Mental Health Exam 2

Fluoxetine

aka Prozac

SSRI → selective serotonin reuptake inhibitor

Indications:

• major depressive disorder

• bulimia

• obsessive-compulsive disorder

• panic disorder

• premenstrual dysphoric disorder

Safety:

• long half-life

• do not take with MAOI

Side Effects of Fluoxetine

Dry Mouth

Weakness

Insomnia and nervousness

Headache

Anorexia

Nausea and diarrhea

Sexual dysfunction

Suicidal ideation

Serotonin syndrome***

Sertraline

aka Zoloft

SSRI → selective serotonin reuptake inhibitor

Indications:

• first-line medication for MDD and anxiety disorders

Safety:

• causes most GI distress among SSRIs

Side Effects of Sertraline

Nausea

Restlessness or jitteriness

Sleep disturbances

Sexual dysfunction

GI distress → diarrhea

Duloxetine

aka Cymbalta

SNRI → serotonin norepinephrine reuptake inhibitor

Indications:

• MDD

• generalized anxiety disorder

• pain from diabetic neuropathy

• fibromyalgia

• chronic musculoskeletal pain

Safety:

• Assess baseline neuro, mental, liver, and cardiac status

• Monitor for suicidal tendencies

Contraindications:

• known allergy

• MAOI use

• can worsen uncontrolled glaucoma

Side Effects Duloxetine

Dizziness

Drowsiness

Headache

Nausea

Anorexia

Excessive sweating

Insomnia

Weight gain

Impaired memory

Tremors

Hepatotoxicity**

Serotonin Syndrome**

Dose-dependent inc. in BP and HR**

Venlafaxine

aka Effexor

SNRI → serotonin norepinephrine reuptake inhibitor

Indications:

• MDD

• anxiety disorders

Safety:

• Do not stop abruptly*

• Can be used to treat neuropathic pain

• Monitor BP and HR at baseline

Side Effects of Venlafaxine

Similar to SSRIs

Excessive sweating

Dose-dependent increase in BP and HR

Antidepressant discontinuation syndrome***

Mirtazapine

aka Remeron

NaSSA → norepinephrine- and serotonin-specific antidepressant

Indications:

• depression (including bipolar associated)

• helps reduce adverse sexual effects in male PT receiving SSRI therapy

• appetite enhancement

Safety:

• less GI and sexual dysfunction symptoms

• don’t take with MAOIs

• used often in PT with insomnia or dec. appetite and weight loss

• don’t mix with other CNS depressants

Side Effects of Mirtazapine

Sedation

Appetite stimulation and weight gain (may be beneficial depending on the PT)

Abnormal dreams

Dry mouth

Constipation

Asthenia

Alprazolam

aka Xanax

Benzodiazepine → enhances GABA

Indications:

• generalized anxiety disorder

• short-term relief of anxiety symptoms

• panic disorder

• anxiety associated with depression

Safety:

• may cause paradoxical reactions

• don’t take with other CNS depressants

• may cause dependency and withdrawal

• don’t operate heavy machinery while taking

• don’t stop abruptly

Side Effects of Alprazolam

Sedation (most common)

Ataxia

Confusion

Headache

Anterograde amnesia

Decreased cognitive function

Paradoxical reactions**

Lorazepam

aka Ativan

Benzodiazepine → enhances GABA

Indications:

• anxiety disorders

• acute agitation

• alcohol withdrawal (treatment or prevention)

• sedation for mechanically ventilated PT

Safety:

• quick onset of action

• do not use longer than a few months → risk of dependency and loss of effectiveness

• don’t combine with other CNS depressants

• monitor for postural hypotension

Side Effects of Lorazepam

Sedation

Ataxia

Decreased cognitive function

Respiratory depression**

Paradoxical reactions**

Dependence and withdrawal**

Clonazepam

aka Klonopin

Benzodiazepine → enhances GABA

Indications:

• absence seizures

• myoclonic seizures

• partial seizures

• panic disorder

• anxiety disorders

Safety:

• tolerance may occur after 6 months of use

• may cause dependency and withdrawal

• taper discontinuation

• monitor SE

• monitor BP and postural hypotension

• complete neuro assessment

Side Effects of Clonazepam

Sedation

Ataxia

Decreased cognitive function

Paradoxical reactions**

Buspirone

aka BuSpar

Partial serotonin receptor agonist

Indications:

• generalized anxiety disorder

• treatment of anxiety

Safety:

• takes 1-4 weeks to reach therapeutic effect

• must be taken on a scheduled basis

• no sedative properties

• no dependency potential

• don’t take with MAOI

• no grapefruit juice

Side Effects of Buspirone

Dizziness

Headaches

Nausea

Nervousness

Lightheadedness

Excitement

Drowsiness

Blurred vision

Paradoxical anxiety*

Propranolol

aka Inderal

Beta-blocker

Indications:

• performance anxiety

• physical symptoms of anxiety

• essential tremor

• cardiovascular health

Safety:

• take as needed

• quick onset of action

• no dependency potential

• does not treat the physiological/cognitive symptoms of anxiety

• taper discontinuation

• report breathing difficulties, dizziness, or unusual fatigue

• may mask hypoglycemia

Side Effects of Propranolol

Bradycardia**

Depression**

Impotence**

Constipation**

Fatigue**

Clonidine

aka Catapres

Alpha-adrenergic agonist

Indications:

• ADHD

• anxiety and agitation

• sleep disorders

• Tourette syndrome

• trauma-related syndromes

• opioid withdrawal management

• antihypertensive

Safety:

• cannot be stopped abruptly

• monitor BP

• Takes 4-6 weeks for full therapeutic effects

Side Effects of Clonidine

Rebound hypertension

Sedation

Fatigue

Hydroxyzine

aka Vistaril, Atarax

Antihistamine

Indications:

• anxiety

• allergic reactions and pruritus

• sedation

• NV

• preoperative sedation

Safety:

• used for short-term anxiety relief

• fast acting

• no dependency potential

• can be taken as needed

• avoid other CNS depressants

• anticholinergic effects are common

Side Effects of Hydroxyzine

Drowsiness

Dry mouth

Changes in vision

Difficulty urinating

Constipation

Haloperidol

aka Haldol

First generation antipsychotic → blocks dopamine receptors

Indications:

• long-term treatment of psychosis and schizophrenia

• control of agitation in adults and children

• nausea (low doses)

• hyperactive behavior in children

Safety:

• high incidence of extrapyramidal symptoms

• baseline motor, sensory, and neurologic function

• BP

• liver and renal function, CBC, and urinalysis monitoring

• takes several weeks to see effects

Side Effects of Haloperidol

Favorable:

• low sedation

• cardiovascular and anticholinergic effects

Problematic:

• Extrapyramidal symptoms

• tremors and muscle twitching

• tic-like movements of hands, face, neck, and head

• Parkinsonian syndrome

• tardive dyskinesia (potentially irreversible)

• hypotension

• dry mouth

• photosensitivity

Quetiapine

aka Seroquel

Second-generation antipsychotic

Indications:

• acute mania

• bipolar depression

• MDD

• schizophrenia and psychosis

Safety:

• has sedative and mood-stabilizing properties

• helps with sleep and agitation

• can be used in combination therapy

• baseline and periodic metabolic screening

• monitor BP

• assess for signs of diabetes

• assess for movement disorders

• do not stop abruptly

• report excessive thirst, urination, or hunger immediately

Side Effects of Quetiapine

Weight gain

Insulin resistance

Diabetes

Dyslipidemia

Cardiovascular impairment

Clozapine

aka Clozaril

Second-generation antipsychotic

Indications:

• treatment-resistant schizophrenia

• reducing suicidal behavior

Safety:

• superior in efficacy to all other antipsychotics

• minimal risk for extrapyramidal symptoms

• regular absolute neutrophil count

• careful dose titration

• monitor for constipation

• monitor for infection

• assess metabolic parameters frequently

• contact provider immediately if changes in blood count or abnormal cardiac function occur

Side Effects of Clozapine

High risk for weight gain

Orthostatic hypotension

Sedation

Severe anticholinergic effects

Bone marrow suppression causing neutropenia

Risperidone

aka Risperdal

Second-generation antipsychotic → D2 antagonist

Indications:

• schizophrenia

• acute mania

Safety:

• assess for extrapyramidal symptoms

• monitor BP

• monitor weight and metabolic parameters

• baseline and ongoing assessment of motor, sensory, and neurologic function

• minimal risk for tardive dyskinesia

Side Effects of Risperidone

Extrapyramidal symptoms**

Hyperprolactinemia

Orthostatic hypotension

Weight gain and metabolic effects

Aripiprazole

aka Abilify

Second-generation antipsychotic → partial D2 receptor agonist

Indications:

• schizophrenia

• bipolar disorder

• MDD

• agitation associated with autistic disorder

Safety:

• assess for suicide risk

• monitor for extrapyramidal symptoms

• monitor for weight gain and metabolic parameters

Side Effects of Aripiprazole

In children:

• extrapyramidal symptoms

• somnolence

• weight gain

• increased risk of suicide

Compulsive behaviors

Inc. risk of death in dementia patients

Somatization

The psychological and emotional expression of stress through physical symptoms

Somatic Symptom Disorder

Characterized by a focus on somatic (physical) symptoms, such as pain or fatigue, to the point of excessive concern, preoccupation, and fear

→ suffering is authentic

→ pt experiences a high level of functional impairment and help-seeking

S/S:

• chest pain

• fatigue

• dizziness

• headache

• swelling

• back pain

• SOB

• insomnia

• abdominal pain

• numbness

Illness Anxiety Disorder

Characterized by extreme worry and fear about the possibility of having a disease

→ symptoms become amplified during times of increased stress

→ reassurance seekers make frequent medical appointments to be sure that their symptoms are nothing

Conversion Disorder

aka functional neurological disorder

Manifests itself as neurologic symptoms in the absence of a neurological diagnosis

Characterized by the presence of deficits in voluntary motor or sensory functions, including:

• paralysis

• blindness

• movement disorders

• gait disorder

• numbness

• paresthesia

• loss of vision or hearing

• episodes resembling epilepsy

→ emotional conflicts or stressors are transferred to physical symptoms

→ La belle indifference: the lack of emotional concern about often dramatic symptoms

Anorexia Nervosa

Restrictions of energy intake relative to the requirements

Intense fear of gaining weight or becoming fat

Disturbance in the way in which one’s body weight or shape is experienced

Types:

• restricting type

• binge eating/purging type

Criteria for Inpatient Care for PT with Anorexia Nervosa

Two primary criteria:

• extreme electrolyte imbalance

• weight below 75%

Other criteria:

• less than 10% of body fat

• daytime HR of less than 50 bpm

• systolic BP less than 90

• a temp of less than 96 F

• arrhythmias

Signs and Symptoms of Anorexia Nervosa

Low weight

Amenorrhea

Yellow skin

Lanugo

Cold extremities

Peripheral edema

Muscle weakening

Constipation

Abnormal lab values

Cardiovascular abnormalities

Electrolyte imbalance, impaired renal function

Hypokalemia

Anemic pancytopenia

Dec. bone density

Bulimia Nervosa

Recurrent episodes of binge eating and recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise

Signs and Symptoms of Bulimia Nervosa

Normal to slightly low weight

Dental caries, tooth erosion

Parotid swelling

Gastric dilation, rupture

Calluses, scars on the hand (Russell sign)

Peripheral edema

Muscle weakening

Abnormal lab values

Cardiovascular abnormalities

Cardiac failure

Seizures

Interventions for the management of Eating Disorders

Monitor:

• VS and electrolyte levels

• Weight

• I/O of fluids

• Self-monitoring of caloric intake

• Observe during/after meals

• Accompany pt to bathroom

• Limit time spent in bathroom

• Monitor physical activity

Pica

The ingestion of substances that have no nutritional value, such as dirt or paint

May interfere with eating nutritious items

Can be dangerous

Mild Anxiety

Least severe level of anxiety

Serves as a catalyst for change

Slight discomfort, restless and/or irritable

An ideal time for learning

Moderate Anxiety

The perceptual field is narrowed

Selective inattention

Clear thinking is hampered

Problem solving is not optimal

Sympathetic nervous system (physical) symptoms begin:

→ GI, inc. HR/RR, perspiration, urinary urgency

Severe Anxiety

Varying levels of functional impairment

Perceptual field is greatly reduced

Difficulty concentrating on environment

Somatic symptoms increase

Learning is not possible

Panic Anxiety

Most severe level of anxiety

Monitor client closely for safety reasons

Markedly disturbed behavior - running, shouting, pacing, screaming

Unable to process reality; impulsivity

Defenses Against Anxiety

Defense mechanisms: automatic coping styles meant to protect the ego from anxiety or stress

Maintain self-esteem by blocking:

• feelings

• conflicts

• memories

Can be either:

• adaptive (healthy)

• maladaptive (not healthy)

Adaptive Defense Mechanisms

Lower anxiety and achieve goals in acceptable ways

Examples:

• humor → finding the funny side or irony of a painful situation

• altruism → handling emotional pain by helping others

• sublimation → channeling negative energy into a productive activity

Maladaptive Defense Mechanisms

Immature defense mechanisms do not completely obscure the individual from reality, but they do enable the person to be out of touch with reality

Examples:

• suppression: conscious decision to deal with the issue later

• repression: unconscious avoidance of unpleasant emotions

• denial: unconscious escape of facts by ignoring their existence

• regression: returning to a previous level of functioning to avoid dealing with current stressors

• rationalization: justifying inappropriate acts/beliefs by making up an acceptable reason

Separation Anxiety Disorder

Developmentally inappropriate levels of concern over being away from a significant other

Specific Phobias

Irrational fear of a specific object, activity, or situation that leads to a desire for avoidance

Social Anxiety Disorder

Severe anxiety or fear provoked by a social or a performance situation that could be seen as negative by others

Panic Disorder

Characterized by recurrent attacks of severe anxiety = “panic attacks”

→ lasts about 15-30 minutes (can be more or less)

→ occur suddenly and spontaneously

→ may resemble a heart attack

Signs and Symptoms of a Panic Attack

Need to have 4 or more

• sweating, trembling, shaking

• shortness of breath, chest pain, discomfort

• nausea or abdominal distress

• dizziness, chills, or hot flashes

• numbness or tingling

• derealization or depersonalization

• fear or losing control or “going crazy”

• fear of dying

Agoraphobia

Fear of leaving the safety of home

→ worry that they might develop panic symptoms

→ dizziness, loss of bowel or bladder control, or cardiac distress in the event escape or help cannot occur

Onset usually occurs in mid-late 20s

Affects women > men

Must fear at least 2 of the following:

• using public transportation

• being in open space

• being in enclosed spaces

• standing in line, being in a crowd

• being outside of the home alone

→ Must last for > 6 months

Causes significant impairment of functional abilities**

Generalized Anxiety Disorder

Pervasive, persistent anxiety that lasts for months

→ without phobias, panic attacks, or obsessions and compulsions

Chronic feelings of nervousness and apprehension for no apparent reason, and unable to control the worry

Worry = muscle tension, restlessness, nausea/GI upset, avoidance of stressful situations, procrastination, seeking reassurance/clingy

Impairment of functional ability

Associated mild depressive symptoms are not uncommon in individuals with GAD

Obsessive-Compulsive Disorder

Affects males > females

Genetics: first-degree relatives = twice the risk

Causes significant impairment of functional abilities

May stem from:

• Child abuse and trauma

• Post-infectious autoimmune syndrome

→ Comorbidity with anxiety disorders, eating disorders, and/or tic disorders

Obsession

Part of the OCD cycle

Characterized by recurring thoughts that cannot be dismissed

→ distressing and anxiety-provoking

Compulsion

Part of the OCD cycle

Uncontrollable urge to perform a behavior to relieve unbearable tension

Most acts are attempts to control the obsession

Behavior is meant to reduce stress → the compulsive behavior eventually increases stress

Examples:

• endless handwashing, checking and rechecking door locks, elaborate dressing rituals

Trauma-Informed Care

A treatment framework that involves recognizing/responding to the effects of trauma to reduce the pervasive and damaging effects of trauma

→ helps us to approach patient care with compassion and empathy

Acute Stress Disorder (ASD)

Similar to PTSD as far as the traumatic events that precipitate it and the symptoms PT experience, but symptoms occur more immediately (3 days to 1 month) after the traumatic event

*PT are at high risk for suicide

Adjustment Disorder

Milder and less specific than PTSD or ASD

The stressor(s) that precipitate it are more within normal life experiences (i.e., divorce, retirement, job loss)

May be diagnosed immediately after or within 3 months of the stressor

Dissociative Disorders

Occur after significant adverse experiences and traumas

Predominant response is an interruption of memory, perception, and/or consciousness

Dissociation

An unconscious, involuntary defense mechanism that protects against overwhelming anxiety through emotional separation

→ separation results in disturbances in memory, consciousness, self-identity, and perception

Positive symptoms: unwanted additions to mental activity, such as flashbacks

Negative symptoms: deficits, such as memory problems or the inability to sense or control different parts of the body

Dissociative Amnesia

The inability to recall important personal information, often of a traumatic or stressful nature

→ the memory is available but not accessible

ACEs are a risk factor

Memory often returns spontaneously after the individual is removed from the stressful situation or when the person is exposed to cues from the past

Depersonalization/Derealization Disorder

Persistent or recurrent episodes of:

• depersonalization

• derealization

Often short-lived and resolve spontaneously without treatment

→Self-hypnosis, CBT, and repetitive TMS can be used for treatment

Depersonalization

An extremely uncomfortable feeling of being an observer of one’s own body or mental processes

PT may feel detached from their entire self or aspects of themselves, including feelings, thoughts, body parts, or sensations

Derealization

A recurring feeling that one’s surroundings are unreal or distant

PT may feel like they are walking around in a fog, bubble, or dream; visual/auditory distortions are common

Dissociative Identity Disorder (DID)

Formerly known as multiple personality disorder

Essential feature is the presence of two or more distinct personality states that recurrently take control of behavior:

→ one personality functions daily and blocks access and response to traumatic memories; usually more moralistic in behavior and unaware of alters

→ second personality (or more) has its own pattern of perceiving, relating to, and thinking about the self and the environment

Severe sexual, physical, or psychological trauma is thought to predispose the individual to develop DID

Treatment → therapy

PT at severe risk of suicide

Schizophrenia

Characterized by psychosis

Must have two or more in one month:

• delusions

• hallucinations

• disorganized speech

• gross disorganization or catatonia

• negative symptoms

• functional impairment of some kind

→ continuous disturbances for at least 6 months

Most cases develop gradually → presenting at 15-25 years old

More frequently diagnosed among males, in urban areas

Risk Factors of Schizophrenia

Genetics

High levels of glutamine and dopamine

Low levels of acetylcholine

Disregulated serotonin

Brain structure abnormalities

Prenatal stressors

Stressful environmental factors

Prognostic variables (outliers)

Schizophreniform Disorder

Similar to schizophrenia but lasts less than 6 months

Impaired social or occupational functioning may not be apparent

May or may not return to previous level of functioning

Schizoaffective Disorder

A combination of schizophrenia and a mood disorder

Not caused by any substance use or a general medical condition

Prodromal Phase

1st phase of schizophrenia disorder

Shy/withdrawn

Deteriorating relationships

Decline at school

Poor sleep, anxiety, irritability

Depressive sx

Perceptual abnormalities

Acute Psychotic Phase

Second phase of schizophrenia

Presents as an exacerbation of schizophrenia symptoms

Stabilization Phase

Third phase of schizophrenia

Symptoms diminish

Move towards a previous level of functioning

Maintenance or Residual Phase

Last phase of schizophrenia

A new baseline is established

Signs and Symptoms of Schizophrenia

Positive Symptoms:

• hallucinations

• delusions

• disorganized speech and thoughts

• depersonalization/derealization

• thought blocking, insertion, or deletion

• magical thinking, paranoia

Negative Symptoms:

• anhedonia

• avolition

• blunted affect

• social isolation

• apathy

• alogia - reduction of speech

Cognitive symptoms:

• memory issues

• inability to process social cues

• impaired sensory perception

• dec. executive functioning

• loss of impulse control

• Anosognosia → believing there is nothing wrong with you

Affective symptoms → lack of emotions and expressions

Anticholinergic Toxicity

A dangerous response to antipsychotics

Reduced or absent peristalsis

Urinary retention

Febrile without sweating (hot, dry skin)

Tachycardia, unstable VS

Delirium, agitation, hallucinations

Reduced responsiveness

Seizure

Repetitive motor movements

*potentially life-threatening

Neuroleptic Malignant Syndrome

A dangerous response to antipsychotics

Severe muscle rigidity, dysphagia

Flexor, extensor posturing

Reduced or absent speech and movement

Decreased responsiveness

Hyperpyrexia → temp over 103

Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence

Delirium, stupor, coma