psych exam 1

tct has 3 phases

introductory, working, termination

mental health exam

• Appearance, speech, motor, activity, mood, affect, perceptions, thought content & process, LOC, memory, insight, suicide assessment

• social assessment-how they interact with others and participate in life activities, work/school

• physiologic assessment (Maslow): appetite, hydration, sleep patterns, pain assessment, sexual function

mental disorders are r/t

deficiency, excess or imbalance of neurotransmitters ( chemical messengers)

serotonin involved primarily in

depressive or anxiety disorders, also personality and eating disorders

norepinephrine

mediates flight or fight response- see with bipolar disorders

doapmine involved with

schizophrenia & adhd

GABA is

• inhibitory neurotransmitter → anti anxiety meds increase the effects of GABA

major depressive disorder

lasts 2+ weeks, more in woman than men, more in single & divorced ppl

major depressive disorder onset

loss of pleasure, somatic symptoms, loss of energy, altered sleep, difficulty concentrating, easily distracted, flat affect

major depressive disorder tx

psychopharmacology, electroconvulsion, psychotherapy

tricyclic antidepressants

least expensive, oldest, + serotonin & norepinephrine levels

• used for depression, mood variations, panic, OCD, eating disorders

tricyclic antidepressants cause

sedation, orthostatic hypotension, and anticholinergic SE

MAOIs

• least cholinergic

• block effects of monoamine oxidase enzymes → + dopamine, norepinephrine & seratonin

most common SE of MAOIs

daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction

MAOI diet

if tyramine is ingested → life threatening HTN

• no banana peel, sauerkraut, bean pods, matured cheese, aged or smoked meat or fish, vegemite, brewers yeast

SSRIs adverse effects

stomach upset, sexual dysfunction, serotonin syndrome

SSRIs prevent

reuptake of serotonin by nerves → + serotonin

• fewer SE compared to cyclic

serotonin syndrome occurs when there is an inadequate

washout period between taking MAOIs & SSRIs or when MAOIs combined w/ meperidine

symptoms of serotonin syndrome

AMS (confusion, agitation), neuromuscular excitement (muscle rigidity, shivering, tremors), autonomic abnormalities (hyperthermia, tachycardia, tachypnea, sweating)

1st priority for pt mental health

safety, suicide risks

mood disorders

pervasive alterations in emotions manifested by depression, mania, or both

fatal interactions w/ MAOI

SSRIs, certain cyclic compounds, buspirone, dextromethorphan, and opiate derivatives i.e meperidine

dx of mania or manic episode

requires at least 1 week of unusual & incessantly heightened/grandiose/agitated mood & 3 or more of these: exaggerated self-esteem, sleepless, pressured speech, flight of ideas, lower ability to filter extraneous stimuli, distracted, + activity + energy, high risk activities

bipolar mixed

cycles alt between periods of mania, normal, depression, normal, mania, and so on

bipolar type I

manic episodes w/ at least 1 depressive episode

bipolar type II

recurrent depressive episodes w/ at least one hypomanic episode

toxicity of _______ is closely r/t serum therapeutic levels

lithium

lithium is a…

mood stabilizer, for bipolar, reduces mood swings & mania episodes

lithium is the first

line agent for tx of bipolar disorder 75% effective

lithium med action

normalizes reuptake of serotonin, norepinephrine, acetylcholine, and dopamine

lithium dosage is determined by

monitoring serum levels & assessing response, 900-3600 mg w/ serum level ~1mEq/L

• monitor blood lithium level every 2-3 days until therapeutic

lithium SE

lethargy, weight gain, diarrhea, metallic taste, tremors, anorexia

noncompliance of lithium from pt is usually d/t

lethargy & weight gain

toxic effects of lithium

severe diarrhea, vomiting, drowsiness, lack of coordination, muscle weakness

diphenhydramine

given for dystonic reactions

haloperidol

• targets positive signs of schizophrenia

• causes EPS

• 1st generation antipsychotic

• avail as long-acting depot

clozapine

• atypical antipsychotic

• targets positive & negative symptoms

• causes agranulocytosis

• requires freq. lab test

benztropine

• given for dystonic reactions

• must + fluids to prevent constipation

• anticholinergic → offer hard candy for dry mouth

TCA-cyclics

least expensive antidepressant

w/ MAOIs avoid

tyramine foods

cannot give ______ with MAOIs

TCA-cyclics

low incidence of anticholinergic effects, HTN crisis can occur

MAOIs

increases risk of suicide, SE include weight gain, sexual dysfunction, insomnia, anxiety

SSRis

works by raising serotonin & norepinephrine in brain, anticholinergic effects

TCA-cyclics

1st generation antipsychotics

ends in “azine” & haloperidol

• tx’s positive symptoms

• most SE

• cheaper & most RX’d

positive symptoms include

hallucinations, delusions, illusions, bizarre behaviors, disorganized speech patterns

2nd (atypical) generation antipsychotics

end in “idone” or “apine” i.e clozapine

• tx both positive & negative symptoms

negative symptoms

blunt affect, lack of motivation, inability to experience pleasure (anhedonia), poverty of thought (alogia)

anhedonia

inability to experience pleasure

agranulocytosis

low WBC count, leads to → ulcerative sore throat

antipsychotic SE

extrapyramidal symptoms (movement disorders), ANS SE, low seizure threshold, janudice, weight gain, endocrine issues, derm issues

extrapyramidal symptoms (EPS)

drug induced parkinsonism, akathesia, akinesia, acute dystonic reaction, tardive dyskinesia

EPS parkinsonism symptoms

rigidity, slowed movements, blunted affect, tremors, pill rolling w/ fingers. cog wheel/ratchet rigidity of arms

akathisia

continuous restlessness & fidgeting r/t antipsychotic use

akinesia

muscle weakness, decreased activity r/t use of antipsychotics

how are parkinsonism symptoms treated

decrease drug dose if possible, administer Cogentin (benztropine) IM

tx of akathisia

decrease antipsychotic dose, give benzodiazepine or beta blocker

tx of akinesia

decrease antipsychotic dose, give Congentin (benztropine) or beta blocker

EPS can include acute dystonic reaction, i.e:

muscle spasm that produce abnormal contortions of neck & above

• may occur within hours of giving 1st dose of antipsychotic

an acute dystonic reaction may..

occlude the airway, and therefore is a medical emergency

tx of acute dystonic reaction

diphenhydramine HCI IV or IM, Congentin (benztropine)

tardive dyskinesia

chronic involuntary movements of face, mouth, tongue, may effect limbs & trunk

• appears w/ prolonged use of psychotropics

• can become irreversible

tx of tardive dyskinesia

ID early w/ periodic AIMS assessment, d/c antipsychotic, give Clozaril (clozapine) or Ingrezza (valbenazine)

autonomic nervous system SE of antipsychotics

drowsiness, dry mouth (common reasons pt’s stop), constipation, urinary hesitancy or retention, orthostatic hypotension (safety 1st)

if a pt has a seizure as a result of being put on antipsychotic, the dose of the drug should be:

discontinued

normal WBC count

5,000-10,000

antipsychotic is stopped if WBC is

3500 or lower

neuroleptic malignant syndrome

medical emergency, can happen to pts on antipsychotics, fatal

• high fever, drooling, muscle rigidity, high CPK (muscle damage), tachycardia, unstable BP, change in LOC

for NMS, remember:

FEVER

• fever, encephalopathy (delirium, coma), vitals unstable, elevated CPK, rigidity

normal CPK levels

male: 12-70

female: 10-55

antipsychotics cause dry mouth, so drooling is…

an ominous sign that pt is developing NMS

CPK level is how

neuroleptic malignant syndrome (NMS) is confirmed

predisposing factors for developing NMS

dehydration, poor nutrition, physical illness, lithium therapy, recent + in dose of antipsychotic, + incidence w/ depot meds, higher incidence in males

NMS neuroleptic malignant syndrome tx

d/c antipsychotics, hydrate w/ IV fluids, control hyperthermia, administer bromocriptine & dantrolene (muscle relaxants)

1st generation cause greatest incidence of _____ compared to 2nd generation

EPS

tardive dyskinesia may present w/ these:

tongue thrusting & profusion, lip smacking, blinking, grimacing

AIMS abnormal involuntary movement scale is

useful for assessment of acute dystonia and tardive dyskinesia

clozapine causes

agranulocytosis

antipsychotic drugs can raise

prolactin levels in both males & females causing breast enlargment

4 types of antidepressants

TCA tricyclic, SSRIs, MAOIs, others

trazodone causes

priapism → sustained, painful erection

buproprian is

4x more likely to cause seizures than other antidepressants

take TCA at night

d/t sedative effects

DSM-5 diagnostic criteria is used to

r/o medical health problems before determining a mental illness

DSM-5 dx criteria 2 or more during 1 month period

delusions, hallucinations, disorganized speech or behavior, neg symptoms (diminished emotions, avolition), schizoaffective r/o, 0 substance abuse

schizoaffective disorder

schizophrenia combined with depression or bipolar

• dx made when 0 hallucinations or delusions for 2 weeks

alogia

tendency to speak very little or no substance of meaning

• negative symptom

catatonia

excessive motor activity, immobility, or motionlessness, catalepsy (waxy flexibility) or stupor. extreme negativism, mutism, peculiar movements, echolalia, echopraxia.

• can occur with schizophrenia, mood disorders, or other psychotic disorders.

apathy

indifference

• negative symptom

blunted affect

restricted range of emotional feeling or tone

catatonia

psychologically induced immobility w/ occasional agitation or excitement, client seems motionless/trance

• negative symptom

flat affect

absence of facial expression

• negative symptom

avolition

absence of will, ambition

• negative symptom

brief psychotic disorder

sudden onset of psychotic symptoms, may or may not be preceded by severe psycholigical stressor

• at least 1 day but less than 1 month

schizophreniform disorder

presents same but duration 1-6 months

AIMS assesses

movement, not muscle

AIMS is used to assess for signs of

tardive dyskinesia

tardive dyskinesia is characterized by

bizarre movements of mouth, face, trunk, & extremities

• from 1st gen, long term use

clang associations

words r/t another based on sound or rhyming

neologisms

new words made up