Psych Disorders Flashcards
Adjustment Disorder
- Occurring within 3 months of an identifiable stressor
- Inability to concentrate
- Sleep disturbances
- Often self-medicated with ETOH, CNS depressants
Adjustment Disorder Medication
- Lorazepam (up to 3x/day PO) for a LIMITED TIME
- Short-term SSRI
Generalized Anxiety Disorder (GAD)
- Chronic Disorder
- Persistent anxiety/fear
- Symptoms present more days than not over a 6 month period
- Triggered by a number of everyday activities
- Often self-medicated with ETOH
GAD Medications
1st line
- SNRIs (venlafaxine, duloxetine)
- SSRIs (escitalopram, paroxetine)
- PRN Benzodiazepines (lorazepam, diazepam, clorazepate, triazolam, flurazepam) HIGH RISK FOR DEPENDENCE
SNRI/SSRI medications may have 2-4 week delay before taking effect. EDUCATE PATIENTS ON THIS!
2nd/3rd line
- TCAs/MAOIs
Others
- Aminoketones (bupropion)
- Anticonvulsants (gabapentin)
- Beta-blockers (propranolol)
Panic Disorder
- Panic attacks that includes chronic fear with changing behavior to avoid triggers of the attack
- Agoraphobia may be present
- Increased risk for major depression and suicide attempts
- Often associated with ETOH abuse and/or dependence on sedatives
Panic Disorder Medications
1st line
- SNRI (venlafaxine)
- SSRIs (fluoxetine, paroxetine, sertraline)
SNRI/SSRI medications may have 2-4 week delay before taking effect. EDUCATE PATIENTS ON THIS!
Others
- Benzodiazepines (lorazepam, midazolam)
- Beta-blockers (propranolol)
Phobia Disorder
- Chronic fear of a specific object or situation (spiders, heights, etc.) that are out of proportion to the actual danger posed
- Includes social phobia and agoraphobia
Treatment
- CBT
Phobia Disorder Medications
1st line
- SNRI (venlafaxine)
- SSRIs (paroxetine, sertraline, fluvoxamine)
- Anticonvulsants (gabapentin)
- Beta-blockers (propranolol)
Obsessive-Compulsive Disorder (OCD)
- Ritualistic/repetitive behaviors that are distressing to the patient
- Often co-morbidity with major depression
- Affects young, divorced, separated, or unemployed
- Treat with
Obsessive-Compulsive Disorder (OCD) Medications
Medications
- SSRIs and clomipramine (can take up to 12 weeks to take effect)
- May need to add antipsychotics and topiramate in resistant cases
Obsessive-Compulsive Disorder (OCD) Treatment
- CBT - patient learns to identify maladaptive cognitions associated with obsessive thoughts and challenge those cognitions
- Thought-stopping when OCD thought begins
OCD Treatment - Clomipramine concerns
- Check plasma levels/metabolites every 2-3 weeks to keep level <500 ng/mL (above 500 leads to toxicity)
Conversion Disorder
- Psychic conflict converts into physical symptoms
- Usually occurs alongside panic disorder or depression
Treatments for Somatic Symptom Disorders
- Behavioral
- working on recognizing symptoms, providing biofeedback
- Social
- Family member involvement
- Peer support groups
- Medical
- Provider must accept that the patient’s distress is real
- Maintain empathetic, realistic, optimistic approach
- Psychological
- Group therapy
- Possible psych referral if other treatment does not show changes
Chronic Pain (Psych) Disorders
- Symptoms frequently exceed physiological signs
- Minimal relief with standard pain tx
- Hx of “doctor shopping” or ED “frequent flier”
- Frequent use of several nonspecific medications
- It is counterproductive for FNP to speculate about whether or not pain is “real”
Chronic Pain (Psych) Disorder
- All relationships suffer
- Combination of behavioral, medical, social, and psychological treatment
- Referrals should not be allowed, care to remain in PCP hands
Clinical findings of Chronic Pain (Psych) Disorder
- Chronic anxiety/depression and/or anger
- Lifestyle changes
- If chronic pain is managed incorrectly it can turn into a never-ending cycle
Chronic Pain (Psych) Disorder Medications
Use for neuropathic pain syndromes:
- SNRIs (venlafaxine, milnacipran, duloxetine)
- TCAs (nortriptyline)
- Anticonvulsants (gabapentin, pregabalin)
Psychosexual Disorders
- Paraphilias (formerly called deviations or variations) - Sexual excitement from woman’s shoe, a child, animals, torture instruments, etc.
- Sexual Dysfunctions in men
- ED
- Ejaculation Disturbances
- Sexual Dysfunctions in women
- Orgasmic disorder - lack of sexual responsiveness
- Hyposexual desire disorder - diminished libido
- Gender Dysphoria - strong desire to be a different gender than assigned at birth
Paraphilia Treatment
- Psychotherapy
- Social - group therapy
- Pharmacologic
- Medroxyprogesterone acetate (MOA)
- suppresses sex drive within 3 weeks of administration
- SSRI (fluoxetine)
- reduces some compulsive sexual behaviors
- LHRH agonist
- prevents relapse
- Medroxyprogesterone acetate (MOA)
ED treatment
Phosphodiesterase Type 5 Inhibitors
- Sildenafil, Tadalafil, Vardenafil
DO NOT USE WITH NITRATES - Risk of significant Hypotension can cause death
Ejaculation Disturbance treatment
- SSRIs are effective for premature ejaculation
Gender Dysphoria treatment
- Psychotherapy
- Peer support groups
- Hormone therapy 1 year prior to gender reassignment surgery
Mood Disorders
- Depression
- Mania
Depression s/s
- Mood varies
- Feelings of guilt, hopelessness, worthlessness
- Loss of interest in normally enjoyable activities
- Somatic complaints
Severe Depression s/s
- Psychomotor retardation
- Anorexia
- Insomnia
- Reduced Sex drive
- Suicidal Ideation
Mania s/s
- Mood ranging from euphoria to irritability
- Sleep disruption
- Hyperactivity
- Racing thoughts
- Grandiosity
- Psychotic symptoms
Mood Disorder considerations
- Genetic factors (neurotransmitter dysfunction)
- Developmental problems (childhood events, personality problems)
- Psychosocial stresses (divorce, unemployment)
- MUST RULE OUT: thyroid dysfunctions, malignancies, strokes, and medication-induced depression
Depressive Disorders
- Major depressive disorder
- Dysthymia
- Premenstrual Dysphoric Disorder
- Bipolar Disorder
Major Depressive Disorder (MDD) S/S
- Occurs at any time of life
- Loss of interest and pleasure (anhedonia)
- Feelings of guilt
- Withdrawal from activities
- Inability to concentrate
- Chronic fatigue
- Somatic complaints
- Loss of sexual drive
- Anorexia with weight loss
Dysthymia S/S
- Symptoms over a period of 2 years or more with relatively persistent course is necessary for diagnosis
- Symptoms are more mild, but longer lasting
Premenstrual Dysphoric Disorder
- Depressive symptoms during the late luteal phase (last 2 weeks) of menstrual cycle
Bipolar Disorder
- Mood shifts from mania, major depression, hypomania, and mixed mood states
- Initial diagnosis difficult due to disorder mimicking other mental disorders and high likelihood of substance abuse with bipolar disorder
Types of Bipolar Disorder
- Bipolar I
- Bipolar II
Bipolar I Disorder
Individual has manic episodes
Bipolar II Disorder
Individuals who experience hypomanic episodes without frank mania
Complications of MDD
- MOST IMPORTANT COMPLICATION IS SUICIDE
Suicide Factors
- Men over age 50 are more likely to complete a suicide
- Women make more attempts, but are less likely to complete
- Ages 15-35 years old increases rate each year
- ETOH use significant factor in many suicide attempts
Red Flags for Suicide
- Depressed patient may make dramatic improvement
- Ask about plans, means, and what is stopping them from going through with plan
- Risk factors (ETOH, family history, depression, male, older age, drug use)
After Suicide Attempt
- Measure patient’s mood using Hamilton OR Montgomery-Asberg rating scale OR PHQ-9
- Often hospitalization is indicated
- Use Columbian-Suicide Severity Risk Scale
MDD Treatment
- SSRIs, SNRIs, and bupropion, vilazodone, vortioxetine, and mirtazapine
- TCAs
- MAOI inhibitors
- Stimulants
- ECT
- Inpatient hospitalization
SSRI for cardiac patients
Sertraline is medication of choice for cardiac patients
Risk of Serotonin syndrome
- Occurs when SSRIs are used in high doses alone or in combination with MAOI inhibitors
Symptoms of Serotonin syndrome
- Rigidity
- Hyperthermia
- Autonomic Instability
- Myoclonus
- Confusion
- Delirium
- Coma
SSRI Bleeding risk
Sertraline and Citalopram are drug of choice when taking warfarin
SSRI Indication
fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
Use for treatment of:
- Panic disorder
- bulimia
- GAD
- OCD
- PTSD
SNRI Indication
venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran
Use for treatment of:
- Neuropathy
- Fibromyalgia
- Stress Incontinence
Atypical Antidepressant side effects
bupropion, nefazodone, trazodone, vilazodone, vortioxetine, mirtazapine
- QT prolongation
- ventricular tachycardia
- elevated cyclosporine levels
- potential risk for liver failure
- Watch for possible agranulocytosis or neutropenia
TCAs and similar meds
- Overuse of TCAs = serious medical emergency (quinidine-like effects) leading to intubation and ICU admission
TCAs and cardiac patients
DO NOT USE TCAs IN CARDIAC PATIENTS
- Use SSRI or Atypical antidepressants
- TCAs can cause altered HR, rhythm, and contractility
- EKG changes can occur
“Washout time” when changing meds
- No need for washout if medication is in the same class
Combining several antidepressants
OR
Adding antipsychotic to antidepressant
Requires extreme caution, and often a psych consult
Combining several antidepressants
OR
Adding antipsychotic to antidepressant
- If combination is successful in symptom relief, continue therapy for 12 months
Stimulants used for depression
- Dextroamphetamine and methylphenidate can be used for short-term treatment of depression in medically ill and geriatric patients
- Benefit of rapid onset (within hours)
ECT
- Most effective to treat severe depression
- Helps control delusions
- SE include memory disturbance and headache
Medication for Acute Mania
- Initial therapy includes: olanzapine, risperidone, aripiprazole + benzodiazepine (if indicated)
- Maintenance using: olanzapine, quetiapine, ziprasidone, aripiprazole, long-acting IM risperidone
Medication for Mania
Valproic Acid
Medication for Mania
Valproic Acid
Side Effects
- GI symptoms
- Weight gain
- Teratogenic Effects - MUST RULE OUT PREGNANCY
Medication for Mania
Valproic Acid
Monitor Lab Studies
- LFTs
- CBC
- Glucose Levels
- Weight (monitored at 2 wks, 4 wks, 3 months, and annually)
Medication for Bipolar
- Lithium is #1 choice for maintenance
- Carbamazepine or Oxcarbazepine
(for patients who cannot be treated with Lithium
Medication for Bipolar
Carbamazepine or Oxcarbazepine
Side Effects
- Skin rashes
- Mild drop in WBC
- Sedation
- Teratogenic Effects - MUST RULE OUT PREGNANCY
Lamotrigine
- Used for maintenance of Bipolar
- Cannot combine with Valproic acid (decreased metabolism = doubles half-life of med = TOXICITY)
- Lamotrigine can cause Steven-Johnson Syndrome (rash + fever = STOP MEDICATION AND SEND TO ED)
Best medication for maintenance of Bipolar and Manic Episodes
Lithium
Lithium dosing
- 2-3x daily
- Trough levels checked 5 days after first dose, but 12 hours after last dose
- 1-1.5 mEq/L is therapeutic (some providers use 0.6-1 mEq/L to reduce SE)
- Monitor lithium levels every 1-2 months initially, then every 6-12 months in long-term, stable patients
Lithium treatment
- Complete full workup BEFORE initiation of treatment
- Check CBC, T4, TSH, BUN, Serum Creatinine, Electrolytes, UA, and EKG for patients >45 years w/hx of cardiac
Lithium SE: GI
- Mild GI (take with food)
Lithium SE: CNS
- fine tremors
- slight muscle weakness
- somnolence
Lithium SE: Renal
- moderate polyuria
- polydipsia - administer K+ to help with this
- weight gain
- leukocytosis
Lithium SE: Thyroid
- goiter
- hypothyroidism
Lithium SE: Cardiac
- EKG changes - T wave flattening or inversion
- SA block in elderly
Lithium SE: Respiratory
- Impairs ventilatory function in patients with airway obstruction
Lithium SE: Skin
- May precipitate or exacerbate psoriasis
- Acne
Lithium SE: Toxicity
- Greater than 2 mEq/L is toxicity
- Can be caused by Na+ loss (diarrhea, diuretics, excessive sweating)
- Dialysis for overdose of Lithium
Lithium SE: S/S of Toxicity
- S/S: Diarrhea, vomiting, tremors, marked weakness, confusion, dysarthria, vertigo, choreoathetosis, ataxia, hyperreflexia, rigidity, poor coordination, myoclonus, seizures, opisthotonos, and coma
Autism Spectrum Disorder (ASD)
- Neurodevelopmental disorder that causes pervasive difficulties with social communication and have repetitive, restricted interests and behaviors
NICE guidelines to assess for ASD
Ask about:
- Core ASD difficulties
- Early development
- Medical and Family Hx
- Behavior
- Education
- Employment
Treatment for ASD
No treatment for the core symptoms of ASD have been validated
2 Stages of sleep
- REM (sleep dream sleep, D state sleep,
- NREM
REM Sleep
- 1st REM cycle starts about 80-120 mins after initiation of sleep and lasts about 10 minutes
- Later REM occurs for 15-40 mins within the last several hours of sleeping
- 4-5 REM cycles happen during sleep each night (approx 1.5-2 hrs each)
Insomnia Common Factors
- Psychiatric disorders often associated with insomnia
- Depression
- Mania (shortened REM)
Hypersomnia
- Obstructive sleep apnea most common
- Narcolepsy Hypocretin Deficiency Syndrome
Sleep Disturbance Causes
- ETOH abuse
- Heavy Smoking
- Caffeine, Cocaine, Other stimulants
Medications for sleep
- Benzos
- Antidepressants
- Research shows that CBT is as effective as Ambien after 1 year
Narcolepsy Treatment
- Dextroamphetamine sulfate - given once PO daily in AM
- Modafinil and armodafinil - IV treatment for excessive narcolepsy
- Imipramine - tx of cataplexy (Cataplexy is a sudden, brief loss of voluntary muscle tone triggered by strong emotions such as laughter) but NOT narcolepsy
Alcohol Abuse
AUDIT tool
ETOH Withdrawals
CIWA-Ar Scores
<8 = Minimal withdrawals
8-15 = Mild withdrawals
16-20 = Moderate withdrawals
> 21 = Severe withdrawals
Max score 67
CIWA-Ar Score <8
- Benzos (lorazepam or chlordiazepoxide)
- Check score Q6 hours
- Assess sedation 30-60 mins after administering benzo
CIWA-Ar Score 8-15
- Check score Q4 hours
- Adjust dose of meds as needed to control withdrawal symptoms
- Additional doses should be given if score remains 8-15
CIWA-Ar Score 16-20
- Check score Q2 hours
- Give chlordiazepoxide 100mg PO or Lorazapem 3-4mg QH for first 2 hours
- Then chlordiazepoxide 50mg or Lorazapam 1-2mg Q2H
- Max dose of chlordiazepoxide is 600mg in 24 hours
- Monitor 30-60 min after each dose is given for sedation
CIWA-Ar Score >21
- Check score every 30 mins
- IV Lorazepam (1-2mg Q15min)
- If pt needs more than 8mg/hour then consider Dexmedetomidine (sedation without respiratory depression)
- Then propofol if withdrawal continues
Opioid Dependencies
- Graded 0-4
Opioid Dependencies
Grade 0
- Craving
- Anxiety
Opioid Dependencies
Grade 1
- Yawning
- Lacrimation
- Rhinorrhea
- Perspiration
Opioid Dependencies
Grade 2
- Previous symptoms plus
- Myadriasis (pupil dilation)
- Piloerection (goosebumps)
- Anorexia
- Tremors
- Hot/cold flashes
- Generalized aching
Opioid Dependencies
Grade 3 and 4
- Increased intensity of previous symptoms…plus:
- Increased temp
- Raised B/P, pulse, RR, and depth
- Possible vomiting, diarrhea, weight loss, spontaneous ejaculation
Opioid Dependency Treatment
- Clonidine multiple times daily (alleviates CV symptoms)
- Naltrexone used to treat patient when they have been opioid free for 7-10 days
- Suboxone (buprenorphine)
