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CMN 568 Unit 5 > Psych Disorders > Flashcards

Psych Disorders Flashcards

1
Q

Adjustment Disorder

A
  • Occurring within 3 months of an identifiable stressor
  • Inability to concentrate
  • Sleep disturbances
  • Often self-medicated with ETOH, CNS depressants
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2
Q

Adjustment Disorder Medication

A
  • Lorazepam (up to 3x/day PO) for a LIMITED TIME

- Short-term SSRI

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3
Q

Generalized Anxiety Disorder (GAD)

A
  • 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
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4
Q

GAD Medications

A

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)
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5
Q

Panic Disorder

A
  • 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
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6
Q

Panic Disorder Medications

A

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)
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7
Q

Phobia Disorder

A
  • 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

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8
Q

Phobia Disorder Medications

A

1st line

  • SNRI (venlafaxine)
  • SSRIs (paroxetine, sertraline, fluvoxamine)
  • Anticonvulsants (gabapentin)
  • Beta-blockers (propranolol)
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9
Q

Obsessive-Compulsive Disorder (OCD)

A
  • Ritualistic/repetitive behaviors that are distressing to the patient
  • Often co-morbidity with major depression
  • Affects young, divorced, separated, or unemployed
  • Treat with
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10
Q

Obsessive-Compulsive Disorder (OCD) Medications

A

Medications

  • SSRIs and clomipramine (can take up to 12 weeks to take effect)
  • May need to add antipsychotics and topiramate in resistant cases
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11
Q

Obsessive-Compulsive Disorder (OCD) Treatment

A
  • CBT - patient learns to identify maladaptive cognitions associated with obsessive thoughts and challenge those cognitions
  • Thought-stopping when OCD thought begins
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12
Q

OCD Treatment - Clomipramine concerns

A
  • Check plasma levels/metabolites every 2-3 weeks to keep level <500 ng/mL (above 500 leads to toxicity)
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13
Q

Conversion Disorder

A
  • Psychic conflict converts into physical symptoms

- Usually occurs alongside panic disorder or depression

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14
Q

Treatments for Somatic Symptom Disorders

A
  • 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
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15
Q

Chronic Pain (Psych) Disorders

A
  • 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”
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16
Q

Chronic Pain (Psych) Disorder

A
  • All relationships suffer
  • Combination of behavioral, medical, social, and psychological treatment
  • Referrals should not be allowed, care to remain in PCP hands
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17
Q

Clinical findings of Chronic Pain (Psych) Disorder

A
  • Chronic anxiety/depression and/or anger
  • Lifestyle changes
  • If chronic pain is managed incorrectly it can turn into a never-ending cycle
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18
Q

Chronic Pain (Psych) Disorder Medications

A

Use for neuropathic pain syndromes:

  • SNRIs (venlafaxine, milnacipran, duloxetine)
  • TCAs (nortriptyline)
  • Anticonvulsants (gabapentin, pregabalin)
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19
Q

Psychosexual Disorders

A
  • 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
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20
Q

Paraphilia Treatment

A
  • 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
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21
Q

ED treatment

A

Phosphodiesterase Type 5 Inhibitors
- Sildenafil, Tadalafil, Vardenafil

DO NOT USE WITH NITRATES - Risk of significant Hypotension can cause death

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22
Q

Ejaculation Disturbance treatment

A
  • SSRIs are effective for premature ejaculation
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23
Q

Gender Dysphoria treatment

A
  • Psychotherapy
  • Peer support groups
  • Hormone therapy 1 year prior to gender reassignment surgery
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24
Q

Mood Disorders

A
  • Depression

- Mania

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25
Q

Depression s/s

A
  • Mood varies
  • Feelings of guilt, hopelessness, worthlessness
  • Loss of interest in normally enjoyable activities
  • Somatic complaints
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26
Q

Severe Depression s/s

A
  • Psychomotor retardation
  • Anorexia
  • Insomnia
  • Reduced Sex drive
  • Suicidal Ideation
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27
Q

Mania s/s

A
  • Mood ranging from euphoria to irritability
  • Sleep disruption
  • Hyperactivity
  • Racing thoughts
  • Grandiosity
  • Psychotic symptoms
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28
Q

Mood Disorder considerations

A
  • 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
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29
Q

Depressive Disorders

A
  • Major depressive disorder
  • Dysthymia
  • Premenstrual Dysphoric Disorder
  • Bipolar Disorder
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30
Q

Major Depressive Disorder (MDD) S/S

A
  • 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
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31
Q

Dysthymia S/S

A
  • Symptoms over a period of 2 years or more with relatively persistent course is necessary for diagnosis
  • Symptoms are more mild, but longer lasting
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32
Q

Premenstrual Dysphoric Disorder

A
  • Depressive symptoms during the late luteal phase (last 2 weeks) of menstrual cycle
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33
Q

Bipolar Disorder

A
  • 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
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34
Q

Types of Bipolar Disorder

A
  • Bipolar I

- Bipolar II

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35
Q

Bipolar I Disorder

A

Individual has manic episodes

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36
Q

Bipolar II Disorder

A

Individuals who experience hypomanic episodes without frank mania

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37
Q

Complications of MDD

A
  • MOST IMPORTANT COMPLICATION IS SUICIDE
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38
Q

Suicide Factors

A
  • 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
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39
Q

Red Flags for Suicide

A
  • 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)
40
Q

After Suicide Attempt

A
  • Measure patient’s mood using Hamilton OR Montgomery-Asberg rating scale OR PHQ-9
  • Often hospitalization is indicated
  • Use Columbian-Suicide Severity Risk Scale
41
Q

MDD Treatment

A
  • SSRIs, SNRIs, and bupropion, vilazodone, vortioxetine, and mirtazapine
  • TCAs
  • MAOI inhibitors
  • Stimulants
  • ECT
  • Inpatient hospitalization
42
Q

SSRI for cardiac patients

A

Sertraline is medication of choice for cardiac patients

43
Q

Risk of Serotonin syndrome

A
  • Occurs when SSRIs are used in high doses alone or in combination with MAOI inhibitors
44
Q

Symptoms of Serotonin syndrome

A
  • Rigidity
  • Hyperthermia
  • Autonomic Instability
  • Myoclonus
  • Confusion
  • Delirium
  • Coma
45
Q

SSRI Bleeding risk

A

Sertraline and Citalopram are drug of choice when taking warfarin

46
Q

SSRI Indication

fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram

A

Use for treatment of:

  • Panic disorder
  • bulimia
  • GAD
  • OCD
  • PTSD
47
Q

SNRI Indication

venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran

A

Use for treatment of:

  • Neuropathy
  • Fibromyalgia
  • Stress Incontinence
48
Q

Atypical Antidepressant side effects

bupropion, nefazodone, trazodone, vilazodone, vortioxetine, mirtazapine

A
  • QT prolongation
  • ventricular tachycardia
  • elevated cyclosporine levels
  • potential risk for liver failure
  • Watch for possible agranulocytosis or neutropenia
49
Q

TCAs and similar meds

A
  • Overuse of TCAs = serious medical emergency (quinidine-like effects) leading to intubation and ICU admission
50
Q

TCAs and cardiac patients

A

DO NOT USE TCAs IN CARDIAC PATIENTS

  • Use SSRI or Atypical antidepressants
  • TCAs can cause altered HR, rhythm, and contractility
  • EKG changes can occur
51
Q

“Washout time” when changing meds

A
  • No need for washout if medication is in the same class
52
Q

Combining several antidepressants
OR
Adding antipsychotic to antidepressant

A

Requires extreme caution, and often a psych consult

53
Q

Combining several antidepressants
OR
Adding antipsychotic to antidepressant

A
  • If combination is successful in symptom relief, continue therapy for 12 months
54
Q

Stimulants used for depression

A
  • Dextroamphetamine and methylphenidate can be used for short-term treatment of depression in medically ill and geriatric patients
  • Benefit of rapid onset (within hours)
55
Q

ECT

A
  • Most effective to treat severe depression
  • Helps control delusions
  • SE include memory disturbance and headache
56
Q

Medication for Acute Mania

A
  • Initial therapy includes: olanzapine, risperidone, aripiprazole + benzodiazepine (if indicated)
  • Maintenance using: olanzapine, quetiapine, ziprasidone, aripiprazole, long-acting IM risperidone
57
Q

Medication for Mania

A

Valproic Acid

58
Q

Medication for Mania
Valproic Acid
Side Effects

A
  • GI symptoms
  • Weight gain
  • Teratogenic Effects - MUST RULE OUT PREGNANCY
59
Q

Medication for Mania
Valproic Acid
Monitor Lab Studies

A
  • LFTs
  • CBC
  • Glucose Levels
  • Weight (monitored at 2 wks, 4 wks, 3 months, and annually)
60
Q

Medication for Bipolar

A
  • Lithium is #1 choice for maintenance
  • Carbamazepine or Oxcarbazepine
    (for patients who cannot be treated with Lithium
61
Q

Medication for Bipolar
Carbamazepine or Oxcarbazepine
Side Effects

A
  • Skin rashes
  • Mild drop in WBC
  • Sedation
  • Teratogenic Effects - MUST RULE OUT PREGNANCY
62
Q

Lamotrigine

A
  • 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)
63
Q

Best medication for maintenance of Bipolar and Manic Episodes

A

Lithium

64
Q

Lithium dosing

A
  • 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
65
Q

Lithium treatment

A
  • 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

66
Q

Lithium SE: GI

A
  • Mild GI (take with food)
67
Q

Lithium SE: CNS

A
  • fine tremors
  • slight muscle weakness
  • somnolence
68
Q

Lithium SE: Renal

A
  • moderate polyuria
  • polydipsia - administer K+ to help with this
  • weight gain
  • leukocytosis
69
Q

Lithium SE: Thyroid

A
  • goiter

- hypothyroidism

70
Q

Lithium SE: Cardiac

A
  • EKG changes - T wave flattening or inversion

- SA block in elderly

71
Q

Lithium SE: Respiratory

A
  • Impairs ventilatory function in patients with airway obstruction
72
Q

Lithium SE: Skin

A
  • May precipitate or exacerbate psoriasis

- Acne

73
Q

Lithium SE: Toxicity

A
  • Greater than 2 mEq/L is toxicity
  • Can be caused by Na+ loss (diarrhea, diuretics, excessive sweating)
  • Dialysis for overdose of Lithium
74
Q

Lithium SE: S/S of Toxicity

A
  • S/S: Diarrhea, vomiting, tremors, marked weakness, confusion, dysarthria, vertigo, choreoathetosis, ataxia, hyperreflexia, rigidity, poor coordination, myoclonus, seizures, opisthotonos, and coma
75
Q

Autism Spectrum Disorder (ASD)

A
  • Neurodevelopmental disorder that causes pervasive difficulties with social communication and have repetitive, restricted interests and behaviors
76
Q

NICE guidelines to assess for ASD

A

Ask about:

  • Core ASD difficulties
  • Early development
  • Medical and Family Hx
  • Behavior
  • Education
  • Employment
77
Q

Treatment for ASD

A

No treatment for the core symptoms of ASD have been validated

78
Q

2 Stages of sleep

A
  • REM (sleep dream sleep, D state sleep,

- NREM

79
Q

REM Sleep

A
  • 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)
80
Q

Insomnia Common Factors

A
  • Psychiatric disorders often associated with insomnia
  • Depression
  • Mania (shortened REM)
81
Q

Hypersomnia

A
  • Obstructive sleep apnea most common

- Narcolepsy Hypocretin Deficiency Syndrome

82
Q

Sleep Disturbance Causes

A
  • ETOH abuse
  • Heavy Smoking
  • Caffeine, Cocaine, Other stimulants
83
Q

Medications for sleep

A
  • Benzos
  • Antidepressants
  • Research shows that CBT is as effective as Ambien after 1 year
84
Q

Narcolepsy Treatment

A
  • 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
85
Q

Alcohol Abuse

A

AUDIT tool

86
Q

ETOH Withdrawals

CIWA-Ar Scores

A

<8 = Minimal withdrawals

8-15 = Mild withdrawals

16-20 = Moderate withdrawals

> 21 = Severe withdrawals

Max score 67

87
Q

CIWA-Ar Score <8

A
  • Benzos (lorazepam or chlordiazepoxide)
  • Check score Q6 hours
  • Assess sedation 30-60 mins after administering benzo
88
Q

CIWA-Ar Score 8-15

A
  • Check score Q4 hours
  • Adjust dose of meds as needed to control withdrawal symptoms
  • Additional doses should be given if score remains 8-15
89
Q

CIWA-Ar Score 16-20

A
  • 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
90
Q

CIWA-Ar Score >21

A
  • 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
91
Q

Opioid Dependencies

A
  • Graded 0-4
92
Q

Opioid Dependencies

Grade 0

A
  • Craving

- Anxiety

93
Q

Opioid Dependencies

Grade 1

A
  • Yawning
  • Lacrimation
  • Rhinorrhea
  • Perspiration
94
Q

Opioid Dependencies

Grade 2

A
  • Previous symptoms plus
  • Myadriasis (pupil dilation)
  • Piloerection (goosebumps)
  • Anorexia
  • Tremors
  • Hot/cold flashes
  • Generalized aching
95
Q

Opioid Dependencies

Grade 3 and 4

A
  • Increased intensity of previous symptoms…plus:
  • Increased temp
  • Raised B/P, pulse, RR, and depth
  • Possible vomiting, diarrhea, weight loss, spontaneous ejaculation
96
Q

Opioid Dependency Treatment

A
  • Clonidine multiple times daily (alleviates CV symptoms)
  • Naltrexone used to treat patient when they have been opioid free for 7-10 days
  • Suboxone (buprenorphine)

CMN 568 Unit 5 (5 decks)

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