Psych

Question 1

DEPRESSION
The following video shows a day in the life of an individual living with depression. The take home point is for you to see what an individual who is clinically depressed goes through on a daily basis .It will also help you to formulate ideas about how to approach a depressed patient in efforts to manage their care in a manner that will improve their quality of life.

Question 2

DEPRESSION

Depression is a condition that many individuals encounter at some point in their lives.

Depression can last from a couple of days to years and has various effects on the individual.

A risk factor for depression is major life changes, which causes the individual to feel worthless and decreases interest in normal activities. Life events or changes include: death of a loved one, severe medical condition , or other bad news.

In addition, hormone and neurotransmitter imbalances may predispose an individual to depression (Barkley, 2021).

Individuals with depression may or may not recognize the symptoms and many do not seek medical for treatment.

Question 3

DEPRESSIVE DISORDERS

Major Depressive Disorder-consists of a syndrome of mood, physical, and cognitive symptoms that occur at any time in life.

Complaints include loss of interest of pleasure, withdrawal from activities, feelings of guilt, inability to concentrate, cognitive dysfunction, anxiety, fatigue, feelings of worthlessness, somatic complaints, loss of sexual drive, and thoughts of death.

Unemployment has been associated with depression.

Question 4

DEPRESSION
DEPRESSIVE DISORDERS

Psychotic major depression- occurs more frequently in adults over the age of 50.

Patients experience delusions, paranoia, impending annihilation (complete destruction ) , and somatic concerns.

**Major Depression with atypical features **is characterized by hypersomnia, overeating, lethargy, and mood reactivity.

**Melancholic Major Depression is characterized **by a lack of mood reactivity seen in atypical depression, the presence of anhedonia (no pleaseure in activity) , and severe vegetative symptoms.

Major Depression with a seasonal onset (SAD: Seasonal affective disorder) is noted with circadian rhythms during fall and winter months thought to be due to decease exposure to full-spectrum light. Symptoms include carbohydrate craving, lethargy, hyperphagia (excessive eatting ) , and hypersomnia.

Major Depression with peripartum onset occurs during pregnancy or begins up to 4 weeks after delivery.

**Persistent Depressive Disorder (dysthymia) **is a chronic depressive disturbance. Sadness, loss of interest, and withdrawal from activities over a a 2 or more year period are necessary for diagnosis.

**Premenstrual Dysphoric Disorder **is depressive symptoms during the late luteal phase of the menstrual cycle.

Question 5

DEPRESSION
DIAGNOSIS

The findings associated with depression include: feeling guilty, worthless and helpless, suicidal ideations, problems with sleep, pain with no apparent cause, and poor appearance (Barkley, 2021).

In order to diagnose an individual with depression, five of the following must be present for 2 weeks:

• Depressed mood
• Marked diminished interest or pleasure
• Significant weight loss or gain
• Cannot sleep or sleeping too much
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Diminished ability to concentrate
• Suicidal ideation

Question 6

DEPRESSON
LABS

The following labs or diagnostic test maybe ordered to make sure the individual does not have an underlying disease process:

Test for vitamin deficiency: B12, Folate

Health conditions: Thyroid function, glucoses, CBC, Renal function, EKG (Barkley, 2021).

Question 7

Major Depression Inventory

The Major Depression Inventory (MDI) is a self-rating scale used for the diagnosis or measurement of depression, according to both DSM-IV major depression and ICD-10 moderate to severe depression criteria.

The symptoms should have been present nearly every day during the past 2 weeks. In both the DSM-IV and ICD-10, the items of depressed mood and lack of interest are considered as the core symptoms of depression.

For the diagnosis of major depression, either item 1 or 2 should be among the 5 of 9 items present. Items 4 and 5 are combined, with only the highest answer category is considered and a total number of items of nine. As a diagnostic tool, the 10 items are dichotomized for the presence (1) or absence (0) of each symptom. As a measuring tool, the items are given a value (0-5) and summed up to a theoretical score of 0 to 50.

The cutoff score is 26 for the diagnosis of major (moderate to severe) depression.

The sensitivity of the MDI algorithms is between 86% and 92%, while the specificity is between 82% and 86% (see the image below). [13]

Question 8

The Patient Health Questionnaire is a self-administered tool of 2 (PHQ2) or 9 (PHQ9) items. A meta-analysis found sensitivity to be 80% and specificity of 92%. The PHQ2 is a screening tool for depression that assesses the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 (“not at all”) to 3 (“nearly every day”).

A PHQ-2 score of greater than 3 had a sensitivity of 83% and a specificity of 92% for major depression. [5, 12]

The PHQ 9 establishes the clinical diagnosis of depression and can additionally be used over time to track the severity of symptoms over time.

The cut point of the PHQ9 is equal or greater than 10, which has a sensitivity of 88% and a specificity of 88% for major depression.

PHQ-9 scores of 5, 10, 15, and 20 are representative of mild, moderate, moderately severe, and severe depression, respectively (see the image below). [4, 6]

Question 9

Geriatric Depression Scale

The Geriatric Depression Scale (GDS) was specifically developed for use in geriatric populations, originally as a 30-item scale. It was modified a 15-item scale, which has been widely used. The GDS was later reduced to 5 items, so as to be better received by elderly patients. The questions elicit only “yes” or “no” responses, making comprehension easier compared with multiple-choice answers.

The 5-item scale has a sensitivity of 94%, specificity of 81%, and demonstrated a significant agreement in the clinical diagnosis of depression with the 15-item scale. The 5-item scale is scored by 1 point for a “no” answer on the first question or a “yes” answer for the remaining questions. A score of greater than or equal to 2 is a positive screen for depression (see the images below). [17]

Question 10

Patients who do not have suicidal or homicidal ideation can be referred for outpatient therapy . Individuals who have the above ideations should be hospitalized and a psychiatric consult should be initiated during the hospitalization.

Question 11

DEPRESSION -MEDICATION

SSRI-1st line therapy due to less side effects and decrease risk for overdose.

SNRI- result in more side effects

Effexor( causes sedation)

Cymbalta( not recommended for older adults, individuals with glaucoma, liver problems, or those who abuse alcohol) Barkley, 2021

Patients should be educated on the medication prescribed and be remined that it can take up to 6 weeks to see results.

Question 12

ANXIETY
Anxiety is a condition that presents with excessive thoughts of fear and worry about a situation. Needless to say, we all have experienced anxiety whether it be from a dread exam, presentation , or other activities. It becomes problematic when there is interference with day to day activities. Anxiety is most often caused by stressors.

Psychological manifestations include tension, fears, apprehension, and difficulty concentrating.

Individuals may have the following symptoms: sleep disturbances, irritability, depression, feeling overwhelmed, headache, tachycardia, and unpleasant GI/GU symptoms (Barkley, 2021).

Anxiety disorders are the most prevalent psychiatric disorder.

Anxiety may be acute or chronic.

Lack of structure is frequently a contributing factor.

Planned-time activities tend to bind anxiety.

Anxiety can be self-generating, as the symptoms reinforce the reaction.

Avoidance of the triggers can lead to reinforcement of the anxiety.

Question 13

DEPRESSION KEY POINTS

Depression is a common disorder that involves depressed mood and/or near-complete loss of interest or pleasure in activities that were previously enjoyed; somatic (eg, weight change, sleep disturbance) and cognitive manifestations (eg, difficulty concentrating) are common.

Depression may markedly impair the ability to function at work and to interact socially; risk of suicide is significant.

Sometimes depressive symptoms are caused by general medical disorders (eg, thyroid or adrenal gland disorders, benign or malignant brain tumors, stroke, AIDS, Parkinson disease, multiple sclerosis) or use of certain medications (eg, corticosteroids, some beta-blockers, interferon, some illicit drugs).

Diagnosis is based on clinical criteria; general medical disorders must be ruled out by clinical evaluation and selected testing (eg, CBC; electrolyte, TSH, B12 and folate levels).

Treatment involves psychotherapy and usually medications; SSRIs are usually tried first, and if they are ineffective, other medications that affect serotonin, norepinephrine and/or dopamine may be tried.

Question 14

ANXIETY

Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown, although it commonly coexists in people who have alcohol use disorder, major depression, or panic disorder. Diagnosis is based on clinical criteria. Treatment includes behavioral interventions, psychotherapy, pharmacotherapy, or a combination.

Question 15

ANXIETY

To meet DSM-5-TR criteria for GAD, patients must have excessive anxiety and worry about a number of activities or events (eg, work and school performance), occurring more days than not for ≥ 6 months (1).

The worries are difficult to control and must be associated with ≥ 3 of the following:

Restlessness or a keyed-up or on-edge feeling
Easy fatigability
Difficulty concentrating
Irritability
Muscle tension
Disturbed sleep
The psychiatric symptoms must cause significant distress or significantly impair social or occupational functioning. Also, the anxiety and worry cannot be accounted for by substance use or a general medical disorder (eg, hyperthyroidism).

Question 16

ANXIETY

MANAGEMENT
Rule out any underlying conditions that maybe causing the individuals anxiety. Be sure to listen to the individuals concerns.

MEDICATIONS

SSRIs and SNRIs are used most often to manage patients long term
Short term relief: Benzodiazepines: Ativan, Xanax, Valium
Psychiatric referral (Barkley, 2021)

Question 17

BIPOLAR

GENERAL FACTS
Formerly called manic/depressive disorder.

Client can have Rapid cycling or slower cycles. Providers watch for how fast the client cycles to assess for future cycling.

Example: rapid cycling reflects a patient who has had 4 or more mood episodes in a 12-month period. However, can occur with a month, or a day.

Characterized by two extreme opposite poles of behavior:

Mania and Depression
Mania is an exaggerated euphoria and/or irritability- called a manic phase
Bipolar is associated with the highest lifetime rate of suicide of any psychiatric disorder; 25-60% will attempt suicide at least once during the life time of this disorder.

Bipolar disorders are chronic, recurrent, and life threatening illnesses that require lifetime psychiatric monitoring and medication

Question 18

BIPOLAR

EPIDEMIOLOGY
Bipolar I onset is more common in males.

Bipolar II onset is more common in females present with a depressed episode, hypomania, and rapid cycling.

As the patient ages, the episodes become more frequent, and the severity increases- functioning decreases.

Substance use is extremely common with Bipolar disorder. Usually an attempt to self-medicate and control the mood swings.

Males tend to have legal problems, and commit acts of violence .

Females tend to abuse alcohol, develop thyroid disease, commit suicide.

There is also a high incidence of anxiety disorders and eating disorders with women who have Bipolar Disorder.

Comorbidity of substance abuse and anxiety puts the patient at greater risk of suicide.

Bipolar disorders have a definite genetic link for the disease.

COMORBIDITY (MOST COMMON CO-OCCURRING DISORDERS)
Panic Attacks (Anxiety Disorder) 62%
Alcohol Abuse (39%)
Social Phobia (38%)
Oppositional Defiant Disorder (37%)
Specific Phobia (35%)
Seasonal Affective Disorder (35%)

When substance abuse is present with Bipolar Disorder, both should be treated at the same time.

High incident of Borderline Personality with Bipolar disorder brings increased risk of impulsiveness, aggression, and suicide.

Question 19

HOW DEPRESSION IS DIFFERENTIATED FROM BIPOLAR D/O
Episodes of depression in bipolar disorders are different from ‘unipolar depression’, which does not have episodes of mania.

HOW WE DIAGNOSE BIPOLAR DISORDERS - MANIC SYMPTOMS
Bipolar I disorder: At least 1 week long episode of mania with excessive energy and activity.
May alternate with depression or mixed state of depression and agitation. Psychosis may be present.

At least 3 of the following behaviors must be present:

Extreme drive/energy
Inflated sense of self importance
Drastically reduced sleep requirements
Racing thoughts
Unusually obsessed/over-focused goals
Purposeless arousal, movement
Over spending/reckless sexual encounters/financial investments

TYPES OF MANIA

Euphoric Mania- feels wonderful in the beginning but turns to scary and dark as it progresses toward loss of control and confusion.

Dysphoric Mania- also referred as mixed state, or agitated depression with depressed symptoms along with mania. Person may be irritable, angry, suicidal, hypersexual, panicky, have pressured speech, agitation, severe insomnia, grandiose, persecutory delusions, and confused.

Bipolar 2 has hypomania.

Bipolar II disorder: low level of mania with profound depression.

Hypomania tends to be euphoric and increases functioning. Person will have demonstrated excessive activity and energy for at least 4 days and shows at least 3 of the symptoms already listed.

Psychosis is not present.

Depressive symptoms increase the risk for suicide.

CYCLOTHYMIA
Hypomanic episodes alternating with minor depressive episodes (for at least 2 years for adults and one year for children).

Tend to have irritable hypomania episodes with adults.

Children tend to exhibit marked irritation and sleep disturbances.

Question 20

ASSESSMENT OF MOOD (DURING MANIA EPISODE)
The euphoric mood is unstable.

Mood can change to irritation and anger rapidly
Irritability and belligerence can be short lived or become the prominent personality.
The inflated and joyful moods are usually out of proportion to the situation.
Tend to laugh, joke and talk continuously. Subject matter changes at a whim; the client will encounter no strangers; energy and self-confidence is over exaggerated.
Can come up with get rich schemes, and ways to become powerful and influential. Will email and make repetitive phone calls to powerful people offering their services and talents.
Inability to sleep or eat, activities are ongoing 24/7, until the body becomes so exhausted they begin the spiral down. This can become a medical emergency and can cause death if not tx.
Will give away money, possessions and expensive gifts; spend large sums of money they don’t have (usually on credit cards).
Gradually the mood is replaced with hostility, irritability and paranoia.
Behavior during mania

Goes from one activity to another.
Projects maybe started, but often not finished.
Inactivity is impossible. These actions range in severity.
If able to stay on task, will write long, descriptive letters, and make excessive long phone calls to anyone with which they have a short or long relationship; i.e. an acquaintance they had in high school.
Sexual acting out is very common. Will undress and walk around the units, go into other patient’s rooms, attack staff of the opposite sex, have make believe relationships with their doctors, nurses, and other patients. Become jealous when they observe their fantasy mate talking with another person.
Constantly push the limits, argumentative.
Family members disown them because of the financial and emotional trauma.
Dress selection can be bizarre, colorful, and noticeably inappropriate for the situation. Make up will be over-done and harsh. Hair styles can be bizarre with ribbons, clips,
Tend to have many relationships and impulsive marriages and divorces.
Thought Processes/ Speech
Speech is rapid and disorganized, incoherent , and loud.
Conversations are often sexually explicit and vulgar.
Clang associations with phases that usually do not make logical sense.
Grandiosity is expressed in behavior and in ideas. These can be of the paranoid nature as well.
Unable to problem solve or to logically plan activities, consequently their cognitive functions are reduced greatly.

COGNITIVE FUNCTIONING
Onset of the disorder is often preceded by high cognitive function.
During the onset of dysfunction; there is a similar decrease in cognitive function much like persons with schizophrenia.
There is significant dysfunction with psychosocial interactions and relationships.
Early diagnosis and treatment are crucial to illness progression, cognitive deficits and poor outcomes.

MANAGEMENT
Lithium
Anticonvulsants (Depakote is most often used)
Antipsychotics: Zyprexa, Risperdal, Seroquel (list not all inclusive) may be used for manic phase or psychosis.
Antidepressants maybe or may not be prescribed depending on depressive qualities BUT never first line therapy.

Question 21

Lithium Carbonate

In approximately 80% of the patients receiving lithium, the manic episodes are stopped in 10-21 days of treatment. High doses of Depakote are used first until Lithium reaches a therapeutic level.

Lithium (+) effects

Reduces:

Elation, grandiosity
Flight of ideas
Irritability and manipulation
Anxiety
Lithium (lesser effects)

Not as effective with these symptoms:

Insomnia
Psychomotor agitation
Threatening/assaultive behavior
Distractibility
Hyper-sexuality
Paranoia

Therapeutic blood levels can be usually reached in 7-14 days; longer in some patients.

Target range 0.6-1.4 mEq/L (Barkley, 2021)

While lithium is very effective in controlling manic behaviors, it is NOT a cure.

Toxicity levels occur with range of 1.5-2mEq/L; levels greater than 2.5 mEq/L usually lead to renal shutdown, seizures, and death.

Blood levels are measured 5-7 days after therapy is initiated and with dosage changes, until the blood level is reached.

After that, blood levels will be done monthly. The monthly blood tests may be reduced to every 3 months, after the patient has been on lithium for 6 months to 1 year.

Initial dosage typically starts at 300 mg TID , can increase dose by 300 mg every three days, serum level should be 0.8-1.2 mEq/L (Barkley, 2021)

In cases of lithium toxicity, gastric lavage, tx with urea, mannitol, and aminophylline will increase lithium excretion.
Hemodialysis may also be required.

Question 22

SCHIZOPHRENIA

Schizophrenia is manifested by a large disruption of thinking, mood, and overall behavior. Schizophrenia is a disorder in which alters an individual’s perception of reality. Individuals with this disorder have a hard time making decisions, managing emotions, and organizing thought. Schizophrenia affects about 1% of the U.S. population; however, the majority of individuals who require long term hospitalization have schizophrenia (Papadakis & McPhee, 2020).

Question 23

SCHIZOPHRENIA
ETIOLOGY
The etiology of schizophrenia is multifactorial; with genetic, environmental, and neurotransmitter pathophysiologic components. There is no laboratory test to confirm the diagnosis. The following video provides the introductory content related to schizophrenia. It reviews what happens in the brain and the behaviors you may see in an individual with schizophrenia.

Question 24

Schizophrenia

SIGNS AND SYMPTOMS
Schizophrenia symptoms are classified into the following categories:

Positive or Psychotic: hallucinations, delusions, disorganized speech (rambling, repetitive statements/words, makes up words), flight of ideas

Negative: relates to the individuals lack of normal emotions (flat or blunted affect, loss of interest in activities/lack of drive)

Cognitive: relates to the individual memory and attention span (cannot focus, short attention span, inability to use learned information (Tamminga, 2020).

Polydipsia is also associated with schizophrenia.

Question 25

SCHIZOPRENIA

DIAGNOSIS
A diagnosis of this disorder is made by several factors. Imaging of the brain may reveal ventricular and cortical enlargement (Papadakis & McPhee, 2020).

In addition, the patient’s history and symptoms are taken into account when formulating a diagnosis.

According to the DSM-5 the following must apply in order to make a diagnosis of schizophrenia:

> /= 2 characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) for the majority of 6 months (symptoms must include at least one of the first 3)

Prodromal or attenuated signs of illness with social, occupational, or self-care impairments evident for a 6-month period that includes 1 month of active symptoms (Tamminga, 2020)

Question 26

MANAGEMENT
Hospitalization maybe required depending on the severity of symptoms. The goal of treatment is to decrease symptoms and prevent relapse. Relapse occurs most often due to non-compliance with treatment regimen. (Tamminga, 2020).

Psychiatric referral for ongoing management

Medications

Medications are typically given by mouth but maybe given in injectable forms especially if the individuals is not responding appropriately to therapy or is non-complaint. Medications typically used to treat schizophrenia are 1st or 2nd generation antipsychotics. Certain drugs in each class can produce very specific side effects but both classes produce anticholinergic symptoms (blurred vision, dry mouth, and urinary retention) (Papadakis & McPhee, 2020).

1st generation antipsychotics treat positive symptoms and are associated with more side effects, especially movement disorders but are not as costly to the consumer. Drugs in this class include:

Chlorpromazine
Fluphenazine
Thiothixene
Haloperidol
Side effects: Dry mouth, blurry vision, urinary retention, extrapyramidal effects (akathisia, parkinsonism, tardive dyskinesia)

2nd generation antipsychotics(atypical)- treat positive and negative symptoms have less side effects associated with movement disorders; however, they increase the risk for new onset diabetes, metabolic syndrome, EKG changes, weight gain, and agranulocytosis (Papdakis & McPhee, 2020). Drugs in this class include:

Clozaril
Risperdal
Zyprexa
Seroquel
Geodon
Review: Memorable Psychopharmacology (2014).