social anxiety disorder **Premenstrual dysphoric disorder** **Posttraumatic stress disorder (PTSD)**

Question 37

*Common Selective Serotonin Reuptake Inhibitors* ## Footnote * (1) (Prozac):* Longest half-life of all SSRIs and the first SSRI (useful for noncompliant patients) * (1):* Shortest half-life * (1) (Celexa):* Has fewer drug interactions compared with other SSRIs * (1) (Lexapro):* Compound derived from citalopram (Celexa) * Other SSRIs:* _____ (Zoloft), \_\_\_\_\_\_(Luvox)

Answer 37

* Fluoxetine (Prozac):* Longest half-life of all SSRIs and the first SSRI (useful for noncompliant patients) * Paroxetine (Paxil):* Shortest half-life * Citalopram (Celexa):* Has fewer drug interactions compared with other SSRIs * Escitalopram (Lexapro):* Compound derived from citalopram (Celexa) * Other SSRIs:* Sertraline (Zoloft), fluvoxamine (Luvox)

Question 38

SSRI Side Effects ## Footnote Causes loss of l\_\_\_\_\_ in men and women, er\_\_\_\_\_ dysfunction, an\_\_\_\_, ins\_\_\_\_\_. Avoid with an\_\_\_\_\_ patients and undernour\_\_\_\_\_ elderly (depresses appetite more). *Paroxetine (Paxil):* Common side effect is (1) dysfunction \_\_\_\_\_ SSRIs over 2 to 4 weeks prior to discontinuation. (1) is the most likely to cause symptoms and may need to be discontinued for a period of 3 to 4 weeks or longer.

Answer 38

Causes loss of libido in men and women, erectile dysfunction, anorexia, insomnia. Avoid with anorexic patients and undernourished elderly (depresses appetite more). *Paroxetine (Paxil):* Common side effect is erectile dysfunction. Taper SSRIs over 2 to 4 weeks prior to discontinuation. Paroxetine is the most likely to cause symptoms and may need to be discontinued for a period of 3 to 4 weeks or longer.

Question 39

SSRI *Side Effects* ## Footnote (1) is least likely to cause discontinuation syndrome because of its long elimination half-life; it can be tapered over 1 to 2 weeks. \_\_\_\_\_ discontinuation may precipitate dysphoria, fatigue, chills, myalgias, headache, dizziness, gastrointestinal distress. Discontinuation syndrome occurs in 20% to 30%.

Answer 39

Fluoxetine is least likely to cause discontinuation syndrome because of its long elimination half-life; it can be tapered over 1 to 2 weeks. Abrupt discontinuation may precipitate dysphoria, fatigue, chills, myalgias, headache, dizziness, gastrointestinal distress. Discontinuation syndrome occurs in 20% to 30%.

Question 40

SSRI *Contraindications* ## Footnote Avoid SSRIs within 14 days of taking an (1) (serotonin syndrome). Can induce _____ with bipolar patients.

Answer 40

Avoid SSRIs within 14 days of taking an MAOI (serotonin syndrome). Can induce mania with bipolar patients.

Question 41

Tricyclic Antidepressants ## Footnote Do we use TCAs for depression? *Other uses:* Postherpetic _____ (chronic pain), urinary \_\_\_\_\_\_\_. Avoid if patient at high risk for _____ because they may hoard pills and overdose. Overdose will cause fatal cardiac (ventricular \_\_\_\_\_\_) and neurologic effects (\_\_\_\_\_). *Examples:*

Answer 41

## Footnote Not considered first-line treatment for depression. *Other uses:* Postherpetic neuralgia (chronic pain), urinary incontinence. Avoid if patient at high risk for suicide because they may hoard pills and overdose (suicide attempt). Overdose will cause fatal cardiac (ventricular arrhythmia) and neurologic effects (seizures). *Examples:* Doxepin (Sinequan), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Norpramin)

Question 42

Serotonin-Norepinephrine Reuptake Inhibitors ## Footnote Increased available serotonin and \_\_\_\_\_\_\_\* in the brain *\_\_\_\_\_\_ (Cymbalta):* Can treat generalized anxiety disorder, fibromyalgia, depression, and diabetic peripheral neuropathy; smoking reduces bioavailability by 33% \_\_\_\_\_\_ (Effexor) \_\_\_\_\_\_ (Pristiq)

Answer 42

Increased available serotonin and norepinephrine in the brain *Duloxetine (Cymbalta):* Can treat generalized anxiety disorder, fibromyalgia, depression, and diabetic peripheral neuropathy; smoking reduces bioavailability by 33% Venlafaxine (Effexor) Desvenlafaxine (Pristiq)

Question 43

Monoamine Oxidase Inhibitors MAOIs Clinical Indication = \_\_\_\_\_\_\_ (Nardil), _______ (Parnate) Do not combine with S\_\_\_\_, T\_\_\_, monoamine oxidase B (MAO-B; selegiline [Eldepryl]), \_\_\_\_\_receptor agonists (e.g., sumatriptan [Imitrex], zolmitriptan [Zomig]).

Answer 43

Rarely used due to serious food (high tyramine content) and drug interactions Phenelzine (Nardil), tranylcypromine (Parnate) Do not combine with SSRIs, TCAs, monoamine oxidase B (MAO-B; selegiline [Eldepryl]), serotonin receptor agonists (e.g., sumatriptan [Imitrex], zolmitriptan [Zomig]).

Question 44

MAOIs CI ## Footnote Do not combine MAOI with S\_\_\_\_ or T\_\_\_ Wait at least 2 weeks before initiating SSRI or TCA (high risk of (1)).

Answer 44

Do not combine MAOI with SSRI or TCA. Wait at least 2 weeks before initiating SSRI or TCA (high risk of serotonin syndrome).

Question 45

*High-Tyramine Foods and Monoamine Oxidase Inhibitors* ## Footnote The combination can cause the tyramine pressor response (elevates BP, risk of stroke); avoid combining with f\_\_\_\_\_\_\_ foods such as beer, Chianti w\_\_\_, some aged \_\_\_\_, fava \_\_\_\_. High-tyramine foods can also cause _____ headache in susceptible persons.

Answer 45

The combination can cause the tyramine pressor response (elevates BP, risk of stroke); avoid combining with fermented foods such as beer, Chianti wine, some aged cheeses, fava beans. High-tyramine foods can also cause migraine headache in susceptible persons.

Question 46

Benzodiazepines (Tranquilizers) ## Footnote Benzodiazepines are indicated for a\_\_\_\_\_ disorders, p\_\_\_\_ disorder, and in\_\_\_\_\_. \_\_\_\_\_\_\_ (Valium) is also used for severe alcohol withdrawal and seizures. Do not discontinue abruptly because it increases risk of \_\_\_\_\_\_; wean \_\_\_\_.

Answer 46

Benzodiazepines are indicated for anxiety disorders, panic disorder, and insomnia. Diazepam (Valium) is also used for severe alcohol withdrawal and seizures. Do not discontinue abruptly because it increases risk of seizures; wean slowly.

Question 47

Benzodiazepines (Tranquilizers) *Examples* ## Footnote * (1) acting:* Midazolam IV only (Versed), triazolam (Halcion) * (1) acting:* Alprazolam (Xanax), lorazepam (Ativan) * (1) acting:* Diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), and clonazepam (Klonopin)

Answer 47

* Ultra–short acting:* Midazolam IV only (Versed), triazolam (Halcion) * Medium acting:* Alprazolam (Xanax), lorazepam (Ativan) * Long acting:* Diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), and clonazepam (Klonopin)

Question 48

Major and Minor Depression Also known as _____ *depression* (vs. bipolar depression). Minor depression is a m\_\_\_\_ form. The criteria of signs and symptoms are the same as major depression except that there are f\_\_\_\_ symptoms (at least \_\_\_, but less than \_\_\_\_). Attributed to dysfunction of the neurotransmitters (1) and (1). Has a strong g\_\_\_\_\_\_ component.

Answer 48

Also known as *unipolar depression* (vs. bipolar depression). Minor depression is a milder form. The criteria of signs and symptoms are the same as major depression except that there are fewer symptoms (at least two, but less than five). Attributed to dysfunction of the neurotransmitters serotonin and norepinephrine. Has a strong genetic component.

Question 49

Depression Symptoms ## Footnote * Mood:* ______ mood most of the time; may become tearful * An\_\_\_\_\_\_:* Diminished interest or pleasure in all or most activities * Energy:* F\_\_\_\_\_ or loss of energy * Sleep:* \_\_\_\_somnia or \_\_\_\_\_somnia * G\_\_\_\_\_\_:* Feelings of worthlessness and inappropriate guilt * Concentration:* Dim\_\_\_\_\_\_\_ concentration and difficulty making decisions * S\_\_\_\_\_\_:* Recurrent/obsessive thoughts of death and suicidal ideation * Weight:* Weight ____ (\>5% body weight) or weight \_\_\_\_\_ * Ag\_\_\_\_\_\_\_:* Psychomotor agitation or retardation

Answer 49

* Mood:* Depressed mood most of the time; may become tearful * Anhedonia:* Diminished interest or pleasure in all or most activities * Energy:* Fatigued or loss of energy * Sleep:* Insomnia or hypersomnia * Guilt:* Feelings of worthlessness and inappropriate guilt * Concentration:* Diminished concentration and difficulty making decisions * Suicide:* Recurrent/obsessive thoughts of death and suicidal ideation * Weight:* Weight loss (\>5% body weight) or weight gain * Agitation:* Psychomotor agitation or retardation

Question 50

Immediate Goal: Assess for Suicidal and/or Homicidal Ideation or Plan If patient is considered to be a real and present threat of harm to self or others: Refer to a psychiatric h\_\_\_\_\_. Patient must be driven by? If none are available, call ____ for police. The police can “\_\_\_\_\_ Act” the patient. What is this act?

Answer 50

If patient is considered to be a real and present threat of harm to self or others: ## Footnote Refer to a psychiatric hospital. Patient must be driven by a family member or friend. If none are available, call 911 for police. The police can “Baker Act” the patient. A Baker Act proceeding is a means of providing emergency services for mental health treatment (72 hours) on a voluntary or involuntary basis.

Question 51

Depression Differential Diagnosis Rule out organic causes, such as hypo\_\_\_\_\_\_, an\_\_\_\_\_, auto\_\_\_\_\_ disorders, vitamin \_\_\_\_deficiency.

Answer 51

Rule out organic causes, such as hypothyroidism, anemia, autoimmune disorders, vitamin B12 deficiency.

Question 52

Screening Tools for Depression * Beck Depression Inventory:* Contains ____ items * Beck Depression Inventory for Primary Care (99% specificity):* Contains ____ items * Two-item question:* Ask the following two questions. If answers yes to either question (or both), positive finding. 1. *During the past month, have you felt?* 2. *During the past month, have you felt?*

Answer 52

* Beck Depression Inventory:* Contains 21 items * Beck Depression Inventory for Primary Care (99% specificity):* Contains seven items * Two-item question:* Ask the following two questions. If answers yes to either question (or both), positive finding. 1. *During the past month, have you felt down, depressed, or hopeless?* 2. *During the past month, have you felt little interest or pleasure doing things?*

Question 53

Depression Labs ## Footnote Complete blood count (CBC), chemistry profile, (1) hormone, F\_\_\_\_ and (1) levels, urinalysis (UA) Rule out organic causes; _____ screen to rule out illicit drug use if at risk

Answer 53

Complete blood count (CBC), chemistry profile, thyroid-stimulating hormone (TSH), folate and vitamin B12 levels, urinalysis (UA) Rule out organic causes; toxicology screen to rule out illicit drug use if at risk

Question 54

Depression Treatment Plan ## Footnote Rule out diseases such as an\_\_\_\_\_\_, diabetes, \_\_\_\_\_thyroid (TSH/thyroid panel), chemistry panel (low potassium for Addison’s disease), and vitamin ____ anemia. Refer for\_\_\_\_\_ therapy. **(1)\*** can reduce symptoms (comparable to an antidepressant medication) and is usually effective; if necessary, refer to psychiatrist or psychiatric-mental health nurse practitioner (PMHNP). If psychotic, refer to the \_\_\_. **(1) +** **(1)** work better than either method alone.

Answer 54

Rule out diseases such as anemia, diabetes, hypothyroid (TSH/thyroid panel), chemistry panel (low potassium for Addison’s disease), and vitamin B12 anemia. Refer for psychotherapy. Cognitive behavioral therapy can reduce symptoms (comparable to an antidepressant medication) and is usually effective; if necessary, refer to psychiatrist or psychiatric-mental health nurse practitioner (PMHNP). If psychotic, refer to the ED. Psychotherapy plus antidepressants work better than either method alone.

Question 55

Depression First Line Medication (1) Advise patients that antidepressant effect may take from ___ to ___ weeks (up to 12 weeks) to manifest. SSRIs are also first-line therapy for el\_\_\_\_\_\_ patients because they have fewer side effects.

Answer 55

SSRIs Advise patients that antidepressant effect may take from 4 to 8 weeks (up to 12 weeks) to manifest. SSRIs are also first-line therapy for elderly patients because they have fewer side effects.

Question 56

SSRIs for Depression ## Footnote Initiation of medications for elderly and patients with renal and hepatic disorders should be? After initiation, follow up when to check for compliance and side effects? How long should you continue SSRIs for once symptoms have resolved? Frequent relapse means patient may need \_\_\_\_time treatment.

Answer 56

Initiation of medications for elderly patients and patients diagnosed with renal or hepatic disorders should **begin at a low dose and increased slowly** and gradually as tolerated. After initiation, follow up in **2 weeks** to check for compliance and side effects. Continue SSRI therapy for at least **4 to 9 months after symptoms** have resolved (usually on first episode) Frequent relapse means patient may need lifetime treatment.

Question 57

* Other Antidepressants* for Depression (1) (amitriptyline [Elavil], nortriptyline [Pamelor]). What is the preferred time of day to dose them, why? Other uses (3) Avoid TCAs with suicidal patients, why?

Answer 57

TCAs (amitriptyline [Elavil], nortriptyline [Pamelor]). ## Footnote Prefer bedtime dosing due to sedation. Other uses are postherpetic neuralgia, chronic pain, stress urinary incontinence. Avoid TCAs with suicidal patients, because they may hoard the pills and take an overdose (causes fatal arrhythmia).

Question 58

*Food and Drug Administration (FDA) Black Box Warning:* There is increased risk of **death in \_\_\_\_\_\_** (with dementia) on antipsychotic drugs such as **\_\_\_\_\_\_ (Haldol) and _______ (Thorazine).**

Answer 58

There is increased risk of **death in _elderly_** (with dementia) on antipsychotic drugs such as **haloperidol (Haldol) and chlorpromazine (Thorazine).**

Question 59

SSRIs: *FDA Black Box Warning* *=*

Answer 59

**Increased risk of suicidal thinking and behavior in children, adolescents, and young adults; the risk of suicidality is increased in young adults age 18 to 24 years during initial treatment (first 1–2 months).**

Question 60

SSRIs *Elderly Patients* *Which SSRIs (2) are preferred? Why?*

Answer 60

Citalopram (Celexa) and Escitalopram (Lexapro) These drugs cause fewer drug interactions than other SSRIs; may prolong QT interval.

Question 61

*Patients with sexual dysfunction caused by an SSRI:* Consider adding (1) to the SSRI prescription. Another option is to switch to an (1) or (1) antidepressant.

Answer 61

Consider adding bupropion (Wellbutrin) to the SSRI prescription. Another option is to switch to an SNRI or atypical antidepressant.

Question 62

*Depressed patient who wants to quit smoking* Consider **\_\_\_\_\_ (Zyban)**. Can be combined with \_\_\_\_\_\_-avoidance products (e.g., patches, gum)

Answer 62

Consider **Bupropion (Zyban**). Can be combined with nicotine-avoidance products (e.g., patches, gum)

Question 63

*Depressed patient with peripheral neuropathy:* Consider **(1)Rx**, which is also indicated for neuropathic pain.

Answer 63

Consider **duloxetine (Cymbalta)**, which is also indicated for neuropathic pain.

Question 64

*Depressed patient with postherpetic neuralgia and chronic pain* Consider **(1)Rx**

Answer 64

**TCAs**

Question 65

*Depressed patient with stress urinary incontinence* Consider 1(Rx)

Answer 65

TCAs

Question 66

Antipsychotics: Adverse Effects ## Footnote (1) Pill \_\_\_\_\_, \_\_\_\_\_gait, and \_\_\_\_kinesia caused by chronic use of antipsychotics. (1) * (1)*: inability to initiate movement * (1)*: A strong inner feeling to move, unable to stay still * (1)*: Slowness in movement when initiating activities or actions that require successive steps such as buttoning a shirt * (1):* Involuntary movements of the lips (smacking), tongue, face, trunk, and extremities (more common in schizophrenics)

Answer 66

Parkinsonism Pill rolling, shuffling gait, and bradykinesia caused by chronic use of antipsychotics. Extrapyramidal Symptoms (EPS) Akinesia: Iinability to initiate movement Akathisia: A strong inner feeling to move, unable to stay still Bradykinesia: Slowness in movement when initiating activities or actions that require successive steps such as buttoning a shirt *Tardive dyskinesia:* Involuntary movements of the lips (smacking), tongue, face, trunk, and extremities (more common in schizophrenics)

Question 67

Anticholinergics: Side Effects Many drug classes have strong anticholinergic effects, including * anti\_\_\_\_\_\_\_ * T\_\_\_\_ * decon\_\_\_\_\_\_\_ * anti\_\_\_\_\_\_ (e.g., pseudoephedrine). Use caution with * benign ______ hyperplasia * narrow-(1) * preexisting h\_\_\_\_\_ disease.

Answer 67

Many drug classes have strong anticholinergic effects, including * antipsychotics * TCAs * decongestants * antihistamines (e.g., pseudoephedrine). Use caution with * benign prostatic hyperplasia (BPH; urinary retention), * narrow-angle glaucoma, * preexisting heart disease.

Question 68

Anticholinergic Effects Mnemonic

Answer 68

SAD CUB ## Footnote ***S***edation ***A***norexia ***D***ry mouth ***C***onfusion and constipation ***U***rinary retention ***B***PH

Question 69

*Complementary/Alternative Treatments for Depression* Complementary treatments for depression include various h\_\_\_\_ and supplements, guided \_\_\_\_\_, and lifestyle measures such as ex\_\_\_\_ and y\_\_\_\_ Be aware of herb–\_\_\_\_\_interactions.

Answer 69

Complementary treatments for depression include various herbs and supplements, guided imagery, and lifestyle measures such as exercise and yoga Be aware of herb–drug interactions.

Question 70

St. John's Wort *(CAM)*

Answer 70

Question 71

Amino acid supplements such as 5-HTP, l-tryptophan *(CAM)* Drug Interactions (4) AE (1)

Answer 71

SSRIs and MAOIs, Dextromethorphan, Triptans (e.g., Imitrex, Zomig) Serotonin Syndrome

Question 72

*CAM* Omega-3 fatty acids (cold-water fish oil such as from salmon) Folate and vitamin B6 (pyridoxine) Any major drug interactions? _AE_ High doses of omega-3 fish oil may increase risk of bleeding Supplements are usually stopped about 1 week before surgery

Answer 72

No Major Drug Interactions _AE_ High doses of omega-3 fish oil may increase risk of \_\_\_\_\_\_ Supplements are usually stopped about ___ week before surgery

Question 73

*CAM* Exercise, yoga, massage, guided imagery, acupuncture, light therapy Can exercise help depression?

Answer 73

Exercise is just as effective in treating depression as some drugs

Question 74

Exam Tips **Mnemonic for remembering signs and symptoms of depression**

Answer 74

**SIG-E-CAPS** ## Footnote * S*leep * I*nterest * G*uilt * E*nergy * C*oncentration * A*ppetite * P*sychomotor * S*uicide

Question 75

Exam Tips ## Footnote Know how to diagnose minor depression and major depression. Differentiate presentations for bipolar disorder and depression. Antipsychotics lead to an increased risk of o\_\_\_\_, type 2 \_\_\_\_\_, hyperl\_\_\_\_\_, m\_\_\_\_\_ syndrome, and \_\_\_\_thyroidism. Learn how medication use should be monitored. Know **FDA Black Box Warnings** for SSRIs and antipsychotics = Know MAOI and **high-tyramine foods** to avoid =

Answer 75

Know how to diagnose minor depression and major depression. Differentiate presentations for bipolar disorder and depression. Antipsychotics lead to an increased risk of obesity, type 2 diabetes, hyperlipidemia, metabolic syndrome, and hypothyroidism. Learn how medication use should be monitored. Know FDA Black Box Warnings for SSRIs and antipsychotics = increased suicide in 18-24 for SSRIs, Frail elderly higher risk of death from antipsychotics (typical antipsychotics) Know MAOI and high-tyramine foods to avoid. = fermented foods such as beer, chianti wine, some aged cheeses, fava beans

Question 76

Exam Tips *Anticholinergics:* Use caution with (1) (urinary retention), (1) eye disorder, preexisting (1) disease. (1) Rx Class (both classic and new generation) have strong anticholinergic effects.

Answer 76

*Anticholinergics:* Use caution with BPH (urinary retention), narrow-angle glaucoma, preexisting heart disease. Antipsychotics (both classic and new generation) have strong anticholinergic effects.

Question 77

Exam Tips In general, there are now more questions on alternative treatments. * St. John’s wort is used for d\_\_\_\_\_, men\_\_\_\_\_\_ symptoms, and other conditions. Herb–drug interactions of St. John’s wort include ind\_\_\_\_\_ (protease inhibitor), cyc\_\_\_\_\_\_, oral cont\_\_\_\_\_, S\_\_\_\_, T\_\_\_\_. * (2) are both used for anxiety and insomnia. Do not mix with benzodiazepines, hypnotics, or any central nervous system (CNS) depressants.

Answer 77

* St. John’s wort is used for depression, menopausal symptoms, and other conditions. Herb–drug interactions of St. John’s wort include indinavir (protease inhibitor), cyclosporine, oral contraceptives, SSRIs, TCAs. * Kava-kava and/or valerian root are both used for anxiety and insomnia. Do not mix with benzodiazepines, hypnotics, or any central nervous system (CNS) depressants.

Question 78

Exam Tips A question on the **(1)** will describe an action (such as asking a patient to spell world backward) and ask you to indicate the name of the tool that is being used.

Answer 78

A question on the MMSE (or the MME) will describe an action (such as asking a patient to spell world backward) and ask you to indicate the name of the tool that is being used.

Question 79

Clinical Pearls ## Footnote Patients starting to recover from depression may (1) (from increase in psychic energy). Monitor closely. If potentially suicidal, be careful when refilling or prescribing certain medications that may be fatal if patient ________ (e.g., benzodiazepines, hypnotics, narcotics, amphetamines, TCAs). Give the smallest amount and lowest dose possible, with close follow-up.

Answer 79

Patients starting to recover from depression may commit suicide (from increase in psychic energy). Monitor closely. If potentially suicidal, be careful when refilling or prescribing certain medications that may be fatal if patient overdoses (e.g., benzodiazepines, hypnotics, narcotics, amphetamines, TCAs). Give the smallest amount and lowest dose possible, with close follow-up.

Question 80

Alcoholism Alcoholism is a compulsive desire to drink alcohol despite per\_\_\_\_, fin\_\_\_\_\_, and s\_\_\_\_\_ consequences. Individuals have a strong craving for alcohol and are unable to limit drinking. With alcohol \_\_\_\_\_, a patient experiences cognitive, behavioral, and physiologic symptoms that are generated from persistent and chronic use. Abrupt cessation causes --\_\_\_\_\_ symptoms. Alcohol _____ occurs when a maladaptive behavior pattern appears from repeated alcohol use.

Answer 80

Alcoholism is a compulsive desire to drink alcohol despite personal, financial, and social consequences. Individuals have a strong craving for alcohol and are unable to limit drinking. With alcohol dependence, a patient experiences cognitive, behavioral, and physiologic symptoms that are generated from persistent and chronic use. Abrupt cessation causes withdrawal symptoms. Alcohol abuse occurs when a maladaptive behavior pattern appears from repeated alcohol use.

Question 81

Alcoholism Definitions Elevated blood alcohol level **\>0.\_\_\_%** is illegal for driving (blood alcohol or breathalyzer) in all U.S. states. Standard drink sizes in the United States (considered “one drink”; Figure 1): * (1): 12 oz * Malt (1): 8 to 9 oz * (1): 5 oz * (1): 1.5 oz or a “shot” of 80-proof gin, vodka, rum, whiskey, or tequila

Answer 81

Elevated blood alcohol level **\>0.08%** is illegal for driving (blood alcohol or breathalyzer) in all U.S. states. Standard drink sizes in the United States (considered “one drink”; Figure 1): * Beer: 12 oz * Malt liquor: 8 to 9 oz * Wine: 5 oz * Liquor/spirits: 1.5 oz or a “shot” of 80-proof gin, vodka, rum, whiskey, or tequila

Question 82

Standard Drink Sizes

Answer 82

Question 83

Dietary Guidelines for Americans (Ethyl Alcohol or Ethanol) * Women*: ____ drinks per day * Men*: _____ drinks per day _Binge drinking:_ * A pattern of alcohol consumption that brings the blood alcohol level to ≥0.\_\_\_% on ____ occasion (generally within 2 hours) * Males: ≥ ____ drinks in a single occasion * Women: ≥ ____ drinks in a single occasion

Answer 83

* Women*: **One** drink per day * Men*: **Two** drinks per day Binge drinking: * A pattern of alcohol consumption that brings the blood alcohol level to ≥0.08% on one occasion (generally within 2 hours) * Males: ≥ five drinks in a single occasion * Women: ≥ four drinks in a single occasion

Question 84

Dietary Guidelines for Americans (Ethyl Alcohol or Ethanol) ## Footnote Women metabolize alcohol (50%) more slowly than do men and are more susceptible to alcohol-related ____ damage. Excessive alcohol consumption is the ____ leading preventable cause of death in the United States. The *DSM-5* diagnosis of alcoholism is called?

Answer 84

Women metabolize alcohol (50%) more slowly than do men and are more susceptible to alcohol-related liver damage. Excessive alcohol consumption is the third leading preventable cause of death in the United States. The *DSM-5* diagnosis of alcoholism is called “alcohol use disorder.”

Question 85

People Who Should Abstain From Alcohol ## Footnote Women who are p\_\_\_\_\_ (or suspect they are pregnant) or br\_\_\_\_\_\_\_ Re\_\_\_\_\_\_ alcoholics or people who cannot control the amount they drink People with _____ that require alertness and coordination (e.g., pilots, truck drivers) People taking _______ that interacts with alcohol

Answer 85

Women who are pregnant (or suspect they are pregnant) or breastfeeding Recovering alcoholics or people who cannot control the amount they drink People with jobs that require alertness and coordination (e.g., pilots, truck drivers) People taking medication that interacts with alcohol

Question 86

Drugs that Interact with Alcohol

Answer 86

Question 87

Alcohol Abuse Lab Results *Gamma-Glutamyl Transferase levels =*

Answer 87

Lone elevation (with/without alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) is a possible sign of occult alcohol abuse.

Question 88

Alcohol Abuse Lab Results ***_AST/ALT Ratio (Liver Transaminases)_*** What will the levels of AST and ALT be? What will the **ratio** usually be? Which one is **more specific to the liver?** AST is also found where besides the liver?

Answer 88

Both AST and ALT elevated (w or w/o GGT) **2:1 AST/ALT** **ALT is more specific to the liver** AST found in liver, cardiac and skeletal muscle, kidneys, and lungs

Question 89

Alcohol Abuse Lab Results ***Mean Corpuscular Volume =*** * Why will they RBCs be this size? ***Platelets =*** ***Triglycerides** =*

Answer 89

**MCV \>100** * large RBCs due to folate deficiency **Thrombocytopenia** (alcohol effects production and function of platelets) **Hypertriglyceridemia** (alcohol inhibits lipoprotein lipase activity → risk of acute pancreatitis)

Question 90

Alcohol Abuse Lab Results *(1)* **Biomarker test for chronic alcohol abuse (2–3 weeks or longer).** An elevated level is highly suggestive of recent high alcohol consumption, especially if abnormal ALT and/or AST. It can detect binge drinking or daily heavy drinking (≥4 drinks a day). It can also be used to detect a relapse. It has been proved to be superior to the GGT or MCV as an indicator of chronic alcohol (ethanol) abuse and hepatitis that is caused by alcohol abuse (with elevated AST and ALT).

Answer 90

*Carbohydrate-Deficient Transferrin*

Question 91

CAGE Test = *Positive result =*

Answer 91

**C:** Do you feel the need to *cut down*? **A:** Are you *annoyed* when your spouse/friend comments about your drinking? **G:** Do you feel *guilty* about your drinking? **E:** Do you need to drink *early* in the morning (an *eye-opener*)? *Positive =* at least **2/4** highly suggestive of alcohol abuse

Question 92

*T-ACE Test* Similar to the CAGE test, except for the first question. The last three questions are from the CAGE test. A **positive finding of at least ____ (out of four)** is highly suggestive of alcohol abuse. T: Does it *take more than ____ drinks* to make you feel \_\_\_\_? **A:** Have you ever been *annoyed* by people’s criticism of your drinking? **C:** Are you trying to *cut down* on drinking? **E:** How you ever used alcohol as an eye-opener in the morning (having a drink when you wake up to treat a hangover)?

Answer 92

Similar to the CAGE test, except for the first question. The last three questions are from the CAGE test. A **positive finding of at least two (out of four)** is highly suggestive of alcohol abuse. ## Footnote **T: Does it** ***take more than three drinks*** **to make you feel high?** **A:** Have you ever been *annoyed* by people’s criticism of your drinking? **C:** Are you trying to *cut down* on drinking? **E:** How you ever used alcohol as an eye-opener in the morning (having a drink when you wake up to treat a hangover)?

Question 93

(1) A \_\_-item questionnaire that is a shorter version of the original (1) Questionnaire (contains 24 items). It can be used in adults and adolescents. A disadvantage is time required to take and score it.

Answer 93

*Short Michigan Alcoholism Screening Test Questionnaire (MAST)* A **13-item questionnaire** that is a shorter version of the original Michigan Alcoholism Screening Test (MAST) Questionnaire (contains 24 items). It can be used in adults and adolescents. A disadvantage is time required to take and score it.

Question 94

(1) **A \_\_\_-question tool that is used with w\_\_\_\_\_, m\_\_\_\_\_\_, and adolescents.** Unlike other alcohol screening tests, it has proved to be accurate across all ethnic and gender groups. It is one of the _____ **accurate alcohol screening tests** (92%).

Answer 94

*Alcohol Use Disorders Identification Test (AUDIT)* **A 10-question tool that is used with women, minorities, and adolescents.** Unlike other alcohol screening tests, the Alcohol Use Disorders Identification Test (AUDIT) has proved to be accurate across all ethnic and gender groups. It is one of the **most accurate alcohol screening tests** (92%).

Question 95

Alcohol Abuse Treatment Plan ## Footnote **Rx(1)** (Librium, Valium), **Rx(1)** if needed (e.g., Haldol) *Vitamins:* **Th\_\_\_\_\_\_** 100 mg IV, **F\_\_\_\_\_** 1 mg orally/IV daily, and m\_\_\_\_vitamins with \_\_\_\_-calorie diet Refer to **(1)** (12-step program), a therapist, and/or a recovery program Avoid prescribing a recovering alcoholic/addict drugs with abuse potential such as nar\_\_\_\_\_ or any medication that contains alcohol (c\_\_\_\_ syrup)

Answer 95

**Benzodiazepines** (Librium, Valium), **antipsychotics** if needed (e.g., Haldol) *Vitamins:* **Thiamine** 100 mg IV, **folate** 1 mg orally/IV daily, and multivitamins with high-calorie diet Refer to **AA** (12-step program), a therapist, and/or a recovery program Avoid prescribing a recovering alcoholic/addict drugs with abuse potential such as narcotics or any medication that contains alcohol (cough syrup)

Question 96

Alcohol Abuse Treatment Plan *Medications* ## Footnote * (1)* *(Antabuse):* Causes severe nausea/vomiting, headache, other unpleasant effects * (1)* *(Vivitrol):* Decreases alcohol cravings

Answer 96

* Disulfiram* *(Antabuse):* Causes severe nausea/vomiting, headache, other unpleasant effects * Naltrexone* *(Vivitrol):* Decreases alcohol cravings

Question 97

*Alcoholic Anonymous* ## Footnote One of the most successful methods for recovering alcoholics. Founded by Bill Wilson and Dr. Robert Smith. Patient is paired with a m\_\_\_\_\_\_ (a recovered alcoholic); believes in a “higher power.” Must follow a \_\_\_\_-step program and attend Alcoholic Anonymous (AA) meetings (uses “ch\_\_\_\_” reward). Support group for family members and friends is called _____ (Al-Anon Family Groups). Support group for teen children of alcoholics is called \_\_\_\_\_.

Answer 97

One of the most successful methods for recovering alcoholics. Founded by Bill Wilson and Dr. Robert Smith. Patient is paired with a mentor (a recovered alcoholic); believes in a “higher power.” Must follow a 12-step program and attend Alcoholic Anonymous (AA) meetings (uses “chip” reward). Support group for family members and friends is called Al-Anon (Al-Anon Family Groups). Support group for teen children of alcoholics is called Alateen.

Question 98

**(1)** Most severe form of alcohol withdrawal that is characterized by a sudden onset of confusion; delusions; transient auditory, tactile, or visual hallucinations; tachycardia; hypertension; hand tremors; disturbed psychomotor behavior (picking at clothes); and grand mal seizures. Considered a medical emergency so refer to ED.

Answer 98

**Acute Delirium Tremens**

Question 99

**(1)** A complication from chronic alcohol abuse. A neurologic disorder with symptoms that include hypotension, visual impairment, and coma. Signs include mental confusion, ataxia, stupor, coma, and hypotension. **Treatment =**

Answer 99

**Korsakoff’s Syndrome (Wernicke–Korsakoff Syndrome)** A complication from chronic alcohol abuse. A neurologic disorder with symptoms that include hypotension, visual impairment, and coma. Signs include mental confusion, ataxia, stupor, coma, and hypotension. **Treatment = high-dose parenteral vitamins, especially _thiamine (vitamin B1)_**

Question 100

(1) **This is a type of _amnesia_ caused by _chronic thiamine deficiency_ due to chronic alcohol abuse.** Problems with acquiring (and learning) new information (antegrade amnesia) and retrieving older information (retrograde amnesia). Symptoms include confabulation, disorientation, attention deficits, and visual impairment. **Chronic thiamine deficiency damages the brain permanently.**

Answer 100

**Korsakoff’s Amnesic Syndrome**

Question 101

Smoking Cessation Tobacco use is the most common cause of preventable death. Discuss smoking cessation at every visit with patients who are smokers. *Nicotine gum use:* * Follow **“\_\_\_\_ and \_\_\_\_\_” pattern.** * Chew gum _____ until the nicotine ____ appears, then “park” next to the _____ (buccal mucosa) until the taste \_\_\_\_\_. * _____ pattern several times and discard nicotine gum after ___ minutes of use.

Answer 101

*Nicotine gum use:* * Follow **“chew and park” pattern.** * Chew gum slowly until the nicotine taste appears, then “park” next to the cheeks (buccal mucosa) until the taste disappears. * Repeat pattern several times and discard nicotine gum after 30 minutes of use.

Question 102

*Nicotine Patches* Can they smoke while on nicotine patches? Can you use nicotine patches with other nicotine products like gum? Why? Nicotine overdose can cause? Can nicotine products be used with buproprion (zyban)?

Answer 102

Patient cannot smoke while on nicotine patches. Do not use with other nicotine products (e.g., gum, inhaler); patient will overdose on nicotine. Nicotine overdose can cause acute myocardial infarction (MI), hypertension, and agitation in susceptible patients. Nicotine products can be used with bupropion (Zyban).

Question 103

Bupropion (Zyban) for Smoking Cessation Decreases _______ to smoke. Individual eventually loses des\_\_\_\_ to smoke and finally quits. Can patients smoke or use other nicotine products with buproprion? Contraindications include s\_\_\_\_\_ disorder, history of an\_\_\_\_\_/bulimia, abrupt cessation of ethanol, benzodiazepines, antiseizure drugs, severe stroke, and brain tumor. Be careful with depressed patients, why?

Answer 103

Decreases cravings to smoke. Individual eventually loses desire to smoke and finally quits. Patients can still smoke while on bupropion; can be combined with nicotine products. Contraindications include seizure disorder, history of anorexia/bulimia, abrupt cessation of ethanol, benzodiazepines, antiseizure drugs, severe stroke, and brain tumor. Be careful with depressed patients; may increase risk of suicidal thoughts and behavior.

Question 104

Varenicline (Chantix) Prescribe varenicline (Chantix) therapy for ___ weeks (or longer). Even if not ready to quit, initiating drug will reduce _____ for tobacco use and facilitate quitting; may be combined with nicotine ____ (increases risk of adverse effects). Take a careful ______ history and avoid prescribing to mentally unstable patients or those with a history of recent ____ ideation. Adverse effects include n\_\_\_\_psychiatric symptoms; may impair ability to d\_\_\_\_\_ or operate heavy machinery. (The Federal Aviation Administration [FAA] prohibits pilots and air traffic controllers from taking the drug.)

Answer 104

Prescribe varenicline (Chantix) therapy for 12 weeks (or longer). Even if not ready to quit, initiating drug will reduce cravings for tobacco use and facilitate quitting; may be combined with nicotine patch (increases risk of adverse effects). Take a careful psychiatric history and avoid prescribing to mentally unstable patients or those with a history of recent suicidal ideation. Adverse effects include neuropsychiatric symptoms; may impair ability to drive or operate heavy machinery. (The Federal Aviation Administration [FAA] prohibits pilots and air traffic controllers from taking the drug.)

Question 105

Electronic Cigarettes E-cigarettes (e-cigs, vapes, vaping, vape pens, e-hookahs) are devices that heat a liquid into aerosol (vapor), which is inhaled by the user. The liquid contains nicotine, flavoring, and other additives. **(1)** acetate, used as a diluent, can cause serious lung damage; the diagnosis is called e-cigarette, or vaping, product use–associated lung injury (\_\_\_\_). **(1)** vapes are also associated with EVALI. More than 2,800 cases of EVALI have been reported to the Centers for Disease Control and Prevention, with 60 deaths.

Answer 105

Vitamin E acetate, used as a diluent, can cause serious lung damage; the diagnosis is called e-cigarette, or vaping, product use–associated lung injury (EVALI). Tetrahydrocannabinol (THC) vapes are also associated with EVALI. More than 2,800 cases of EVALI have been reported to the Centers for Disease Control and Prevention, with 60 deaths.

Question 106

Electronic Cigarettes \_\_\_\_\_\_ vapes (e.g., cotton candy, mint, grape) are very popular with teens. The newer vapes are smaller, easier to hide, and resemble ___ flash drives. In 2018, one in five high school students reported using e-cigarettes in the past month. According to the CDC and FDA, e-cigarettes are ____ safe for youth, young adults, and pregnant women.

Answer 106

Flavored vapes (e.g., cotton candy, mint, grape) are very popular with teens. The newer vapes are smaller, easier to hide, and resemble USB flash drives. In 2018, one in five high school students reported using e-cigarettes in the past month. According to the CDC and FDA, e-cigarettes are not safe for youth, young adults, and pregnant women.

Question 107

EVALI (E-cigarette or Vaping-Associated Lung Injury) Symptoms of possible lung damage due to vaping: * Difficulty breathing, ______ of breath, and/or chest \_\_\_\_ * Mild-to-moderate gastrointestinal (GI) symptoms such as v\_\_\_\_ and d\_\_\_\_\_ * F\_\_\_ and fa\_\_\_\_ EVALI should be suspected in y\_\_\_\_\_\_ patients with a history of vaping (or other e-cigarette products) with p\_\_\_\_\_\_-like symptoms, progressive dy\_\_\_\_\_, and/or worsening h\_\_\_\_emia. Some have a history of as\_\_\_\_\_, which can become exacerbated with vaping.

Answer 107

Symptoms of possible lung damage due to vaping: * Difficulty breathing, shortness of breath, and/or chest pain * Mild-to-moderate gastrointestinal (GI) symptoms such as vomiting and diarrhea * Fevers and fatigue EVALI should be suspected in younger patients with a history of vaping (or other e-cigarette products) with pneumonia-like symptoms, progressive dyspnea, and/or worsening hypoxemia. Some have a history of asthma, which can become exacerbated with vaping.

Question 108

Insomnia (Sleep Disorder) What is thought to be the ideal number of hours of sleep? About 40 to 70 million Americans (20% of the population) suffer from either tr\_\_\_\_\_ (\<1 week), sh\_\_\_\_\_-term (1–3 months), or ch\_\_\_\_\_ (\>3 months) insomnia. Insomnia can manifest either as difficulty falling asleep (sleep-\_\_\_\_insomnia) or falling asleep but _____ up during the night or too early and being unable to go _____ to sleep. Can cause \_\_\_time drowsiness, fatigue, tension headache, irritability, and difficulty concentrating/focusing on tasks. Insomnia is a clinical diagnosis. Patient self-medicating using _____ to facilitate sleep may indicate a coexistent alcohol/drug-dependence problem. Abrupt cessation of these agents may cause \_\_\_creased insomnia and/or anxiety.

Answer 108

It is thought that **7 to 8** hours of sleep is the ideal amount About 40 to 70 million Americans (20% of the population) suffer from either transient (\<1 week), short-term (1–3 months), or chronic (\>3 months) insomnia. Insomnia can manifest either as difficulty falling asleep (sleep-onset insomnia) or falling asleep but waking up during the night or too early and being unable to go back to sleep. Can cause daytime drowsiness, fatigue, tension headache, irritability, and difficulty concentrating/focusing on tasks. Insomnia is a clinical diagnosis. Patient self-medicating using alcohol to facilitate sleep may indicate a coexistent alcohol/drug-dependence problem. Abrupt cessation of these agents may cause increased insomnia and/or anxiety.

Question 109

Insomnia Risk Factors * D\_\_\_\_\_, severe a\_\_\_\_\_ * GI disease (1) * ______ gender * illicit dr\_\_\_use, alcohol, caff\_\_\_\_, and nicotine * musculo\_\_\_\_\_ illness, p\_\_\_, chronic health problems * sh\_\_\_\_ work * Certain m\_\_\_\_\_\_ (e.g., SSRIs; cardiac, BP, and allergy meds; steroids; angiotensin-converting enzyme inhibitors [ACEIs]; angiotensin II receptor blockers [ARBs]) can cause insomnia.

Answer 109

* Depression, severe anxiety * gastroesophageal reflux disease (GERD) * female gender * illicit drug use, alcohol, caffeine, and nicotine * musculoskeletal illness, pain, chronic health problems * shift work * Certain medications (e.g., SSRIs; cardiac, BP, and allergy meds; steroids; angiotensin-converting enzyme inhibitors [ACEIs]; angiotensin II receptor blockers [ARBs]) can cause insomnia. Circadian rhythm disorders, psychic issues, mental illness, environmental factors, certain medications, jet lag, noise, idiopathic causes Medical conditions such as obstructive sleep apnea, restless legs syndrome, chronic fatigue syndrome, bipolar disorder, GERD, Alzheimer’s disease, Parkinson’s disease, arthritis pain, stroke

Question 110

Insomnia Classification ## Footnote * (1) insomnia (25%):* Not caused by disease, mental illness, or environmental factors * (1) insomnia:* Caused by disease (physical, emotional, mental) or environmental factors * (1) insomnia:* Duration of up to 3 nights * (1) -term insomnia:* Also known as acute insomnia; duration of \<3 months; caused by pain, stress, grief, or other factors; expected to resolve when stressor is gone or when patient has adjusted * (1) insomnia:* Presence of symptoms for at least 3 months, occurs at least 3 nights per week; it can be primary or secondary insomnia

Answer 110

* Primary insomnia (25%):* Not caused by disease, mental illness, or environmental factors * Secondary insomnia:* Caused by disease (physical, emotional, mental) or environmental factors * Transient insomnia:* Duration of up to 3 nights * Short-term insomnia:* Also known as acute insomnia; duration of \<3 months; caused by pain, stress, grief, or other factors; expected to resolve when stressor is gone or when patient has adjusted * Chronic insomnia:* Presence of symptoms for at least 3 months, occurs at least 3 nights per week; it can be primary or secondary insomnia

Question 111

Insomnia Treatment Plan First line treatment = Maintain regular sleeping time, nighttime ri\_\_\_\_\_ Avoid caff\_\_\_\_/tob\_\_\_\_/h\_\_\_\_ meals before bedtime Get ____ of bed in 30 minutes if not asleep Use bed only for (1) and (1) Avoid using m\_\_\_\_\_ with screens (smartphones, TV, computers) when in bed; the blue light can disrupt _______ secretion by the pineal gland.

Answer 111

Sleep hygiene ## Footnote Maintain regular sleeping time, nighttime ritual Avoid caffeine/tobacco/heavy meals before bedtime Get out of bed in 30 minutes if not asleep Use bed only for sleep and sex Avoid using media with screens (smartphones, TV, computers) when in bed; the blue light can disrupt melatonin secretion by the pineal gland.

Question 112

*Medication for Insomnia* **Rx(1)** an over-the-counter antihistamine, can cause excess sedation and confusion in the elderly. It is the most sedating antihistamine. Avoid with the elderly.

Answer 112

**Diphenhydramine (Benadryl),** an over-the-counter antihistamine, can cause excess sedation and confusion in the elderly. It is the most sedating antihistamine. Avoid with the elderly.

Question 113

Benzodiazepines/Hypnotics for Insomnia Some benzodiazepines are ____ sedating and are used as hyp\_\_\_\_\_. This includes triazolam (Halcion) and temazepam (Restoril). Hypnotics and “sleeping pills” are ideally used for a ____ duration. But many insomniacs continue using sleeping pills daily to help them sleep. Physical dep\_\_\_\_\_\_ may develop with long-term use. If a patient has been on a benzodiazepine for a long time, do not ________ abruptly (will increase risk of \_\_\_\_\_). Wean off slowly and gradually. * *Short acting (half-life \<5 hours):* Alprazolam (\_\_\_\_\_), triazolam (Halcion), midazolam (Versed) * *Intermediate acting (half-life 5–24 hours):* Lorazepam (\_\_\_\_\_), temazepam (Restoril), clonazepam (\_\_\_\_\_\_) * *Long acting (half-life \>24 hours):* Diazepam (\_\_\_\_\_), chlordiazepoxide (Librium)

Answer 113

Some benzodiazepines are more sedating and are used as hypnotics. This includes triazolam (Halcion) and temazepam (Restoril). Hypnotics and “sleeping pills” are ideally used for a short duration. But many insomniacs continue using sleeping pills daily to help them sleep. Physical dependence may develop with long-term use. If a patient has been on a benzodiazepine for a long time, do not discontinue abruptly (will increase risk of seizures). Wean off slowly and gradually. * *Short acting (half-life \<5 hours):* Alprazolam (Xanax), triazolam (Halcion), midazolam (Versed) * *Intermediate acting (half-life 5–24 hours):* Lorazepam (Ativan), temazepam (Restoril), clonazepam (Klonopin) * *Long acting (half-life \>24 hours):* Diazepam (Valium), chlordiazepoxide (Librium)

Question 114

Nonbenzodiazepine Hypnotics These drugs have ____ onset (15–30 minutes). Do not take if unable to get 7 to 8 hours of sleep. Adverse effects include agitation, hallucinations, nightmares, and ______ ideation. There have been cases in which a person wakes up and does their normal routine (sleep driving, eating, working) but is unable to re\_\_\_\_ the incident. * ______ (Ambien) and eszopiclone (Lunesta) for sleep onset or inability to stay asleep * _______ (Rozerem) for sleep-onset insomnia (melatonin agonist) * Temazepam (Restoril), ______ (Ativan) for sleep-onset insomnia and sleep maintenance insomnia

Answer 114

These drugs have quick onset (15–30 minutes). Do not take if unable to get 7 to 8 hours of sleep. Adverse effects include agitation, hallucinations, nightmares, and suicidal ideation. There have been cases in which a person wakes up and does their normal routine (sleep driving, eating, working) but is unable to recall the incident. * Zolpidem (Ambien) and eszopiclone (Lunesta) for sleep onset or inability to stay asleep * Ramelteon (Rozerem) for sleep-onset insomnia (melatonin agonist) * Temazepam (Restoril), lorazepam (Ativan) for sleep-onset insomnia and sleep maintenance insomnia

Question 115

*Complementary/Alternative Treatments for Insomnia* ## Footnote **Avoid (1)-**containing supplements. FDA Consumer Advisory issued; they are associated with **liver injury** (hepatitis, cirrhosis, fulminant liver failure). \_\_\_\_\_\_ root (sedating, also used for anxiety) \_\_\_\_\_\_\_\_ (also for circadian rhythm disorders such as shift work, jet lag) \_\_\_\_\_\_\_\_ tea Med\_\_\_\_\_, yoga, tai chi, ac\_\_\_\_\_\_\_, regular ex\_\_\_\_\_ (avoid 4 hours before bedtime)

Answer 115

**Avoid kava-kava** or kava-containing supplements. FDA Consumer Advisory issued; they are associated with **liver injury** (hepatitis, cirrhosis, fulminant liver failure). Valerian root (sedating, also used for anxiety) Melatonin (also for circadian rhythm disorders such as shift work, jet lag) Chamomile tea Meditation, yoga, tai chi, acupuncture, regular exercise (avoid 4 hours before bedtime)

Question 116

Exam Tips ## Footnote Lone **(1)** elevation can be a sign of occult alcohol abuse. **AST/ALT ratio of \_\_\_\_\_** or higher is more likely in alcoholism. Recognize **Korsakoff’s syndrome** and that it is caused by **(1)** **(1)** is the support group for an alcoholic’s family and friends. A male who drinks ____ glass of wine or ____ beer per day is not considered an alcoholic. Questions may be asked about who is most likely (or least likely) to become an alcoholic.

Answer 116

**Lone GGT** elevation can be a sign of **occult alcohol abuse.** **AST/ALT ratio of 2.0** or higher is more likely in alcoholism. Recognize **Korsakoff’s syndrome** and that it is caused by **chronic thiamine deficiency** = neuro disorder with hypotension, visual impairment, and coma - signs include confusion, ataxia, stupor, coma, hypotension - treat with high dose IV vitamin especially thiamine (VB1) **Al-Anon** is the support group for an alcoholic’s family and friends. A male who drinks one glass of wine or one beer per day is not considered an alcoholic. Questions may be asked about who is most likely (or least likely) to become an alcoholic.

Question 117

Exam Tips ## Footnote Can you mix nicotine patches with nicotine gum? Can you smoke while on patches? (1) (Zyban) is for smoking cessation. Can patients smoke while on this? Women are allowed ____ drink/day, and men are allowed ____ drinks/day. (2) are natural supplements used for insomnia/anxiety. Do not mix with benzodiazepines, hypnotics, or CNS depressants. Discuss smoking _______ with patients (who are smokers) at _____ visit.

Answer 117

Do not mix nicotine patches with nicotine gum. Do not smoke while on patches. Bupropion (Zyban) is for smoking cessation. Patients can smoke while on Zyban. Women are allowed one drink/day, and men are allowed two drinks/day. Kava-kava and valerian root are natural supplements used for insomnia/anxiety. Do not mix with benzodiazepines, hypnotics, or CNS depressants. Discuss smoking cessation with patients (who are smokers) at every visit.

Question 118

Bipolar Disorder **Bipolar disorder is characterized by _____ instability, alternating cycles of (1) and (1).** Peak incidence of onset is in the ____ (ranges from age 14 to 30 years). There are two types: bipolar type 1 and bipolar type 2 (\_\_\_\_\_\_ instead of mania). Bipolar patients are at higher risk of \_\_\_\_\_\_; 10% to 15% die by suicide

Answer 118

**Bipolar disorder is characterized by mood instability, alternating cycles of mania and depression.** Peak incidence of onset is in the 20s (ranges from age 14 to 30 years). There are two types: bipolar type 1 and bipolar type 2 (hypomania instead of mania). Bipolar patients are at higher risk of suicide; 10% to 15% die by suicide

Question 119

Bipolar Disorder Manic and Depressive Symptoms **Manic symptoms** are increased en\_\_\_\_/act\_\_\_\_\_, gr\_\_\_\_\_\_, less need for sl\_\_\_\_\_, disin\_\_\_\_\_\_, t\_\_\_ativeness, and eu\_\_\_\_\_ mood. **Depressive symptoms** are similar to major depression. At higher risk of ______ during the depressive phase of the illness. Look for signs and symptoms of depression and suicide warning signs.

Answer 119

**Manic symptoms** are increased energy/activity, grandiosity, less need for sleep, disinhibition, talkativeness, and euphoric mood. **Depressive symptoms** are similar to major depression. At higher risk of suicide during the depressive phase of the illness. Look for signs and symptoms of depression and suicide warning signs.

Question 120

Bipolar Disorder ## Footnote May have psychotic episodes (d\_\_\_\_\_\_, h\_\_\_\_\_\_). Bipolar patients have higher rates of ______ abuse (40%–60%) and other comorbidities (AD\_\_\_, an\_\_\_\_\_, O\_ _ *,* e\_\_\_\_\_ disorders). Refer to psychiatrist or PMHNP for management.

Answer 120

May have psychotic episodes (delusions, hallucinations). Bipolar patients have higher rates of substance abuse (40%–60%) and other comorbidities (ADHD, anxiety, OCD *,* eating disorders). Refer to psychiatrist or PMHNP (Psychiatric-Mental Health Nurse Practitioner) for management.

Question 121

Bipolar Disorder Medications L\_\_\_\_\_\_ Anticonvulsants (3) 2nd Generation Antipsychotics (\_\_\_\_\_\_ [Risperdal], ______ [Seroquel], ________ [Zyprexa])

Answer 121

Lithium Anticonvulsants (Divalproex (Depakote), Lamotrigine (Lamictal), Carbamazepine (Tegretol)) 2nd Generation Antipsychotics (risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa]) *Lithium salts* *(adversely affect kidney and thyroid gland)*

Question 122

Schizophrenia Psychotic symptoms include del\_\_\_\_\_\_ and par\_\_\_\_\_\_ (disorganized speech and behavior). H\_\_\_\_\_\_\_ are common (usually aud\_\_\_\_\_ ) with loss of ego boundaries; f\_\_\_\_ and restricted affect with poor s\_\_\_\_\_ skills; \_\_\_\_\_\_function is very poor (ability to plan and organize day-to-day activities). * Onset is usually around? * Refer patients to?

Answer 122

Psychotic symptoms include delusions and paranoia (disorganized speech and behavior). Hallucinations are common (usually auditory) with loss of ego boundaries; flat and restricted affect with poor social skills; executive function is very poor (ability to plan and organize day-to-day activities). * Onset is usually around the second decade; peak incidence is between 16 and 30 years of age. * Refer patients to a psychiatrist or PMHNP for management.

Question 123

Schizophrenia Medications *Safety Issues* ## Footnote Use of _______ antipsychotics increases the risk of sudden _____ among elderly who are in long-term care. Antipsychotics can prolong ____ intervals and cause a fatal arrythmia called *(1)*, Antipsychotics including = _____ (Clozaril), th\_\_\_\_\_\_ (Mellaril), Z\_\_\_\_\_\_\_ (Geodon), H\_\_\_\_\_ (Haldol), Q\_\_\_\_\_ (Seroquel). Pr\_\_\_\_\_\_\_ testing (all medications)

Answer 123

Use of typical antipsychotics increases the risk of sudden death among elderly who are in long-term care. Antipsychotics can prolong QT intervals and cause a fatal arrythmia called *torsade de pointes* Including clozapine (Clozaril), thioridazine (Mellaril), ziprasidone (Geodon), haloperidol (Haldol), quetiapine (Seroquel). Pregnancy testing (all medications)

Question 124

Schizophrenia Medications *Safety Issues* ## Footnote * (1)Rx:* Check **Serum creatinine, estimated glomerular filtration rate (eGFR)**, TSH, chemistry profile, electrocardiogram (EKG; if cardiac risk factors) * Anti\_\_\_\_\_\_:* Check **A1C**, **lipid** profile, **EKG** (if cardiac risk factors) * D\_\_\_\_\_\_:* CBC, comprehensive metabolic profile

Answer 124

* Lithium:* Serum creatinine, estimated glomerular filtration rate (eGFR), TSH, chemistry profile, electrocardiogram (EKG; if cardiac risk factors) * Antipsychotics:* Check A1C, lipid profile, EKG (if cardiac risk factors) * Divalproex (Depakote):* Check CBC, comprehensive metabolic profile

Question 125

(1) **It is an irrational preoccupation with an i_ntense fear of gaining weight_ along with _distorted perception of body shape and weight._ Patients tend to be _secretive, perfectionistic, and self-absorbed._** Onset is usually during \_\_\_\_\_\_\_. Mortality rate is 5%; the death rate of anorexics is \_\_**-**\_\_ times greater than that of the general population.

Answer 125

Anorexia Nervosa Onset is usually during adolescence. Mortality rate is 5%; the death rate of anorexics is 5 to 10 times greater than that of the general population.

Question 126

Anorexia Nervosa Characteristics Characterized by severe res\_\_\_\_\_ of food intake, marked weight loss (BMI If purging, loss of dental _____ may be present Anorexics engage in severe food restriction or cycles of (1) and (1). Some examples of purging are use of lax\_\_\_\_, v\_\_\_\_\_. Ex\_\_\_\_\_ daily exercise is common.

Answer 126

Characterized by severe restriction of food intake, marked weight loss (BMI \<18.5), lanugo (face, back, and shoulders) *fine, soft hair*, and amenorrhea for 3 months or longer. If purging, loss of dental enamel may be present. Anorexics engage in severe food restriction or cycles of binge eating and purging. Some examples of purging are use of laxatives, vomiting. Excessive daily exercise is common.

Question 127

Anorexia Nervosa Complications ## Footnote **(1)** is due to prolonged estrogen depletion (from amenorrhea) and low calcium intake; higher risk of (1). **Female athlete triad** is seen in physically active slender females with (3) Peripheral _____ may occur (low albumin from low protein intake). **(1) complications** are the most common cause of death (e.g., arrhythmias, cardiomyopathy, atrophy of heart muscles, bradycardia). \_\_\_\_tension is common with BP \<90/50 mmHg.

Answer 127

**Osteopenia/osteoporosis** is due to prolonged estrogen depletion (from amenorrhea) and low calcium intake; higher risk of stress fractures. **Female athlete triad** is seen in physically active slender females with **amenorrhea, premature osteopenia/osteoporosis, and disordered eating**. Peripheral edema may occur (low albumin from low protein intake). **Cardiac complications are the most common cause of death** (e.g., arrhythmias, cardiomyopathy, atrophy of heart muscles, bradycardia). Hypotension is common with BP \<90/50 mmHg.

Question 128

Anorexia Nervosa Treatment Plan Refer to (1) therapist or (1) in eating disorder unit.

Answer 128

Refer to **eating disorders therapist** or **inpatient hospitalization** in eating disorder unit.

Question 129

(1) **Condition characterized by flashbacks, nightmares, intrusive thoughts, avoidance of reminders of trauma, sleep disturbance, and hypervigilance. Causes include being in combat/war, sexual assault (12%), MI, stroke, ICU stay (20%).** Comorbidity, such as depression, anxiety, antisocial disorder, and substance abuse, is _____ in PTSD. Assessment tools include the (1), a 20-item self-report measure (for screening and for monitoring symptoms over time).

Answer 129

**Posttraumatic Stress Disorder** Comorbidity, such as depression, anxiety, antisocial disorder, and substance abuse, is **higher** **in PTSD**. Assessment tools include the **PTSD Checklist (PCL-5)**, a 20-item self-report measure (for screening and for monitoring symptoms over time).

Question 130

PTSD Treatment Plan First line treatment = (1)-(3) Preferred Drug Class to Treat PTSD (1)

Answer 130

The first-line treatment is trauma-focused psychotherapy (exposure therapy, cognitive behavioral therapy, or eye movement desensitization and reprocessing [EMDR]). SSRIs = preferred drug class to treat PTSD, Medication can be used alone or with psychotherapy.

Question 131

(1) Also known as **“factitious disorder imposed on self.”** Patient falsifies symptoms of factitious disorders (e.g., abdominal pain, chest pain, seizures) and/or injures self and seeks medical treatment, including multiple surgeries (1) A related disorder, refers to a parent using a child (and making the child sick) to obtain medical care. These are rare conditions (1%) that are hard to diagnose.

Answer 131

Munchausen Syndrome Munchausen by proxy

Question 132

Exam Tips *Female athlete triad =* Recognize how anorexic patients present: lan\_\_\_\_, peripheral \_\_\_\_\_, \_\_\_\_orrhea, BMI Anorexic patients are at higher risk for o\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_ (Wellbutrin) is contraindicated for anorexic/bulimic patients. It lowers the seizure threshold.

Answer 132

*Female athlete triad:* Amenorrhea, low bone mass, low BMI. Recognize how anorexic patients present: lanugo, peripheral edema, amenorrhea, BMI \<18.5. Anorexic patients are at higher risk for osteopenia/osteoporosis. Bupropion (Wellbutrin) is contraindicated for anorexic/bulimic patients. It lowers the seizure threshold.

Question 133

Exam Tips ## Footnote **(1)** has a short half-life (compared with other SSRIs), and patients need to be weaned. Do not discontinue abruptly; will cause withdrawal symptoms. A common side effect of paroxetine (Paxil) is ______ dysfunction. (1) is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs. (1): Used for herpetic neuralgia, migraine headache prophylaxis (not acute treatment).

Answer 133

Paroxetine (Paxil) has a short half-life (compared with other SSRIs), and patients need to be weaned. Do not discontinue abruptly; will cause withdrawal symptoms. A common side effect of paroxetine (Paxil) is erectile dysfunction. Bupropion is used off-label for antidepressant-induced sexual dysfunction caused by SSRIs. TCAs: Used for herpetic neuralgia, migraine headache prophylaxis (not acute treatment).

Question 134

Abuse: All Types Abusive behaviors are multifactorial. They may include ph\_\_\_\_\_, em\_\_\_\_\_, and s\_\_\_\_\_ abuse and/or neglect, as well as ec\_\_\_\_\_ abuse or material exploitation. Abuse can happen at ____ age and during pr\_\_\_\_\_ (higher risk). The state of pregnancy is also associated with a higher incidence of abuse due to j\_\_\_\_\_ over the pregnancy.

Answer 134

Abusive behaviors are multifactorial. They may include physical, emotional, and sexual abuse and/or neglect, as well as economic abuse or material exploitation. Abuse can happen at any age and during pregnancy (higher risk). The state of pregnancy is also associated with a higher incidence of abuse due to jealousy over the pregnancy.

Question 135

Abuse All Types Upon presentation to the ED, for example, the pattern of the injuries is in\_\_\_\_\_\_ with the history given. Elderly who are most likely to be abused are those \>\_\_\_ years old and/or who are fr\_\_\_\_\_. Children with mental, physical, or other dis\_\_\_\_\_\_\_ and s\_\_\_\_children are more likely to be abused.

Answer 135

Upon presentation to the ED, for example, the pattern of the injuries is inconsistent with the history given. Elderly who are most likely to be abused are those \>80 years old and/or who are frail. Children with mental, physical, or other disabilities and stepchildren are more likely to be abused.

Question 136

Abuse All Types Types of abuse are phy\_\_\_\_ abuse, s\_\_\_\_\_ abuse, em\_\_\_\_\_/psychological abuse, and neg\_\_\_\_\_. A common finding is a d\_\_\_\_\_ in seeking medical treatment for the injury. **(1)** is defined as intentional control or victimization performed by a person to another with whom the person has an intimate or spousal relationship. The most significant reason for missing the diagnosis of IPV or other abuse is failure to \_\_\_\_.

Answer 136

Types of abuse are physical abuse, sexual abuse, emotional/psychological abuse, and neglect. A common finding is a delay in seeking medical treatment for the injury. Intimate partner violence (IPV) is defined as intentional control or victimization performed by a person to another with whom the person has an intimate or spousal relationship. The most significant reason for missing the diagnosis of IPV or other abuse is failure to ask.

Question 137

Risk Factors That Increase Likelihood of Abuse (All Types) ## Footnote Increased st\_\_\_\_\_ (partner/parent/caregiver) Al\_\_\_/dr\_\_\_ abuse Personal or family _____ of abuse Major l\_\_\_\_\_(e.g., financial, job loss) Social is\_\_\_\_\_\_\_ Pr\_\_\_\_\_\_\_ (domestic abuse) *Elderly abuse:* Fr\_\_\_\_\_elderly and those with dem\_\_\_\_\_ are more likely to be abused; about two-thirds of all elder abuse is perpetrated by ______ members (usually an adult child or a spouse); most abused elderly also suffer ec\_\_\_\_\_\_ abuse. Only certain states have ______ reporting of partner abuse; be mindful of institutional abuse of elderly, children, and the disabled.

Answer 137

Increased stress (partner/parent/caregiver) Alcohol/drug abuse Personal or Family history of abuse Major loss (e.g., financial, job loss) Social isolation Pregnancy (domestic abuse) *Elderly abuse:* Frail elderly and those with dementia are more likely to be abused; about two-thirds of all elder abuse is perpetrated by family members (usually an adult child or a spouse); most abused elderly also suffer economic abuse. Only certain states have mandatory reporting of partner abuse; be mindful of institutional abuse of elderly, children, and the disabled.

Question 138

Physical Exam: Abuse (All Types) ## Footnote You are going to do an exam, who should be in the same room during the exam? Interview victim _____ abuser in the same room. Abused patient is very fearful and q\_\_\_\_ when with the “abuser.” Collect visual evidence of trauma via (1) to document all injuries. Keep all evidence in a safe place. Use a _____ to identify and document the size of the injuries. Document direct “\_\_\_\_\_” in the patient’s history. Use the abuse assessment screening tool with a b\_\_\_\_\_ map to document assessment findings.

Answer 138

Another health provider (witness) should be in the same room during the exam. Interview victim without abuser in the same room. Abused patient is very fearful and quiet when with the “abuser.” Collect visual evidence of trauma via Polaroid or digital camera to document all injuries. Keep all evidence in a safe place. Use a ruler to identify and document the size of the injuries. Document direct “quotes” in the patient’s history. Use the abuse assessment screening tool with a body map to document assessment findings.

Question 139

Physical Exam: Abuse (All Types) ## Footnote Look for sp\_\_\_\_\_\_ fractures (greenstick fracture), multiple h\_\_\_\_\_ fractures (especially in r\_\_\_ area), b\_\_\_ marks with pattern, welts, and so forth. Look for signs of n\_\_\_\_\_\_ (e.g., dirty clothes, inappropriately dressed for the weather). For partner abuse, focus on developing a **plan for \_\_\_\_\_** with the patient when appropriate. **Give the patient the (1) of a _____ center and/or safe place.**

Answer 139

Look for spiral fractures (greenstick fracture), multiple healing fractures (especially in rib area), burn marks with pattern, welts, and so forth. Look for signs of neglect (e.g., dirty clothes, inappropriately dressed for the weather). For partner abuse, focus on developing a **plan for safety** with the patient when appropriate. **Give the patient the phone number of a crisis center and/or safe place.**

Question 140

Physical Exam: Abuse (All Types) *Sexually transmitted disease (STD) testing:* * (2) cultures (must use cultures in addition to the Gen-Probe) * H\_\_\_, hepatitis __ **,** s\_\_\_\_\_\_, h\_\_\_\_ type 2 * (3) area culture and testing must be done.

Answer 140

*Sexually transmitted disease (STD) testing:* * Chlamydial and gonorrheal cultures (must use cultures in addition to the Gen-Probe) * HIV, hepatitis B, syphilis, herpes type 2 * Genital, throat, and anal area culture and testing must be done.

Question 141

Abuse Treatment Plan ## Footnote Provide prophylactic treatment against several (1) (with parental consent for minors). Teach the patient the c\_\_\_\_ of abuse; educate the patient regarding safety issues and having an es\_\_\_\_ plan ready for use. Healthcare professionals must report actual or suspected ch\_\_\_\_ abuse. Be aware of individual st\_\_\_\_ guidelines on reporting suspicion of elder abuse. Abuse of a _______ person must be reported to the Disabled Person Protective Commission; contact adult protective services or law enforcement agencies with concerns regarding self-neglect.

Answer 141

Provide prophylactic treatment against several STDs (with parental consent for minors). Teach the patient the cycle of abuse; educate the patient regarding safety issues and having an escape plan ready for use. Healthcare professionals must report actual or suspected child abuse. Be aware of individual state guidelines on reporting suspicion of elder abuse. Abuse of a disabled person must be reported to the Disabled Person Protective Commission; contact adult protective services or law enforcement agencies with concerns regarding self-neglect.

Question 142

Good Communication Concepts State things \_\_jectively; do not be j\_\_\_\_\_\_. * *Example:* Say: “You have bright-red stripes on your back” instead of “It looks as if you have been whipped on your back.” \_\_\_\_\_-ended questions are preferred. * *Example:* Say: “How can I help you?” instead of “What type of object was used to hurt your back?” Do not re\_\_\_\_\_\_\_ patients (this stops the patient from talking more about their problems). * *Example:* Say: “We will make sure you get help” instead of “Don’t worry, everything will be fine.” Let the patient v\_\_\_ their feelings. Do not discourage patient from talking. * *Example:* Say: “Please tell me why you feel so sad.” V\_\_\_\_\_\_ feelings. * *Example:* Say: “Yes, I understand your anger when someone hits you.”

Answer 142

State things objectively; do not be judgmental. * *Example:* Say: “You have bright-red stripes on your back” instead of “It looks as if you have been whipped on your back.” Open-ended questions are preferred. * *Example:* Say: “How can I help you?” instead of “What type of object was used to hurt your back?” Do not reassure patients (this stops the patient from talking more about their problems). * *Example:* Say: “We will make sure you get help” instead of “Don’t worry, everything will be fine.” Let the patient vent their feelings. Do not discourage patient from talking. * *Example:* Say: “Please tell me why you feel so sad.” Validate feelings. * *Example:* Say: “Yes, I understand your anger when someone hits you.”

Question 143

(1) A counseling method used to help an individual resolve a state of indecision (ambivalence) into finding the internal motivation (motivational enhancement) to make positive and healthier behaviors.

Answer 143

Motivational Interviewing Recent meta-analyses have shown that motivation interviewing is effective in decreasing drug and alcohol use in adolescents and adults. This method is used for substance abuse, smoking cessation, alcohol abuse, losing weight, reducing sexual risk behaviors, and other types of unhealthy behaviors.

Question 144

Five Principles of Motivational Interviewing 1. Express and listen with \_\_pathy about patient’s issues (through reflective listening). 2. Understand the patient’s own mot\_\_\_\_\_\_. 3. Avoid arg\_\_\_\_\_ (or direct confrontation). 4. Ad\_\_\_\_\_ to the patient (rather than opposing the patient). 5. Support self-eff\_\_\_\_\_\_ (emp\_\_\_\_\_the patient). (Alfred Bandura, a psychologist, defined self-efficacy as one’s belief in one’s ability to succeed in accomplishing a task.)

Answer 144

1. Express and listen with empathy about patient’s issues (through reflective listening). 2. Understand the patient’s own motivations. 3. Avoid argument (or direct confrontation). 4. Adjust to the patient (rather than opposing the patient). 5. Support self-efficacy (empower the patient). (Alfred Bandura, a psychologist, defined self-efficacy as one’s belief in one’s ability to succeed in accomplishing a task.)

Question 145

Exam Tips ## Footnote \_\_\_\_\_\_ (BuSpar), a nonbenzodiazepine drug for chronic anxiety, is taken twice a day; it is not an as needed drug like benzodiazepines. \_\_\_\_\_ are also indicated for chronic anxiety disorders (social anxiety disorder, panic disorder). Of all the SSRIs, (1) is most likely to cause erectile dysfunction. There will always be a few questions on physical ab\_\_\_\_. The questions may address physical abuse, child abuse, sexual abuse, and/or elder abuse. The _____ is described as a person who does not want the abused person out of sight or interviewed alone.

Answer 145

Buspirone (BuSpar), a nonbenzodiazepine drug for chronic anxiety, is taken twice a day; it is not an as needed drug like benzodiazepines. SSRIs are also indicated for chronic anxiety disorders (social anxiety disorder, panic disorder). Of all the SSRIs, paroxetine (Paxil) is most likely to cause erectile dysfunction. There will always be a few questions on physical abuse. The questions may address physical abuse, child abuse, sexual abuse, and/or elder abuse. The abuser is described as a person who does not want the abused person out of sight or interviewed alone.

Question 146

Exam Tips ## Footnote The abuser typically answers all the questions ___ the patient and will exhibit “con\_\_\_\_\_\_ ” behaviors toward the abused patient. *Abuse cases:* Interview _____ and then \_\_\_\_\_. Any answer choice that reassures patients is usually \_\_\_\_\_. Delaying an action (e.g., waiting until the patient feels better) is always \_\_\_\_\_. (1) is used to treat major depression, seasonal affective disorder, and smoking cessation. It increases risk of \_\_\_\_\_\_; avoid if patient at higher risk of seizures (during abrupt discontinuation of ethanol, benzodiazepines).

Answer 146

The abuser typically answers all the questions for the patient and will exhibit “controlling” behaviors toward the abused patient. *Abuse cases:* Interview together and then separately. Any answer choice that reassures patients is usually wrong. Delaying an action (e.g., waiting until the patient feels better) is always wrong. Bupropion is used to treat major depression, seasonal affective disorder, and smoking cessation. It increases risk of seizures; avoid if patient at higher risk of seizures (during abrupt discontinuation of ethanol, benzodiazepines).