substantia nigra
dopamine is produced here
Aplastic anemia
Tegretol side effect
Serotonin discontinuation syndrome
Sensory disturbance, sleeping disturbance, disequilibrium, flu like sx, dizzy, n/v
Sign of fetal alcohol syndrome
small head, smooth palpebral fissure, inner epicanthal folds
*sign of serotonin syndrome
hyperthermia, shivering, anxiety, diaphoresis, diarrhea
to get reluctant patient to engage use what
open ended questions
Rhett syndrome
a rare disorder found virtually exclusively in girls, is a neurodevelopmental disorder in which the child usually develops normally unitl about 6 to 18 months of age at which characteristics of the syndrome emerge; characteristics include: hypotonia (loss of muscle tone), reduced eye contact, decelerated head growth, and disinterest in play activities
Risk factor for serotonin syndrome
more than 1 SSRI, St Johns wart, tramadol, demerol, Ultram
State board of nursing, ANA, regulates what
Scope of practice
PHQ-9 over 20
Severe depression
Cranial nerve VII, sensory and motor
Puff cheeks
Trichotillomania/OCD
Pulling hair out
Raphi Nuclei
Serotonergic neurons in the brain, produce serotonin
“I don’t know answers”
Pseudo dementia, depression
PANDAS associated with
Strep, Pediatric autoimmune neuropsychiatric disorder. If OCD, did they have strep recently
Lyrica
Patient has neuropathic pain, gabapentin not helping. What med may
Almost completely absorbed, 3 times more than gabapentin
Why Lyrica works better for pain
Conversion syndrome
Patient lost friend and now experiences paralysis. Repressed unconscious intrapsychic conflicts
Tardive dyskinesia
a person with EPS will most likely experience
Alpha 2 delta protein
pain is linked to ability to bind to what
Double Serum Lithium level
NSAID and Ace inhibitors do what to lithium
NMS labs
increased creatinine kinase, WBC, LDH, LFT’s (rhabdomyolysis due to muscle tremors and rigidity)
Norepinephrine
helps control alertness and arousal, mood hunger and sleep
This is synthesized in the Locus Coeruleus
Norepinephrine
Identify NMS with these key features
Rigidity, Autonomic instability, fever, change LOC, drooling
Meningitis
nuchal rigidity, stiffness in cervical neck
These can cause mania
steroids, antabuse, isonaizid, antidepressants in bipolar
MMSE
test for abstract versus concrete operations
MMSE 0-17 shows
Severe cognitive impairment
MMSE 24-40
No cognitive impairment
Dopamine and GABA
Neurotransmitters involved in alcoholism
Dantrolene
Muscle relaxant for NMS
Bromocriptine
Dopamine receptor agonist, for NMS
Phallic state age 3-6
masturbate is normal
Primary prevention
Classes, education, modify environment, prevent and promote
Secondary prevention
screening and early detection, crisis hotline
Tertiary prevention
Rehab, day treatment, social skills, treat to prevent further deterioration
Lithium toxicity hits at what value
1.5 with nausea and vomiting
startle reflex (moro)
last 5-6 months, if absent do an xray
motivational interviewing is
non-confrontational style, helps patients move further along the continuum of change, based on transtheoretical model of stages of change
Ace and Arbs
Two classes of meds shouldn’t be used together
Renal dysfunction
Don’t give Ace and Arbs together because they cause this
Anxiety
SSRI started in 65yr old can cause this. Expect increased side effects, do ekg
Accutane
This can cause depression and birth defect
Congestive heart failure
Drugs known as ace inhibitors ending in “pril” can cause this
Nucleus basal is of Meynert
These are vulnerable in age related neurodegenerative disease such as Alzheimer’s due to decreased acetylcholine in brain
Hip disease
Abnormal trendelenberg test indicates
Adjustment disorder
Symptoms within 3 months but not more than 6 months. Reaction to specific life event (stressor)
Normal Tanner stage, start by 16
14yr old no axillary hair no period
Concern for rhabdomyalysis
Adolescent with substance abuse but works out and muscle aches. What may this indicate
What does Erythromycin do to Tegretol
Inhibitor, so it increases the level, you need to decrease the dose
What is first line neuroprotective med for bipolar
Lithium
First symptom of metabolic syndrome
Large waist circumference
Flonase interacts with what mood stabilizer
Tegretol
Flonase has what in it
Steroids
Steroids are an inhibitor and lead to increase in what level
Tegretol
Tegretol has a known risk for what, which means if you give it with steroid you do what to dosing
Agranulocytosis, decrease
First sign of frontal lobe dementia
Personality changes, social changes
Patient with irritability, depression, edginess should be screened for what
Bipolar if 7/13 bipolar likely
How long does Parkinsonism take to develop
Months
How long does akathisia take to develop
Days
How long does tardive dyskinesia take to decelop
Years
Grade 2/5 hoarse systolic heart murmur indicates
Aortic stenosis
Most commonly used anxiety scale is what
Hamilton
Hamilton anxiety scale 14 indicates, 18-24 indicates, 25-30 indicates
Lower is mild, over 25 severe
Hamilton depression scale normal range is what
0-7
Hamilton depression scale mild is scored as what
8-13
Hamilton depression scale of 19-23 indicates what and what do you monitor for
Severe depression, suicide
Health care policy is assess, cost, and what
Quality
How does Tegretol interact with Cipro
Cipro and erythromycin are inhibitors, decrease dose
How you get paid for Medicare
CPT, current procedural terminology
How does ibuprofen effect lithium
Increases serum level of lithium to double
Organization accountability focus on universal safety in healthcare to find error and what went wrong is defined as
Just culture
What is quantitative data
In numbers
What is qualitative data
Measures natural setting like observation
Research like experimental design but uses naturally occurring groups rather than assigning subjects to groups
Quasi-experimental design
Rare complication anorexia nervosa binge purge includes
Delayed gastric emptying and motility
How To check for decreased gastric motility
Measure stomach
Delayed intervention of delayed gastric emptying can lead to
Gastric necrosis, perforation, shock, death
Male with more than 1 X chromosome (xxy) Little to no sperm, fertility treatment indicates
Klinefelter syndrome
Keeping chronically mental ill in community is part of what therapy model
Assertive community therapy model (ACT)
Labs for macrocyclic anemia
Folic avid, b12, ESR/CRP, HGB, MCV liver
Labs for rheumatoid arthritis
ESR elevation, synovial fluid analysis, X-ray joints, crp, hgb, Rheumatoid factor titer
Labs on lithium
Leukocytes is, creatinine, BUN, NA, 4+ protein in urine
Law makes sure people with mental health issues get same financial treatment
Mental health parity act requires annual lifetime dollar limits be no lower than any medical surgical benefits. 1996
Pt with severe diarrhea, n/v, metallic taste, tremor, slurred speech, May be going through what
Lithium toxicity
What intervention for lithium toxicity and what level is emergent
Give fluids, 3
Tegretol strong inducer of what neurotransmitter
3A4
Tergretol (carbamazepine) induces Flonase so you need to do what to flonase
Increase the Flonase
How to test for fungal Infection
Shavings of toes
How to check for dementia
Have patient tell you risk/benefits and test capacity
Involuntary, spasmodic, twitching, uncontrolled vocal sounds, inappropriate words indicates
Tourette’s
What does Tagamet (cimetidine) do
Prevents acid from backing up into esophagus and causing heartburn
Tagamet is an antacid and blocks what neuro receptor
H2
What to do for patient on Tagamet but also Benzo or coumadin
Increase benzo increase coumadin
To be diagnosed Tourette’s the patient has to have symptoms for how long and usually occurs by what age
1 year and by 3-9
A patient has to have these symptoms by what age to get diagnosed..involuntary vocal sounds, twitching, spasmodic
Tourette’s 18
Serotonin and Norepinephrine are the two associated with
Depression
This medicine can cause glaucoma
Trazodone
Patient starting trazodone (desyrel) should have what Base line test completed
EKG
Most severe reaction to trazodone perhaps by overdose is what
Priapism, QT prolongation, respiratory arrest, seizure
Normal development 6yr old diagnosed leukemia 1 month ago what do you expect
Thinks he is being punished for doing something wrong
When should a patient take Vardenafil (Levitra)
45 minutes prior to sex
This is a statistical measure of 2 independent samples significantly different
T test
Chromosomal disorder in female X chromosome missing making coffee instead of xx, or part of X chromosome deleted, delayed puberty, amenorrhea, poor social skills, web neck, osteoporosis
Turner syndrome
In schizophrenia most all structures decrease but what
Ventricles
To start a consulting firm you need what to show economic viability
Revenue and expenses
What birth control pills do to lamictal
Inducer so lowers the level of lamictal
What does a 17 indicate on mmse
Moderate cognitive impairment
What does a decreased reticulocyte count indicate
Anemia, acute or chronic bleeding
What does an abnormal reticulocyte count indicate in general
Doesn’t diagnose anything first step is to identify source of issue
What does increased reticulocyte count indicate
Bone marrow disorder or vitamin deficiency
A test to measure reticulocyte in your blood and should range 0.5 to 1.5%
Reticulocyte count
I’ll
Hamilton depression scale 14-18 indicates what
Moderate depression
What are two important things to measure when using zyprexa
Lipid and abdomen circumference
What class controlled substance is Np approved prescribing
Schedule II-V only
What cranial nerve assessed when patient shrug shoulders
Spinal accessory 11 (XI)
What cranial nerve tested patient clench jaw and assess temporal muscle
Trigeminal 5 V
What schedule drug is PCP, heroin, MDMA
1 nobody has these
What schedule drug significant abuse potential
2, morphine, methadone, methylphenidate
What schedule has moderate abuse potential
3 hydrocodone, codeine
What schedule has low abuse potential
Benzo, ambien, phentermine
What schedule has very low abuse potential
5 antitussive, lomotil
What 3 atypical can be used for teens
Seroquel, ability, zyprexa
These are the three CK muscle enzyme test
CKBB, CKMM, CKMB
To qualify for GAD, or must have 3 symptoms for how long
6 months, worry, anxiety, tension, sleep trouble, restless, energy loss
If an Asian makes no eye contact with provider it indicates
Respect
What does messenger RNA code for
Amino acids
What is normal lab for ANC
1500-8000
What to do if or on Tegretol and ANC is less than 1000
Stop and repeat lab
What erythromycin does to trileptal
Inhibits so increases Trileptal you need to decrease trileptal
Patient with HIV dementia lab shows CD4 level as
Less than 200 and viral load is high
Delano year inhibits lamictal so what does it do to the lamictal level
Increases lamictal level
Risk in using tramadol
Serotonin syndrome
Often times this is mistaken for depression in the neginning
Hiv related dementia
What is often common in patient with fibromyalgia
Sexual abuse
Refeeding syndrome
Anorexic teen with pain when eating due to delayed gastric emptying
Aggression in the brain
Dysfunction in the amygdala and prefrontal cortex leading to violent tendencies can cause
hypothalmus
believed to regulate aggression
apoptosis
programmed cell death, neuron loss due to suffocation ,enzyme breakdown
CN V Trigeminal
Clenched teeth
CBT
Best therapy for negative thinking
WBC and ANC
Labs to check if patient is on clozaril
1000
Stop clozaril if ANC is less than what
What does low dopamine do to prolactin
Increases and cause milk extract
High dopamine in the hypothalmus does what to prolactin
decrease
If FSH is inhibited what happens
Amenorrhea, galactorrhea
What does antipsychotic do to mesolimbicc pathway
decreases dopamine but too much causes parkinsonism
Greatest risk of EPS and NMS comes from typical or atypical antipsychotic
Typical such as Haldol
This atypical antipsychotic increases prolactin
Risperidone
This drug causes high risk of agranulocytosis and what lab should you obtain
clozaril, run CBC
Oculogyric crisis, sustained muscle contraction is example of what
Dystonia
Restless, Pacing, knees tapping quickly, example of what
Akathesia
A patient having akathesia should be given what
Beta blocker to relax
Cogwheel rigidity, shuffling gait, tremor, example of what
parkinsonism
Treatment for dystonia or parkinsonism
Anticholinergic, cogentin or benadryl
Lip, tongue smacking repetitive is an example of
tardive dyskinesia
treatment for tardive dyskinesia
discontinue antipsychotic and start clozaril
Danrolene is what
dopamine agonist
Which lobe impacted if working memory or impulse control issue
frontal lobe
Which lobe cause auditory visual hallucinations, aphasia, amnesia
temporal
Obsession is
a recurrent, unwanted thought, idea, or image
Compulsion is
uncontrollable urge to perform an act repeatedly
Babinski reflex disappears, (goes up and other toes fan out)
9 months
MMSE score 25-30
normal
MMSE: Score that indicates mild cognitive impairment
21-24
MMSE score of less than _ is suggestive of dementia (total maximum is 30).
10
Dementia due to HIIV disease
Subcortical dementia
If person age 5 or even 40 can complete project they are in what stage
formal operation
Lack of self control or self esteem shows failure when
Early childhood
A failure of infancy stage leads to
unable to form meaningful relationship
Inability to set goals or self initiated behavior is a failure when
late childhood
Psych disorder schizo, substance abuse, paranoia associated with failure of what stage
Oral according to Freud
Inability to form social relationships is failure of what stage
Latency
Depressive disorders associated with failure of what stage
Anal stage
This therapy focuses on emotional regulation
DBT
This therapy focus is present focus on life and self confrontation
Existential
This therapy is self directed growth and self actualization- each person has potential to find meaning
Humanistic
This therapy identifies distorted thoughts and substitutes reality oriented interpretations
Cognitive Behavioral Therapy
This therapy most common use is PTSD
EMDR
Biofeedback is used for what
Anxiety and pain, not depression
Family Systems Theory
focus on chronic anxiety within family, Use triangles and genograms with goal to increase self-differentation
This family therapy uses only genogram
Structural family therapy
Interventions are problem focused, more symptom focused with straightforward directives
Strategic therapy
Paradoxical directive
A negative task assigned when family resistant to change
Solution focused therapy
emphasizes solutions that worked previously
Wash out period for patient on SSRI to MAOI
Wait 2 weeks before initiate
Prozac to MAOI
wait 5-6 weeks due to longer half life
what do serial 7 test
concentration
where do you document SI or HI
Thought content
Ask patient where they ate breakfast and they tell whole story before answer is an example of
Circumstantial
Ask patient what they ate and they tell you about a vacation
tangential
To test concentration or attention have patient do what
Count backward from 100 by 7s
Sensory perceptual disturbance or taste associated with this lobe
parietal lobe
The largest part of the brain is the
cerebrum
mechanism of action that makes antipsychotic atypical is
serotonin 5H2A antagonism
yes, yes, yes example of what (repeating words)
perservation
ADHD is linked to problem in what lobe
Executive functioning, frontal lobe
This diagnosis thinks their thoughts and actions caused something to occur- magical thinking-if look at computer 5 times it will fly
schizotypal
Neologisms
use of made up words
antipsychotic with least weight gain
geodon
Grouping words usually rhyming is known as what association
clang
There is a medication class that is contraindicated when a patient has tics. What is that class of medication?
Stimulants –often used for ADHD
What action do you take if a patient reports being a victim of abuse.
Safety first!
Provide patient with an environment of safety and reassure them of their safety in the clinic/hospital.
If you work inpatient, what do you do before discharging a patient who says they have been abused?
Make sure the patient will be safe.
If you work inpatient, is a safety contract sufficient to determine that you are releasing a patient into a safe home?
No. A safety contract is not enough. The NP has to confirm that the patient is going to be safe for themselves or their environment is safe.
Inpatient–for safety, where should the NP interview the patient and why?
Safety is more important than privacy. In an office with a door open or partially open. The day room would be a breach of confidentiality and a closed door or in their room would give the patient access to harming the NP.
If a child comes into the office with their parents and say they have been abused, what action does the NP take?
interview the child separately from the parents THEN report to CPS
If a child comes into an appointment without their parents and plays with a toy in a sexual way, what action does the NP take?
This makes the NP suspect abuse so initial action is to immediately report to CPS.
What is the cornerstone of building a therapeutic alliance with adolescents?
Confidentiality with the explanation that confidentiality must be broken if they are a danger to self or others
Do we interview adolescents with their parents in the room?
No because the adolescent may have info that they want kept confidential from their parents.
If an adolescent comes in with their parents, do you keep the parents and adolescent together or separate theme?
Separate them and speak to adolescent alone because the adolescent has a right to confidentiality.
Which ethnic group has the highest incidence of suicide and suicide attempts ?
Native American
Native Americans believe in their healing stick. If a staff member tries to take it away, what should the NP do?
Educate the staff member in cultural competency and sensitivity.
If a patient wants a traditional healer to accompany them to an appointment, what does the NP have to do ?
Get consent from the patient and allow the traditional healer to attend as well. With permission from the patient, you can include the healer in the care plan as follow up.
Which labs should be taken before treating for depression or mania?
TSH
What is the normal range of TSH?
0.5-5.0 mu/L
Symptoms of hypothyroidism mimic which mental illness?
Depression
Symptoms of hyperthyroidism mimic which mental illness?
Mania
If TSH is low i.e. 0.4 or lower, what is happening to T4 an T3 and what condition does patient have?
T4 and T3 will be high and patient will have hyperthyroidism
If TSH is high e.g. 7.0, what is happening to T4 an T3 and what condition does patient have?
T4 and T3 will be low and patient will have hypothyroidism.
What are the symptoms of hyperthyroidism that can mimic mania? And what are other symptoms?
agitation, anxiety, irritability, mood swings, weight loss.
Other symptoms are heat intolerance and tachycardia
What are symptoms of hypothyroidism that mimic depression? And what are other symptoms?
lethargy, weight gain, decreased libido.
And, cold intolerance
What is the Black Box warning for Depakote?
Pancreatitis
What are physical side effects/ dangers of Depakote (Divalproex)–for patient or fetus
Spina bifida in fetuses
Hepatotoxicity
If a patient taking depakote has signs of hepatotoxicity what would those signs and symptoms be ?
Abdominal pain in upper right quadrant of abdomen
Reddish brown urine
Yellowing of the skin and whites of eyes
Fatigue
If patient taking depakote has signs of hepatotoxicity, what should the NP do?
A liver function test –check AST and ALT levels
Signs of valproic acid toxicity?
Disorientation
lethargy
Respiratory depression
Nausea/vomiting
What action do we take at signs of valproic acid (Divalproex/Depakote) toxicity?
Dc medication and check depakote levels, do a LFT and check ammonia levels
What are the signs and symptoms of pancreatitis
upper adbominal pain
abdominal pain that radiates to patient’s back
tenderness when touching the abdomen
fever
rapid pulse
nausea
vomiting
oily stools
What in mental illness is Kava (or Kava Kava) used for ?
Kava Calms
anxiety
stress
insomnia
What is the major side effect of Kava? What do we monitor?
Liver damage
We monitor patient for RUQ pain and do LFTs
Kava is contraindicated with which meds/med classes?
Xanax (Alprazolam)
CNS depressants/ sedative medications
Benzos (CLonazepam/Klonopin), (Lorazepam/ Ativan),
phenobarbital (Donnatal)
Zolpidem (Ambien)
Lamictal and weight
Lamictal is the mood stabilizer that causes the least weight gain
Lamictal and rash
Can cause Stevens Johnson
What are the symptoms of Stevens Johnson syndrome?
Body aches, red rash, peeling skin, facial and tongue swelling
Which antipsychotics cause the least weight gain?
ZAL
Ziprasodone (Geodon)
Aripriprazole (Abilify)
Lurasidone (Latuda)
For patients taking antipsychotics that have caused weight gain, what routine labs do we check?
bmi
hip-to-waist ratio
glucose
lipid panel
Non-pharm treatment of antipsychotic induced weight gain (AIWG)–1st line
Exercise and nutritional counseling
This is first line treatment
Pharm intervention for Antipsychotic Induced Weight Gain
Switch to antipsychotic with lower potential for weight gain: ZAL
Black Box Warning for Carbamazepine
agranulocytosis, aplastic anemia, Stevens –Johnson syndrome
symptoms of Aplastic anemia
pallor
fatigue
HA
fever
nosebleeds
bleeding gums
skin rash
SOB
If prescribing Carbamazepine for an Asian patient, what gene do you screen for ?
HLA-B* 1502 allele is highly associated with Carbamazepine-induced Stevens-Johnson syndrome
ANC level that indicates NP should DC clozapine or Carbamazepine?
An ANC less than 1000 mm3 whether patient is showing signs of infection or not.
What are signs of infection for which we should monitor patients on Clozapine or Carbamazepine to DC it?
Sudden fever
Chills
sore throat
weakness
Lithium and neuroprotection
Lithium is neuroprotective treatment of choice for bipolar disorder– can protect nerve cells from damage.
What is the therapeutic range of Lithium
0.6-1.2 mEq/L
At what Lithium level does lithium toxicity occur?
1.5 mEq/L or higher
Lithium is the gold standard for treating what?
Mania
Lithium and suicide.
Lithium is the only mood stabilizer with evidence of anti-suicidal effects in bipolar
What is the therapeutic range of depakote?
50-125 micrograms (ug/ml)
What is the toxic range of depakote(valproic acid)?
150 microgrms (ug/ml)
Necessary labs for Lithium
TSH
Serum creatinine
BUN
Urinalysis
HCG for females age 12-51
Signs of lithium toxicity
In mild lithium toxicity, symptoms include WATCAD–Weakness, Ataxia, Tremor, Concentration poorness and Diarrhea.
weakness, worsening tremor, mild ataxia, poor concentration and diarrhea.
With worsening toxicity, vomiting, the development of a gross tremor, slurred speech, confusion and lethargy emerge
When to DC Lithium
serum level of 1.3 or 1.4 and signs of Lithium toxicity.
with or without symptoms if 1.5 serum level –toxicity level
If creatinine or BUN are high because Lithium is processed through kidney
Preventative tests when prescribing antipsychotics to women
Take HCG test/ aka pregnancy test before placing any woman on antipsychotic -for females of age 12-51.
If patient has 4+ protein in urine while on lithium what do we do ?
Monitor closely for lithium toxicity
What are side effects of Lithium?
hypothyroidism, ebstein anomaly, and nephrogenic diabetes insipidus, fine hand tremors, Maculopapular rash, GI upset(Diarrhea, vomiting, cramps, anorexia), polyuria, polydispsia, T-wave inversions, Leukocytosis (increased WBCs)
What do we do in cases of Lithium toxicity?
DC Li and check serum Li levels
What are some factors that can increase Lithium levels?
Kidney disease or drugs that reduce renal clearance
NSAIDS(ibuprofen, Indocin)
Thiazides (hydrochlorothiazide)
ACE inhibitors
Medications used for cardiac failure (lisinopril)
Dehydration
Hyponatremia (low sodium levels)
What causes Neuroleptic Malignant Syndrome (NMS)?
Antipsychotics
What are the symptoms of Neuroleptic Malignant syndrome (NMS)?
Extreme musclular rigidity
Mutism
Elevated CPK (happens due to muscle contraction and destruction)
Myoglobinuria
Elevated WBCs(leukocytosis)
Elevated LFTs
What is the treatment for NMS?
DC the antipsychotic and treat with:
There are two with different MOAs:
Bromocriptine (Parlodel) which is a Dopamine (2) agonist
Dantrolene which is a Muscle Relaxant
What are the signs of both NMS and serotonin syndrome?
Hyperthermia
Tachycardia
Diaphoresis
Altered level of consciousness
What are the signs of Serotonin Syndrome?
Hyperreflexia
Myoclonic jerks
What causes serotonin syndrome?
SSRIs/SNRIs/TCAs/MAOIs
How do we treat Serotonin Syndrome?
DC the offending agent and treat with
Cyproheptadine
When switching from an SSRI to an MAOI, how long wait before starting the MAOI?
wait 14 days
When switching from fluoxetine (Prozac) to MAOIs how long to wait before starting the MAOI?
5-6 weeks
When switching from an MAOI to Prozac how long wait until start Prozac?
wait 2 weeks
Why the wait times for switching from between SSRIs and MAOIs?
need a washout period of 5 half-lives between cessation of previous drug and introduction of new drug. This is the time it takes for the medication to degenerate out of the system
Due to risk of Serotonin Syndrome, which combination of meds to we avoid?
Combinations of SSRIs and SNRIs or TCAs or MAOIs or St. John’s Wort
If we see “regenerate” in answers related to serotonin, what do you do ?
eliminate. “Regenrate” is wrong answer
Why are SSRIs the 1st line antidepressants used in depression
because they are safer in cases of overdose
Serotonin Syndrome and triptans?
Triptans can cause serotonin syndrome so no triptans (for migraines) or sumatriptan (imitrex)
Which antidepressant to do we give a patient who is depressed and has cancer?
Citalopram or escitalopram because lower incidence of drug-drug interaction.
Which antidepressant to do we give a patient who is depressed and has neuropathic pain?
SNRI or TCA
An SNRI is safer
What do we prescribe for patients in chronic neuropathic pain?
Alpha 2 Delta Ligands= Gabapentin and Pregabalin (Lyrica)
antidepressants and sexual dysfunction
SSRIs/SNRIs can cause sexual dysfunction
Important info about Wellbutrin
NDRIs do not cause sexual dysfunction = Wellbutrin
Patient depressed +Low energy +fatigue give Wellbutrin
Wellbutrin contraindicated in hx of seizures or eating d/o = Wellbutrin increase seizure risk
Black Box Warning on all depressants and responsibiltity of NP
increase thoughts of self-harm in adolescents.
assess for frequency and severity of these thoughts at every visit.
Alcohol and depression
If patient is depressed, assess alcohol intake because some patients use alcohol to self-medicate and this can become a barrier to treatment
Prozac and Insomnia
Prozac can cause insomnia; encourage pt to take Prozac in the morning
Mental illnesses that cause thoughts of self-harm
Depression
bipolar
alcohol abuse
eating disorder
schizophrenia
mental illness most often associated with Homicidal ideation
Antisocial personality disorder
Placebo rate, children, antidepressants
few experimental studies exist that investigate the placebo effect of antidepressants in children and adolescent (When compared to adults, children with depression have a reduced placebo representation in studies but a higher placebo rate).
positive symptoms of schizophrenia
•Hallucination, Delusion, Loose association
•Ideas of reference (paranoia/ paranoid delusions)
•Agitated and bizarre behavior
Negative symptoms of schizophrenia
•Avolition – Asociality (Hygiene, Work)
•Anhedonia – Asociality (Interest, Relationship)
•Blunted affect
•Paucity of thought
age of onset of schizophrenia
18-25 males
25-35 in females
What is going on in brain of a schizophrenic that we see in an MRI/PET scan?
Ventricular enlargement
Everything else is decreasing in size
–Different lobes
–Different parts of limbic system
–Cerebral blood flow
What are the parts of the brain in which abnormalities or changes/deficits cause agression, impulsitivity, and abstract thinking problems in schizophrenia?
prefrontal cortex
amygdala
basal ganglia
hippocampus
limbic regions
Medications for which schizophrenics have a low tolerability so they are not as neuroprotective for schizophrenics as they are for others
Alpha 2 adrenergic receptor agonist (guanfacine and clonidine)
Why should we not give stimulants to schizophrenics?
Because stimulants can potentiate dopamine release
Non-pharm management of schizophrenia
manualized group therapy and assertive community treatment (ACT)
What is ACT?
ACT is a form of rehabilitation post-hospitalization
If a schizophrenic has a long-term history of non-adherence what may they need for in home care?
Referral to case management team so a nurse can go to their home and administer their medication. And, referral to aerobic exercise program
What level of care is social skills training for a schizophrenic?
Tertiary
How does exercise help schizophrenics?
Improve cognition
Improve quality of life
Improve long term health
A schizophrenic is taking oral Haldol and is at high risk of relapse (multiple hospitalizations), what should we do about administering medication
switch to intramuscular Haldol
Dosing for switching from oral Haldol to Haldol Decanoate
20 X the total daily oral doses=Decanoate dose–example:
5 mg PO BID
LAI–20 X 10 mg = 200 mg
What is the dose limit of LAI Haldol that can be given in one week?
100 mg
If they need 200 mg then give 100 mg on day one and come back in 5-7 days for another 100 mg;
same for 300 mg= 100 mg day one
5-7 days for second 100 mg
and 5-7 days for third 100 mg
What is a delusion?
Firm belief maintained despite evidence to the contrary.
If doing a MSE of preschooler(3-5y/o), what is the most important approach to
listen and observe cues—depends on clinical observation
Components of a Mental Status Exam–what do you assess with thought process assessment?
Assess the organization of the patient’s thoughts and ideas.
Components of a Mental Status Exam–what do you assess with thought content assessment?
Refers to the themes that occupy the patient’s thoughts and perceptual disturbances. Ex:
Suicidal ideations
homicidal ideations
SI or HI plan
visual hallucinations
auditory hallucinations
Mental status exam–when evaluating thought process or thought content, what are we evaluating? Are we evaluating organization of speech?
We are evaluting thoughts and ideas
NO, we are not evaluating organization of speech
The Folstein Mini Mental Status Examination is used with which population and for what ?
Adults–to assess cognitive decline
What are some important components of the mini-mental status examination
Concentration/attention/ calculation–examples: count backward from 100 by 7s
Orientation: Year, season, date, day, month, country, town, hospital, floor
Registration/ability to learn new material: say names of three unrelated objects clearly and slolwy, ask patient to repeat immediately
Recall (memory): Ask patient if they can recall the three object words previously asked to remember 5 minutes after introducing the object words
Fund of knowledge: Who is president/govenor
What is the purpose of the Clock drawing test ?
Very quick way to screen for possible dementia– takes 1-2 minutes to complete
If there are impairments on the CDT (Clock Drawing Test), which part of the brain may be damaged?
right parietal lobe i.e. the right hemisphere of the brains
What makes an antipsychotic atypical?
Atypical antipsychotics have both dopamine and 5HT2A receptor antagonism
Lower chance of EPS syndromes
Which type of antipsychotic for first psychotic episode?
Atypical antipsychotic that can be administered IM like Invegga, Geodon or Abilify.
Dopamine Pathway: Mesocortical pathway relationship between dopamine and schizophrenic symptoms
Meso–not major depression but meso depression + other negative symptoms
decreased dopamine in the mesocortical pathway is thought to be responsible for negative and depressive symptoms of schizophrenia
Nigrostriatal pathway of brain controls what ?
Nigrostriatal pathway mediates motor movements
Dopamine blockade in this pathway can lead to increase acetylcholine levels–increase salivation, teary eyes, diarrhea
Dopamine Pathway: Nigrostriatal pathway relationship between dopamine and EPS
Blockade of dopamine receptors in the nigrostriatal pathways can lead to EPs e.g. acute dystonia, parkinsonism, and akathisia
Long standing D2 blockade in the nigrostriatal pathway can lead to Tardive Dyskinesia.
Neurotransmitters and EPS
Increased acetylcholine and decreased dopamine can cause EPS’
EPS and metoclopramide
Metoclopramide (Reglan) can cause EPS like Tardive dyskinesia and parkinsonism
How do you treat EPS except Tardive Dyskinesia?
Benztropine
How do we treat Tardive Dyskinesia?
stop/decrease meds, switch to new anti psych that doesn’t cause tardive dyskinesia (possibly clozapine)
Dopamine Pathway: Tuberoinfundibular pathway relationship between dopamine and physical symptoms
Blockade of D2 receptors in this pathway can lead to increased prolactin levels leading to hyperprolactinemia which clinically manifests as amenorrhea, galactorrhea (Risperidone), sexual dysfunction, and gynecomastia.
Long term hyperprolactinemia can be associated with osteoporosis.
Normal prolactin levels
Men–less than 20 ng/ml
Women — less than 25 ng/ml
impact of Cytocrome P450 enzyme CYP1A2 inducers on drugs metabolized on the pathway
decrease serum levels of drugs that are substrates of CYP1A2 enzymes which causes subtherapeutic drug levels
impact of Cytocrome P450 enzyme CYP1A2 inhibitors on drugs metabolized on the pathway
Increase serum levels possibly causing toxic levels of drug
Olanzapine (Zyprexa) and Clozapine are both metabolized on which enzyme?
Cytochrome P450 Enzyme CYP1A2
If a patient on olanzapine or clozapine stops smoking what do we do with the dose
Decrease the dose because smoking is an inducer and it is no longer decreasing the serum levels of the drug.
Which are more worrisome? Inhibitors or Inducers?
Inhibitors because they can cause toxic levels of a drug in the body.
Is Tegretol(carbamazapine) an Inducer or Inhibitor ?
Inducer
Are clarithromycin and erithromycin inducers or inhibitors?
Inhibitors
If a patient is taking tegretol (carbamazapine) and clarithromycin, tegretol an inducer and clarithromycin an inhibitor, what should an NP do?
Decrease the tegretol (carbamazapine) to avoid the inhibitors causing a toxic level of tegretol in the blood
Medications that cause mania
Steroids
Disulfram (Antabuse)
Isoniazid(INH)
Antidepressants in persons with bipolar
Medications that cause depression
Steroids
Beta blockeres
Interferon
Isotretinoin (Accutane)
Some retroviral drugs
Antineoplastic drugs
benzodiazepines
progesterone
Steroids and psychosis
Steroids can cause psychosis
Are flonase and prednisone steroids?
Yes
When taking medications that cause mania and depression, how do you dose the antidepresant or antipsychotic?
Increase the dose.
Neurotransmitters involved in addiction
Dopamine and GABA
What causes pain in anorexics after eating?
Delayed gastric emptying
medications that can delay gastric emptying
Ranitidine–Antihistamine and Antacid
Famotidine–Antihistamine and Antacid
Omeprazole–proton pump inhibitor
If a med decreases the absorption of psychotropic medications, what is the best way to take it?
Take 2 hours apart
Some medications that decrease absorption of psychotropics?
Antacids
PPIs like Protonix, Omeprazole
If a patient aged 65+ is given SSRIs, for what should we monitor them?
monitor for increased anxiety
What is a paradoxical effect of a medication?
when medication causes opposite effect for which is was prescribed. Avoid giving in the future
Heart issues and Geodon and Citalopram
Geodon and Citalopram can cause QT prolongation
What is the maximum recommended dosage per day for Citalopram?
40 mg
for those 65+– 20 mg
What is the greatest risk factor for bipolar
multigenerational bipolar
If a person’s first bipolar episode is after the age of 45, what is the likely cause?
A medical condition like a stroke
What are the symptoms of Mania?
Distractability
Insomnia
Grandiosity
Flight of ideas
Agitation/Activity increase
Sexual indiscretions (or other pleasurable activity)
Talkativeness
DIG FAST
What is apoptosis
programmed cell death
Primary symptoms of Borderline Personality Disorder
self-harming behavior
recurrent suicidal behavior
What is the only treatment for Borderline Personality Disorder?
DBT–decreases suicidality in Borderlines
Who created DBT?
Marsha Linehan
What is the diagnostic process for borderline
use their journals/diaries to help diagnose borderlines
Medication for a pateint with borderline presenting with irritability, anger and self-harming behavior
Lithium
Specific Medication for a patient with borderline presenting with depressed mood, emotional lability, interpersonal problems, rejection sensitivity, aggresion, hostility
Depakote
What is conversion disorder?
a mental condition–usually begining suddenly after a stressful experience– in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation
Treatment is therapy
What is an adjustment disorder?
An unhealthy or excessive response to an event or change within 3 months of it happening
What are symptoms of adjustment disorder
with depressed mood — feelings of sadness, decreased interest, sleep disturbance, appetite changes
with mixed disturbance of emotion and conduct — A child has a mix of symptoms from anxiety, depression and conduct dysfunction–possible peer conflict, verbal altercations, insomnia, frequent crying
Differentiation between Adjustment disorder and MDD
Adjustment disorder has a specific cause.
How do we treat Oppositional Defiant Disorder?
Family therapy with emphasis on child management skills; teaching parents about positive reinforcement and boundary settings.
Child and parent problem-solving skills training
In ODD therapy, if no parenting skills are developed, what can ODD turn into
Conduct Disorder
What are key symptoms of conduct disorder
Aggression toward people or animals and property.
Lack of remorse for ill deeds done
Pharmacological treatment for conduct disorder
Targets mood and aggression–treat with antipsychotics, mood stabilizers, SSRIs and alpha agonists (Clonidine and guanfacine)
Diagnosing Tourette Syndrome
At least 2 motor tics and at least 1 vocal tic have been present, not necessarily at the same time–for more than a year
Tics are not caused by using a subtance or other medical condition
When children have motor tics are they rare and permanent ?
No. Children’s tics are common and often temporary
Primary neurotransmitter involved in Tourette Syndrome
Dopamine, Norepinephrine, serotonin (DNS)
Hyperactivity of Dopaminergic systems in brain can lead to Tourette’s
Pharmacological treatment of Tourette Syndrome
Clonidine (Catapres or Kapvay) or Guanfacine (Intuniv)
What is acute stress disorder?
Psychiatric diagnosis that may occur in patients within 4 weeks after a traumatic event Features include anxiety, insomnia, re-experiencing, avoidance behaviors–basically PTSD symptoms but duration of symptoms is less than a month. (PTSD has to last at least one month)
What are hallmark symptoms of PTSD?
Intrusive re-experiencing
Increased arousal (hyperarousal)
Avoidance of stimuli associated with trauma
Pharmacological management of PTSD
SSRIs, TCAs, Prazosin for nightmares
Non-Pharmacological management of PTSD
EMDR (preferred over CBT)
CBT
What are the phases of EMDR?
Desensitization phase
Installation phase
body scan phase
Which parts of the brain are affected in ADHD?
Frontal cortex
Basal ganglia
Abnormalities in prefrontal cortex–inattentive
Abnormalities of reticular activating system
ADHD — age amphetamines are approved for
children age 3 to adult
Heart and ADHD meds
Assess cardiac hx before beginning stimulants.
There can be elevated heart rate and BP; increase risk of heart attack and stroke
ADHD — age methylphenidate are approved for
children age 6 to adult
ADHD– what does the dorsolateral prefrontal cortex control?
Executive function
Cognitive process such as planning, working memory
Problem solving
How to direct and maintain attention to a task
Signs of stimulant abuse
Insomnia
Tremors
Increased BP
Heart palpitations
ADHD–If patient starts having symptoms again during the day, what does that indicate; what should be done?
Medication has been cleared by the body; consider an extended release dose.
If parent is anxious or scared of child starting stimulants what should be done?
address their anxiety—give them some support before continuing with psychoedcation
What is OCD?
Presence of anxiety-provoking obsessions (recurrent and persistent thoughts, impulses, or images) or compulsions (for example motor tics) that function to reduce the person’s subjective anxiety level
Which autoimmune illness should be considered with sudden onset OCD symptoms in children?
PANDAS–Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
Differentiate OCD from Tourettes
Tourettes= tics only
OCD = intrusive/ persistent thoughts and tics
Factitious disorder
Condition in which a person presents with physical or mental illness symptoms that are induced.
Malingering
symptoms are faked for secodary gain such as avoiding work or prison
factitious disorder imposed on another
a condition in which one person induces illness symptoms in someone else
Reactive Attachment Disorder
product of severely dysfunctional early relationships between principle caregiver and child —- results when caregiver disregards child’s physical/emotional needs–> behavioral/interpersonal problems later in life (fearful/inhibited/withdrawn/apathetic/shows no emotion towards caregivers/ disruptive/disorganized)
GAD (general anxiety disorder)
excessive worry for at least 6 months
Panic Attack
surge of intense fear or discomfort that reaches a peak within minutes as well as a sense of impending doom
Panic Disorder
diagnosis given when patient experiences recurrent panic attacks without apparent triggers
SSRIs for treatment of panic disorder
fluoxetine
Paroxetine
Sertraline
Venlafaxine
Definition and Symptoms of DMDD (disruptive mood dysregulation disorder)
Childhood (<18) depressive disorder that includes
Chronic dysregulated mood (“moody”)
Frequent intense temper outburts/temper tantrums
Severe irritability
Anger
Treatment for panic attacks
Betablocker like propranolol.
Contraindications for propranolol
Can cause bronchospasms so contraindicated in patients using bronchodilators like albuterol
Anorexia Nervosa symptoms
Low BMI (<15)
Amenorrhea
Emaciation
Bradycardia
Hypotension
Action if Anorexic with BMI less than 15?
Refer for hospitalization. If parent refuses, report to CPS
BMI of bulimia nervosa
Usually in normal range
What is the non-pharm treatment for Oppositional Defiant Disorder?
- Family therapy, with emphasis on child management skills;
- teaching parents about positive reinforcement and boundary settings
- Child and parent problem-solving training
If no parenting skills are developed what can ODD develop into?
CD-conduct disorder
What are the primary symptoms of Conduct disorder
Aggression towards human and animals and lack of remorse
What is the pharm treatment for conduct disorder?
Meds that target mood and aggression:
- antipsychotics
- mood stabilizers
- SSRIs
- alpha agonists (Clonidine and guanfacine)
What are the defining symptoms of Tourette Syndrome/Disorder
- At least 2 motor tics and at least 1 vocal tic
- Tics are not caused by a substance or other medical conditions
What is the expected permanence of children’s motor tics?
They are fairly common and can be temporary.
What are the primary neurotransmitters involved in tourette’s syndrome?
DNS= Dopamine, Norepinephrine, Serotonin
Hyperactivity of Dopaminergic systems in the brain can lead to Tourette’s
What is the primary pharm treatment for Tourette’s
Clonidine (Catapres, Kapvay)
Guanfacine (Intuniv)
What are secondary pharm treatments for Tourette’s ?
Atypical Antipsychotic
Haldol, Pimozide, Aripiprazole
DSM-5 of Acute Stress Disorder
Acute stress disorder occurs within 4 weeks of traumatic event.
Features include anxiety, insomnia, poor concentration, intense fear or helplessness, re-experiencing the event and avoidance behaviors–
It presents as PTSD but the onset of symptoms is less than PTSD
What is the minimum length of time that PTSD has to last?
One month
Hallmark symptoms of PTSD
Intrusive re-experiencing
Increased arousal
Avoidance of stimuli associated with the trumatic event
What is the pharm management of PTSD?
Prazosin for nightmares
SSRIs
TCAs
What is primary important non-pharm treatment for PTSD?
EMDR
What are the different Non-pharm treatments for PTSD?
EMDR
CBT
What are the parts of the brain involved in ADHD?
BAFaP
Basal ganglia
Abnormalities in reticular activating system
Frontal cortex
abnormalities in the Prefrontal cortex–inattentive type
Cardiology and ADHD stimulant
Assess cardiac history before placing patient on stimulants as they can cause elevated heart rate and bP and increase risk of Heart attack and stroke
If history or family hx of cardiac issues, get an ECG before starting.
What are the ages for amphetamines?
3 and up
what are the ages for methylphenidate?
Ages 6 and older
What are the ages for Alpha agonist or alpha 2 adrenergic receptors agonist?
Age 6 and up
What are the ages for Strattera?
Ages 6 and up
Which aspect of ADHD does the Dorsolateral prefrontal cortex control?
Executive function
Signs of Stimulant Abuse
Insomnia
tremors
increased blood pressure and HR
Heart palpitations
If a patient is having ADHD symptoms during the day after having taken their stiumlant, what does that indicate and what should we do?
Indicates the medication has been cleared by the body
We should consider an extended release
What to do if parent is really anxious or scared about Medication for their kid?
Address their anxiety–support them then continue with psychoeducation
Differentiate OCD from Tourettes
OCD–intrusive/persistent thoughts and tics
Tourettes: Tics only
Symptoms of OCD
presence of anxiety provoking obsessions–recurrent and persistent thoughts, impulses, or images or compulsions for example motor tics that funtion to reduce the person’s subjective anxiety level
What does PANDAS stand for and which mental illness’ acute onset may be an indication of having PANDAS?
Should be considered in all children with sudden onset OCD symptoms
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
Malingering
Deliberate faking of a physical or psychological disorder motivated by secondary gain.
factitious disorder
Condition in which a person does things to make themselves sick when they are not organically sick
Reactive Attachment Disorder
in children, a pattern of inhibited, withdrawn, apathetic behavior toward adult caregivers and show no emotion towards caregivers.
The product of a severely dysfuntional early relationship between the principal caregiver and the child
GAD
General Anxiety Disorder:
excessive worry for at least 6 months
Panic Attack
Abrupt surge of intense fear of discomfort that reaches a peak within minutes; a variety of psychological and physical symptoms including a sense of impending doom
Panic Disorder
Patient experiences recurrent unexpected panic attacks
Treatment for Panic disorder
Fluoxetine
Paroxetine
sertraline
SNRI–venlafaxine
Beta Blocker–this manages the elevated BP that occurs with a panic attack
Can also give benzos which aren’t as safe
Beta blockers can cause bronchospasms so they are contraindicated with
bronchodilators like albuterol
DMDD–Disruptive mood dysregulation disorder
Childhood depressive and mood disorder–diagnosis age 6-17
Chronic dysregulated mood
Frequent intense temper outbursts/ temper tantrums
Hallmark symptoms of Anorexia Nervosa
Low BMI (15 or less than 15)
Amenorrhea
Emaciation
Bradycardia
Hypotension
BMI for Bulimia Nervosa
BMI usually in normal range
if a patient has an irritable, depressed, labile mood, what is the first thing we should do ?
Administer the mood questionnaire
When should we assess for nightmare disorder?
if pt reports a nightmare and parents or other family members have nightmares
Which neurotransmitters are affected in autism?
Glutamate, GABA, Serotonin
What are the symptoms of autism?
Persistent deficits in social communication and social interaction
No response when called by name
Nonverbal communication
Little or no eye contact
often like to line up, stack, or organize objects and toys in long, tidy rows
Broken mirror theory of autism
Claims that dysfunction of the mirror neuron system may be the cause of poor social interaction and cognition
If delirium is caused by ETOH or substance abuse what treatment can we give patient?
Benzos
What are often the causes of delirium in older people and what should we test them for?
Infections
We should do a urinalysis with culture and sensitivity
Dementia and which vitamins levels should be checked
Progressive mental decline; personality changes occur, irritability
Check Vit B12 and Folic Acid levels
Differentiating between depression and dementia
with depression it is acute onset of memory problems like happening over 5 months.
Also, in combination with memory issues, they have depression issues.
“I do not know” responses are commonly depression. In dementia, patient often confabulates answers–will not say “I do not know”
Dementia memory decline happens over time i.e. over 12 months or longer
Pseudodementia
Primary diagnosis is depression
acute onset of memory problems like happening over 5 months
Which parts of the brain are involved in Dementia
subcortical–motor symptoms: lack of coordination, tremors, ataxia, dystonia
Cortical: Language (aphasia) and memory impairments
Early signs of HIV dementia
Cognitive decline
motor abnormalities
behavioral abnormalities
Lewy Body Disease symptom of importance for the test
Presents with recurrent visual hallucinations
Pick’s disease
AKA frontotemporal dementia/frontal lobe dementia
Personality, behavioral, and language changes (slurred) in early stage
What meds treat HIV dementia?
Antiretrovirals
if patient has history of high risk behavior and HIV dementia symptoms, what should we do?
give them an HIV test
Pharm treatment of psychosis and agitation in dementia?
atypical antipsychotics
What does the amygdala control?
aggression
fear
anxiety
emotions
What does the Hippocampus control?
emotions
stress
learning
memory
What does dopamine produced in the substantia nigra regulate?
motor movements
If you are taking care of a terminal infant what do you do with the parents?
give infant to parents and allow them to grieve for their loss
How should we speak of and refer about grief to children
Normalize grief and loss in children—psychoeducation on grief responses; group therapy
Grief responses vary so do not tell a patient or family how they should grieve
What is the most important factor in children’s healing from grief?
an intact family so they can adapt easily
mood disorder neurotransmitters
DNS (dopamine, nor, serotonin+ GABA+ Glutamate )
What are most important risk factors for osteoporosis?
Smoking
Caffeine
Lack of weight bearing exercises
Lack of dietary calcium and vitamin D