Psych

Substance Abuse: Marijuana

Active agent: Tetrahydrocannabinol (THC) Depressant & Hallucinogenic

Tourette's Disorder

Age of onset: Can be early as 2 Most common onset: 6-7 y.o. Characterized by motor & verbal tics.

MAO Diet—Tyramine restrict

Aged or hard cheese, Aged meats, Pickled/fermented foods, Yeast extracts. Some Asian, Thai, Indian foods (fermented soy). Cough syrup, Decongestants, Narcotic sedatives/analgesics, Anesthetics, Other Antidepressants. See Table 25-4, p. 488

Substance Abuse: CNS Sedatives, Hypnotics, & Anxiolytics

Alcohol Barbiturates Benzodiazepines Chloral Hydrate Club drugs - Date Rape Drugs. Ex. Flunitrazepam (Rohypnol or "roofies") γ-Hydroxybutyric acid (GHB)

Alzheimer's disease (AD) Manifestations

Confabulation: making up stories to hide memory deficit. Perseveration: repetition of phrase or behaviors. Aphasia: loss of language ability Apraxia: loss of ability to perform once familiar purposeful tasks Agnosia: loss of ability to recognize objects Agraphia: inability to read/write

Depakote (valproate)

Mood Stabilizers - Anticonvulsants. Need baseline and interval LFT's (hepatitis) and platelets. Monitor therapeutic index. Common S/E tremors, GI upset, wt gain.

Tegretol (carbamazepine)

Mood Stabilizers - Anticonvulsants. Requires monitoring blood levels to avoid toxicity. Baseline lab work including LFT's. Common S/E: anticholinergic.

Topamax (topiramate)

Mood Stabilizers - Anticonvulsants. S/E include wt loss, cognitive, fatigue, dizziness, paresthesia.

Neurontin (gabapentin)

Mood Stabilizers - Anticonvulsants. Serious S/E: dyspnea, edema of lips, rash, slurred speech, drowsiness and diarrhea. Common S/E: fatigue, somnolence, dizziness, ataxia, diploplia, HTN.

Antidepressant Drugs

Most regulate neuro transmitters: Norepinephrine (NE) or Serotonin (SE). >Important General Information: side effects of nausea, insomnia, dizziness & headaches usually disappear in 2-6 wks. *Typical or Standard Antidepressants - Tricyclic Antidepressants (TCA's) *Selective Serotonin Reuptake Inhibitors (SSRI's) *Monoamine Oxidase Inhibitors (MAOI's) *Atypical or Novel Antidepressants

Neuroleptic Malignant Syndrome (NMS)

NMS is rare (0.2-1% of pts taking antipsychotics) but may be fatal (~ 10%) May be due to acute reduction in dopamine. Signs and symptoms (S/S) include decreased level of consciousness (LOC), increased muscle tone, hyperpyrexia, labile hypertension (HTN), tachycardia, tachypnea, diaphoresis, and drooling

Moderate Anxiety

Narrows focus Sees, hears, grasps Less Info. - Selective inattention Can attend other things Can still problem solve—not optimal Usually can state anxious Physiological sx's: Ex. ht. pounding, inc P, GI upset

Amino Acids - Glutamate

Neurotransmitter. Excitatory, role in learning & memory. Decreased in Psychosis. Increase in Neuro-degeneration in Alzheimer's.

Monoamines - Histamine

Neurotransmitter. Involved in alertness, inflammatory response, stimulates gastric secretion. Decreased in depression, sedation, weight gain.

Monoamines - Dopamine (DA)

Neurotransmitter. Involved in fine muscle movement, integration of emotions & thoughts, decision making. Decreased in Parkinson's, depression, SUBSTANCE ABUSE. Increased in Schizophrenia and mania.

Monoamines - Norepinephrine (NE) (noradrenaline)

Neurotransmitter. Level in brain affects mood; sleep, arousal; "fight or flight" NS response. Decreased in depression. Increased in anxiety, mania, schizophrenia.

Amino Acids - GABA (Gamma aminobutyric acid)

Neurotransmitter. Role in inhibition, decreased aggression, excitation, and anxiety. Anticonvulsant & muscle-relaxing properties. Decreased in Anxiety DO, schizophrenia, mania. Increased in GABA Reduction of anxiety.

Cholinergics - Acetylcholine (ACh)

Neurotransmitter. Role in memory, learning; regulates mood; affects sexual & aggressive behavior; pain perception, movement. Decreased in Alzheimer's, Parkinson's. Increased in Depression.

Monoamines - Serotonin (5-HT)

Neurotransmitter. Sleep regulation, appetite/hunger, mood states, libido, aggression, and pain perception. Decreased in Depression. Increased in Anxiety.

Alzheimer's disease (AD)

Progressive neurodegenerative disorder that gradually erodes cognitive function and eventually causes death. Characteristic in AD: High concentration of beta-amyloid plaques. Neurofibrillary tangles seen on postmortem examination. Cerebral atrophy. Theories on Causes of AD: *Early onset (30-60y.o.—Genetic) *Genetic mutations—Chromosome 18 *Environmental exposures *Abnormalities in brain proteins or neurotransmitters--↓ Acetyltransferase Stages 1-4

Medications for Depression

Selective serotonin reuptake inhibitor (SSRIs): First Line. ex. Prozac (Fluoxetine) Luvox (Fluvoxamine) Zoloft (Sertraline) Paxil (Paroxetine) Lexapro (Escitalopram) Celexa (Citalopram) Tricyclic antidepressants (TCAs): ex. Elavil (Amitriptyline) Anafranil (Clomipramine) Norpramin (Desipramine) Sinequan (Doxepin) Tofranil (Imipramine) Pamelor, Aventyl (Nortriptyline) Vivactil (Protriptyline) Surmontil (Trimipramine) Monoamine oxidase inhibitors (MAOIs): ex. Nardil (Phenelzine) Parnate (Tranylcypromine) Marplan (Isocarboxazid) Emsam (Selegiline) Atypical antidepressants: Encompasses all other antidepressants, including Serotonin-norepinephrine reuptake inhibitor (SNRIs) ex. Desyrel (Trazodone) Wellbutrin (Bupropion) Cymbalta (Duloxetine) Effexor (Venlafaxine) Remeron (Mirtazapine) Serzone (Nefazodone) Viibryd (Vilazodone) Brintellix (Vortioxetine)

Serotonin Syndrome

Serotonin Syndrome is when the body has too much serotonin. This can be from too high a dose of medication or interactions with other drugs. Decrease incidence by having adequate "wash out" period when introducing another serotonin-enhancing agent. Time period depends upon half-life of drug. Generally, D/C all SSRI's 2-5 wks before starting MAOIs. S/S: mental status change (delirium), sweating, fever, abd pain, diarrhea, tachycardia, HTN, myoclonus. *Symptoms can progress to coma, seizures, metabolic acidosis, renal failure & even death.

Severe Anxiety

Sig. decrease perceptual field All behavior focused on decreasing Anxiety Learning & problem solving not possible May be unaware/unable to name anxiety Somatic sx's increase

Medications for Schizophrenia

Typical Antipsychotics Atypical Antipsychotics Antidepressants: treats comorbid depression Anti-manic/Mood Stabilizers: mainly for schizoaffective disorder

Panic (Anxiety)

dread, helpless, fear losing control BLOW things out of proportion Can't do things with direction inc. motor activity Decreased rational thinking Increased physiological sx's feelings of unreality

Anticholinergic symptoms

dry mouth, urinary retention, constipation, blurred vision, impotence

Medications for Anxiety

*Anxiolytics Benzodiazepines Buspar *Antihistamines β-Blockers - Propranolol, Clonidine *Anticonvulsants/Mood Stabilizers: Used for some Anxiety disorders. Ex. Tegretol, Neurontin, Depakote. OCD SSRIs - ex. Fluoxetine (Luvox) Rx resistant: TCAs. Ex. Clomipramine (Anafranil)

Antianxiety or Anxiolytic Drugs

*Benzodiazepines Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) *Non-benzodiazepines BuSpar (buspirone) *Antihistamines *Beta-blocker Inderal (propranolol)

Treatment for Alcohol Withdrawal

*Fluids *Medications should not be given unless withdrawal sx's are seen: **Benzodiazepines - Dec. withdrawal sx's. Stabilize VS. Prevent seizures & DT's **Beta-Adrenergic blockers (Atenolol or Propranolol) - Stabilize VS, dec. craving, dec. withdrawal sx's **Alpha-adrenergic blocks (Clonidine) - Dec. withdrawal sx's **Anticonvulsants (Tegretol) - Dec. withdrawal sx's, prevent seizures **Multivitamins combination with Thaimine - for chronic alcoholics (they're commonly deficient)

Treatment of Opioid Addiction

*Maintenance **Dolophine (methadone) - Synthetic opiate blocks craving for and effects of heroin. Only medication currently approved to treat pregnant opioid addict. Need to take daily. Highly addictive, when stopped -> withdrawal. Some pts. need for lifetime to maintain drug free. Side effects. **Buprenorphine (Suboxone, Subutex) - Tx opioid dependence by relieving craving. Less powerful than Methadone but fewer side effects. Best for cts. with Mild- Moderate addiction. Problematic use drug diversion. Blocks sx's of withdrawal. *Narcotic Antagonists **Revia (Naltrexone) - Antagonist that blocks euphoric effects of opioids. Low toxicity, few side effects, does not produce dependence. **Clonidine (Catapres) - Nonopioid suppressor of opioid withdrawal symptoms.Effective when combined with naltrexone. Not addicting.

Tolerance

1. Acquired resistance to substance effect. 2. Need to take increasing amts. of substance to achieve same effect or have decreasing effect from cont. fixed dosage

Withdrawal

1. Follows cessation/dec. substance intake 2. Starts earlier w. shorter acting drugs. 3. Signs of alcohol withdrawal: sweating, ↑P, tremor, insomnia, nausea & vomiting, agitation, possible tonic-clonic (grand mal) seizure 2-3 days after abstinence

Intergenerational Family Systems therapy (Murray Bowen)

1. General Concepts: a. family within a multi-generational context--patterns of family interactions repeat themselves across generations. b. view of dysfunction in the family---sx's in individual rel'd. to dysfunction in family system Emotional interactions patterns: Differentiation, Triangles, Anxiety. Differentiation of self: Maintain emotional contact with another & be individual. Human functioning on continuum. Describes indiv. & family -> Static concept Family system with low level of differentiation (LOD) - Operate from feeling system. High anxiety system. Much difficulty with stress. More physical & emotional probs. No room for individuality. More emotional cutoffs: Extreme stress in relationship. Have fight and don't associate with that person/or side of the family -> Leads to fewer support systems. Family system with high LOD- Operate more from thinking: use critical thinking skills. Better able to handle crises. Can be individuals & with others: Still can be oneself and not swayed by others. Can state "I" position: be assertive. Nicely state their mind, have emotional intelligence. Triangle: key to understanding how emotional systems function. How people function in relationships. Three sides to triangle: Two people and third person, Two people and object (e.g. Alcohol), Two people and an issue (working too much). Emotional process around triangles. When triangles become fixed and members can't/don't change their pattern of functioning: Problematic! Families with low level of differentiation: more triangles and more fixed ones. Families with high level of differentiation: fewer triangles and less fixed ones.

Schizophrenia

A brain disorder in which people interpret reality abnormally. DSM V: For a diagnosis, symptoms must have been present for six months and include at least one month of active symptoms. The patient must have experienced at least 2 of the following symptoms: Delusions, Hallucinations, Disorganized speech, Disorganized or catatonic behavior, Negative symptoms.

Dementia

A cognitive disorder manifested by: Insidious onset. Deterioration of: Memory, Judgment, Abstract thinking, Orientation, Language ability, Sensory & motor function. Impairment in personality & mood. Usually progressive & irreversible Most common form of Dementia is Alzheimer's disease (AD) - Progressive neurodegenerative disorder that gradually erodes cognitive function and eventually causes death. Secondary dementias are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma, Lewey Body).

Schizoaffective disorder

A mental health condition including schizophrenia and mood disorder symptoms. Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times.

Learned Helplessness

A mental state in which an organism forced to bear aversive stimuli, or stimuli that are painful or otherwise unpleasant, becomes unable or unwilling to avoid subsequent encounters with those stimuli, even if they are "escapable," presumably because it has learned that it cannot control the situation.

Cyclothymia

A type of chronic mood disorder widely considered to be a milder or subthreshold form of bipolar disorder. Cyclothymia is characterized by numerous mood disturbances, with periods of hypomanic symptoms alternating with periods of mild or moderate depression. According to the DSM-5, there are six diagnostic criterion, with one specifier: For at least a two year period, there have been episodes of hypomanic and depressive experiences which do not meet the full DSM-5 diagnostic criteria for hypomania or major depressive disorder. The above criteria had been present at least half the time during a two year period, with not more than two months of symptom remission. There is no history of diagnoses for manic, hypomanic, or a depressive episode. The symptoms in criterion A are cannot be accounted for by a psychotic disorder, such as schizophrenia, schizoaffective disorder, schizophrenifrom disorder, or delusional disorder. The symptoms cannot be accounted for by substance use or a medical condition. The symptoms cause distress or significant impairment in social or occupational functioning. A specifier the clinician can add is With anxious distress. The disorder can also be diagnosed in children or adolescents, but the observational period for symptoms is one year rather than two.

Substance Use Disorders

A. Def: maladaptive pattern of substance use leading to sig. impairment/distress manifested by: 1. failure to meet obligations--work, school &/or home 2. recurrent usage in physically hazardous situations 3. recurrent related legal problems 4. cont. usage despite persistent probs. R/t usage 5. compulsion to take substance 6. substance taken in larger amts. 7. loss of control over patterns of usage. 8. attempts to restrict use unsuccessful 9. much time spent to obtain substance 10. cont. use despite neg. consequences. 11. withdrawal sx's when substance intake interrupted 12. tolerance sx's develop from usage

Standard First-Generation or Conventional Antipsychotics

Antagonists (block the action) of dopamine D2 receptors on postsynaptic neurons. Antagonists to some degree of acetylcholine, norepinephrine, and histamine. For "positive" symptoms i.e. delusions, hallucinations. Related to Major side-effects: Anticholinergic symptoms, cardiovascular effects, histamine blocking, Extra-Pyramidal Side-effects (EPS). *Phenothiazines: Thorazine, Prolixin, Trilafon *Thioxanthenes: Navane *Butyrophenones: Haldol (Haldol is okay to use with pregnancy)

Monoamine Oxidase Inhibitors (MAOI's)

Antidepressant Drugs Blocks monoamine oxidase from metabolizing NE, 5HT, DA↑ availability. **↑ tyramine can be problematic- when not broken down by MAO can lead to HTN, hypertensive crisis, & eventually CVA. Therefore food and drugs containing tyramine must be avoided/restricted! (No chocolate!) Minimum 2 week "wash out" between SSRI/TCA- depends on drug half-life. EMSAM (selegiline transdermal system)- Topical administration of MAOI. May experience skin irritation or erythema with patch. Patches for MAOIs much less likely to trigger tyramine reactions. Particularly effective for: *Atypical depression (Mood reactivity, Oversleeping, Overeating) *Panic disorder *Social Phobia *Generalized Anxiety disorder *PTSD *Bulimia (Stated in book. However, caution with eating disorder.) Common S/E: Orthostasis, wt gain, edema, change in cardiac rate/rhythm, anticholinergic effects (dry mouth, constipation, urinary hesitancy), sexual dysfunction, weakness, fatigue, vertigo, hypomania, mania, insomnia, weakness, fatigue Examples: Parnate (tranylcypromine) Nardil (phenelzine)

Tricyclic Antidepressants (TCA's)

Antidepressant Drugs Blocks reuptake of Norepinephrine (NE), 5HT, dopamine; also blocks Acetylcholine (Ach) and H1 (Histamine). Multiple drug-drug interactions (p.487). Use with MAOI is contraindicated. Multiple side effects: *Anticholinergic: dry mouth, constipation, urinary retention, blurred vision, tachycardia *Antihistamine: wt gain, sedation *Alpha-adrenergic: postural hypotension *Antidopaminergic: movement disorder (d/o) Potential toxic effects: cardiovascular. Overdose is lethal. Examples: Elavil (amitriptyline) Norpramin (desipramine)

*Selective Serotonin Reuptake Inhibitors (SSRI's)

Antidepressant Drugs SSRI's block reuptake & destruction of serotonin (Inc. availability of SE). No effect on other monoamine transmitters. Lower lethality index, but watch for serotonin syndrome. Safe to use SSRI's & during 1st trimester of pregnancy. Use late in pregnancy may cause problems in newborns. **1st line therapy for most types of depression. S/E include initial GI upset, diarrhea, insomnia; sexual dysfunction. Examples: Prozac (fluoxetine) Zoloft (sertraline) Celexa (citalopram) Luvox (fluvoaxamine) Paxil (paroxetine) Lexapro (escitalopram)

Parnate (tranylcypromine)

Antidepressant Drugs - Monoamine Oxidase Inhibitors (MAOI's) Not used in patients >60 yrs old. Thrombocytopenia, agranulocytosis, leukopenia.

Nardil (phenelzine)

Antidepressant Drugs - Monoamine Oxidase Inhibitors (MAOI's) Very sedating.

1st Generation Antipsychotic Drugs - Treatment of (EPS) side effects

Antihistamine- Diphenhydramine hydrochloride (Benadryl): usually for acute situations Antiparkinsonian drugs- Amantadine hydrochloride (Symmetrel) Anticholinergic drugs- Trihexyphenidyl (Artane) Benztropine mesylate (Cogentin) Biperiden (Akineton)

Benzodiazepines

Anxiolytic Drugs Increase effectiveness of GABA (inhibitory NT) - slows down metabolism of serotonin and norepinephrine. Potential for dependence - should be used for short periods, initial Tx. Should be avoided w/pregnancy (can cause dependence in baby). Advantages: Rapidly effective. Safe in overdose -> rarely inhibit respiratory drive. Well tolerated. Many choices. Few drug interactions. Disadvantages: Sedation at high therapeutic doses. Can interfere with motor ability. Fall risk w/ elderly. Abuse/Dependence. Withdrawal symptoms. Fatal respiratory depression/coma if used with ETOH! Examples: Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) The '...am' s

BuSpar (buspirone)

Anxiolytic Drugs: Non-benzodiazepines Increase synaptic level of serotonin. Advantages: No dependency, habituation. No sedation. Safe in overdose. Decreases interactions with CNS depressants Disadvantages: Delayed effect (~2-4 weeks). Ineffective in many patients. Side effects: HA, dizziness, nausea, insomnia.

Clozaril (clozapine)

Atypical Antipsychotics. 1st of atypicals; increased seizure rate; possibly fatal side effect (s/e) in 1-2% of pts due to agranulocytosis. Most common S/E sedation, wt gain, hypersalivation, tachycardia, dizziness. Not first-line, used in refractory cases. Requires monitoring WBC. Fed requires: wkly WBC for 6ms, then every 1ms, then 2ms

Zyprexa (olanzapine)

Atypical Antipsychotics. Drowsiness, wt gain; can cause constipation, hyperprolactinemia, seizures

Fanapt (iloperidone)

Atypical Antipsychotics. For rx of Schizophrenia

Latuda (lurasidone HCl)

Atypical Antipsychotics. For rx of Schizophrenia

Saphris (asenapine)

Atypical Antipsychotics. For rx of Schizophrenia

Abilify (aripiprazole)

Atypical Antipsychotics. Little sedation, & wt gain; can cause insomnia, akathisia, nausea, vomiting. Also used to as a Mood Stabilizer in Bipolar Disorder.

Geodon (ziprasidone)

Atypical Antipsychotics. Main S/E dizziness & sedation. Major safety concern prolonged QT interval.

Risperdal (risperidone)

Atypical Antipsychotics. Can cause orthostatic hypotension, wt gain, sedation, sexual dysfunction (Varcarolis); Inc. risk of EPS with higher dose, NMS, TD

Seroquel (quetiapine)

Atypical Antipsychotics. High sedation, wt gain, orthostasis, low risk of EPS (Varcarolis); constipation

Invega (paliperidone)

Atypical Antipsychotics. Inc. risk of EPS with higher dose, sedation, wt. gain, tachycardia, headache

Atypical or Novel Antidepressants

Atypical antidepressants target other neurotransmitters either alone or in addition to serotonin. Examples: Wellbutrin (buproprion) Desyrel (trazodone) Ludiomil (maprotiline) Serzone (nefazodone) Remeron (mirtazapine) Serotonin & Norepinephrine Reuptake Inhibitors (SNRI's): Cymbalta (duloxetine) Effexor (venlafaxine) Pristiq (desvenlafaxine)

Remeron (mirtazepine)

Atypical or Novel Antidepressants Anxiolytic (anti-anxiety) & antidepressant properties. Minimal s.e. of sexual dysfunction. Anti-emetic effect. May cause sedation/wt. gain-> may be helpful for pt's with poor sleep/appetite.

Wellbutrin (buproprion)

Atypical or Novel Antidepressants dopamine-norepinephrine reuptake inhibitor Also used for smoking cessation (Zyban). Side effects: agitation, insomnia, dec. seizure threshold. Less likely to trigger mania, sexual dysfunction, but may decrease appetite.

Desyrel (trazodone)

Atypical or Novel Antidepressants serotonin reuptake inhibitor and 5-HT2 receptor antagonist Not first-line for depression. S/E of somnolence.

Cymbalta (duloxetine)

Atypical or Novel Antidepressants - SNRI's Used for neuropathic pain. Mild S/Es (nausea, constipation, dry mouth, fatigue).

Effexor (venlafaxine)

Atypical or Novel Antidepressants - SNRI's Useful for treatment-resistant depression. Low potential for drug interaction. Possible increase in BP, somnolence, dizziness, dry mouth.

Structural Family Therapy (Salvador Minuchin)

Basic tenets: Family structure creates organization for family interaction. There are rules that govern family structure Underlying structure: Maintain functional/dysfunctional family structure. Boundaries. Subsystems. Family as developing system: Transition times: stressful times. Family as a developing system: a. family is a growing system influenced by internal & external changes b. maladaptation to these changes - problematic for family

Atypical Antipsychotics or 2nd Generation Antipsychotics

Bind to dopamine receptors in limbic system Less incidence of EPS and TD. Lit. states targets negative & positive symptoms. May decrease affective symptoms. Antagonists for 5-HT2 receptors for serotonin- may related to (r/t) treating negative symptoms. Provides relieve of acute mania. Atypical antipsychotics: risk to baby cannot be ruled out. Chosen more as first-line treatment due to more favorable side effect (S/E) profile. But atypical has an increased risk of Metabolic Syndrome. Examples: Clozaril (earliest atypical) Risperdal (risperidone) Invega (paliperidone) Seroquel (quetiapine) Zyprexa (olanzapine) Geodon (ziprasidone) Abilify (aripiprazole) Fanapt (Iloperidone) Saphris (asenapine) Latuda (lurasidone HCl)

Bipolar I

Bipolar I is characterized by one or more manic episodes or mixed episodes (which is when you experience symptoms of both a mania and a depression). Typically a person will experience periods of depression as well. Bipolar I disorder is marked by extreme manic episodes.

Bipolar II

Bipolar II disorder is diagnosed after one or more major depressive episodes and at least one episode of hypomania, with possible periods of level mood between episodes. The highs in bipolar II, called hypomanias, are not as high as those in bipolar I (manias).

Extra-Pyramidal Side-effects (EPS)

Blockage of D2 (dopamine) in motor areas responsible for most troublesome side effects: Akathisia, Dystonia, Parkinsonism, Tardive Dyskinesia

Namenda (Memantine)

Blocks overstimulation by glutamate which contributes to neurodegenerative disease. First drug used to target moderate to severe stages of Alzheimer's.

Cognex (Tacrine)

Cholinesterase Inhibitors High frequency of side effects: hepatic effects, GI effects. No longer used extensively

Aricept (Donepezil)

Cholinesterase Inhibitors Most widely prescribed. Dosage once/daily. Possible GI side effects

Exelon (Rivastigmine)

Cholinesterase Inhibitors Nausea, vomiting, loss of appetite & wt. loss.

Alzheimer's disease (AD) Psychopharmacology

Cholinesterase Inhibitors Target: Cognitive decline, behavior & ADL's from Alzheimer's-mild to moderate symptoms Action: Increase brain's supply of acetylcholine Start early - Cannot gain lost function & memory. Antidepressants SSRI's well tolerated in elderly. Avoid agents with anticholinergic activity. Anti-anxiety agents Buspar (No serious side effects, should be considered). Atypical antipsychotic medications Widely used to treat delusions, aggression, and agitation in Alzheimer disease; Concerns increased risk for cerebrovascular adverse events, rapid cognitive decline, and mortality with use.

Schizotypal Personality Disorders

Cluster A Characterized by severe social anxiety, paranoia, and often unconventional beliefs (odd beliefs/thinking - magical thinking, ideas of reference).

Paranoid Personality Disorders

Cluster A Pervasive distrust &suspiciousness. Reluctant to confide in others. Jealous & controlling. Bears grudges. Perceives attacks on character not apparent to others.

Schizoid Personality Disorders

Cluster A Pervasive pattern of emotional detachment from social relationships. Restricted range of expression. Emotional coldness, detachment & flattened affect. Indifference to praise or criticism. ->Can be precursor to schizophrenia

Personality Disorders - Clusters

Cluster A: Odd or eccentric Paranoid, Schizoid, Schizotypal Cluster B: Dramatic, emotional, erratic Antisocial, Borderline, Narcissistic, Histrionic Cluster C: Anxious or fearful Dependent, Obsessive Compulsive, Avoidant

Narcissistic Personality Disorders

Cluster B A disorder in which a person has an inflated sense of self-importance. Believes they have a special talent. Looking for excessive admiration. Lack empathy.

Antisocial Personality Disorders

Cluster B Pervasive pattern of disregard for & violation of rights of others. Failure to conform to social norms; commits unlawful acts. Irritability & aggressiveness. Lack of remorse & indifference for actions. Repeated failure to sustain consistent work behavior or honor financial obligations. Manipulative behavior Associated with Substance abuse, Childhood Conduct D.O.

Borderline Personality Disorders

Cluster B Pervasive pattern of unstable interpersonal relationships. Frantic efforts to avoid real or imagined ABANDOMNENT. Identity disturbance - unstable sense of self. Affective instability. Intense stress -> maladaptive response. Impulsivity- Recurrent suicidal behavior, gestures, or self-mutilating behavior. Self-soothing behaviors - Substance use, cutting, promiscuity. Unstable relationships alternating between idealization & devaluation (Splitting). Higher incidence of ED's, anxiety, substance use

Histrionic Personality Disorders

Cluster B Seeks attention, talks dramatically with strong opinions, theatrical, hyper-sexual, is easily influenced, has rapidly changing emotions, and thinks relationships are closer than they are.

Obsessive Compulsive Personality Disorders

Cluster C Characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one's environment, at the expense of flexibility, openness, leisure and efficiency.

Avoidant Personality Disorders

Cluster C Characterized by social discomfort and avoidance of interpersonal contact. View themselves as socially inept.

Dependent Personality Disorders

Cluster C Pervasive need to be taken care of submissive & clinging behavior. Difficulty making independent decisions. Needs others to assume responsibility for most areas of life. Difficulty initiating projects, lacks self-confidence. Uncomfortable or helpless when alone - R/t exaggerated fears of being unable to care for self.

Substance Abuse: Central Nervous System Stimulants

Cocaine, Crack, Amphetamines: Methamphetamine--highly addictive Bath salts: Inhaled, injected, mixed with food or drink

Cholinesterase Inhibitors

Cognitive decline from Alzheimer's Disease- mild to moderate symptoms. Drugs work by interfering with action of acetylcholinesterase. Leads to higher concentration of Acetylcholine at synapse. Examples: Aricept (donepezil) Exelon (rivastigmine) Reminyl (galanamine) Cognex (tacrine) - *hepatic effects

Eating Disorder: Anorexia Nervosa- Restricting or Binge-eating/ purging type

Compulsive nature. Refusal to gain wt. at/above minimally normal level. Sig. wt. loss & intense fear of gaining wt. Disturbance in body image Difficulty coping w. anxiety Extremely perfectionistic Rituals exercising & with eating Ego syntonic - consistent w/body image. Amenorrhea. Drugs: No drugs approved by FDA. Ones that help: Fluoxetine (Prozac) Olanzapine (Zyprexa)

Panic Disorder

DSM-5 Criteria Both A & B A. Recurrent unexpected panic attacks B. Usually no precipitant C. Physical sx's can mimic life threatening cardiac condtion ie MI D. Dx. not made until med. Probs. R/o'd. E. At least one of attacks followed by 1 month of 1 (or more) of following: 1. Persistent worry about having attacks 2. Worry about consequences of having attack 3. Significant change in behavior r/t attacks

Major Depressive Disorder (MDD)

DSM-IV Criteria for Major Depressive Disorder (MDD) • Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks. • Mood represents a change from the person's baseline. • Impaired function: social, occupational, educational. • Specific symptoms, at least 5 of these 9, present nearly every day: 1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2. Decreased interest or pleasure in most activities, most of each day 3. Significant weight change (5%) or change in appetite 4. Change in sleep: Insomnia or hypersomnia 5. Change in activity: Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt 8. Concentration: diminished ability to think or concentrate, or more indecisiveness 9. Suicidality: Thoughts of death or suicide, or has suicide plan

Craving

Desire to use abused substance

Namenda (memantine)

Effects N-Methyl-D-Aspartate (NMDA) receptor involved in memory. Blocks overstimulation by glutamate which contributes to neurodegenerative disease. Moderate to severe symptoms Able to add to cholinesterase inhibitors: often used with Aricept.

Acetylcholinesterase (CE)

Enzyme, destroys neurotransmitters. Enzyme acts on acetylcholine. Immediate inactivation of transmitter at postsynaptic membrane.

Monoamine Oxidase (MAO)

Enzyme, destroys neurotransmitters. Norepinephrine, dopamine, and serotonin are all inactivated by MAO.

Mild Anxiety

Everyday tension. Inc. sees, hears, grasps. Inc. motivation learning. Slight discomfort. Person can recognize anxiety.

Generalized Anxiety Disorder

Excessive anxiety/worry over days, lasts 6 months or longer. Difficult to control anxiety. Experiences physical sx's r/t anxiety. Distress or impairment. Risk of self-medication--substance abuse Physical sx's: sleep and energy alterations, poor concentration, restlessness, irritability, tension. Distress/impairment - social, occupational ex's. Greater risk for ht. problems

Stages of Family Development

Family development theory: Individual's life cycles occurs in fam. life cycle. Mirrors individual life cycle. Starting from formation of couple to aging & death (expected) . Transition times - Relationship to stress. Stressful times in the family (Example deaths, births). Stage 1. The single young adult Goal: accepting separation from parents and responsibility for self. Tasks: Forming an identity separate from the parents. Establishing intimate peer relationships. Advancing toward financial independence . Problems: example: difficulty with young adult leaving home and vice versa. Stage 2. The family joined through marriage/union Goal: commitment to the new system Tasks: New identity as a couple. Realigning relationships with extended family friends, and community. Decisions about having children. Problems partner has difficulty separating from family of origin (extended family) or couple cut themselves off completely from extended family - think they can totally meet each others needs. Stage 3. The family with young children Goal: accepting a new generation of members system Tasks: Adjusting couple system to make space for children. Sharing equally in the tasks of childrearing. Integrating extended family members into family. Problems: parents' lack of knowledge about normal childhood development interferes with satisfactory childrearing. Have knowledge deficit. Stage: 4 Family with Adolescents Goal: increasing flexibility of family boundaries to include children's independence & grandparents' frailties. Tasks: Shifting of parent-child relationships to permit adolescents to move in & out of system. Refocusing on midlife couple & career issues. Beginning hift toward concerns for older generation. Problems: Parents are unable to relinquish control and allow the adolescent increasing autonomy OR parents cannot agree and support each other in this effort. Stage 5. The family launching children and moving on in midlife. Goal: accepting multitude of family system exits & entries Tasks: Renegotiation of couple system as a dyad. Development of adult-to-adult relationships between grown children and parents. Realignment of relationships to include in-laws and grandchildren. Dealing with care needs, disabilities, and death of parents (grandparents). Problems arise when parents are unable to accept departure of their children from home. Difficulty: *Accepting status as adult - Responsible for self & others. Death anxiety. *Death of their own parents Stage 6. The family in later life Goal: accepting the shifting of generational roles. Tasks: Maintaining own and/or couple functioning & interests in face of physiological decline. Support for more central role for middle generation. Dealing with loss of spouse, siblings, and other peers, and preparation for own death; life review. Managing reversed roles in care taking between middle and older generations.

Reminyl (Galantamine)

For 1st & 2nd stages of Alzheimer's

Boundary maintenance (Minuchin)

Function of boundaries: regulate flow of info. affection, connection with others. Clarity (Clear boundaries) vs Continuum of boundary structure: **Enmeshment (Enmeshed/diffuse boundaries) - Boundaries too open. No age appropriate independence. **Disengagement (Rigid/enmeshed boundaries) - Family not connected overly distant **Hierarchy problems: Coalition across generation - Ex. Grandmother and grandchild in an over close relationship with mother in a distant relationship. Grandmother regularly makes decisions about grandchild and mother is out of this process Problems occur with extremes in boundary structure: Too tight, too loose

Substance Abuse: Inhalants

Glue Cleaning fluid Spray paint Cigarette lighter fluid

St. John's Wort (Hypericum)

Herbal treatment. Preparation non-standard/ not regulated by FDA. Do not take with amphetamines, stimulants, other antidepressants due to potential for serotonin syndrome. May cause photosensitivity, GI upset, abdominal pain. Concerns: *Lack of regulation by FDA -Safety? Dosage? *Potential long term effects Important for nurse to ask client if using OTC meds or herbals!

Eating Disorder: Bulimia nervosa- Purging or Nonpurging type

Impulse disorder. Recurrent episodes of binge eating lg. amts. Lack of control over eating during episode. Self-eval. unduly influenced by body shape & wt. At or slightly above nl wt. Ego dystonic - doesn't confirm w/body image. Shame & guilt. Affective component. At risk for suicide. Recurrent inappropriate compensatory behavior to prevent wt. gain: *Self-induced vomiting *Laxatives *Diuretics, other meds, enemas *Excessive exercise Drugs: More effective with BN. Fluoxetine (Prozac) SSRIs & TCA may help with binge eating & vomiting short term.

Attention deficit hyperactivity disorder (ADHD)

Inappropriate degree of: Inattention, Hyperactivity, Impulsivity. Low tolerance for frustration. Temper outbursts. Interventions: *Behavior therapy - Only psychosocial TX found effective. Parent training included. *Special education programs *Pharmaceutical agents

Metabolic Syndrome

Inc. wt gain Inc. blood Glucose Inc. triglycerides

Tardive Dyskinesia (TD)

Involuntary movement. Does not remit in 50% of cases.

Post-traumatic Stress Disorder

Involvement/witness of event involved in actual or threat of death/serious injury Response of fear, helplessness, horror Intrusive re-experiencing event: Recurring distressing dreams of event, Acting/feeling trauma recurring, Intense psych distress r/t cues of trauma (trigger) Avoidance of situations r/t trauma & numbing of responsiveness. Characteristics: Hyper-arousal, Sleep problems, ↑ Anger, Hypervigilance, Exaggerated startle response. Sig. Usage of Substances SIG. DISTRESS OR IMPAIRMENT Prognosis: Chronicity

Persistent Depressive Disorder (Dysthymia)

Lasting for 2 years or more, atleast two of the following six symptoms are present: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness

Mood Stabilizers

Lithium Anticonvulsants: Depakote (valproate) Tegretol (carbamazepine) Lamictal (lamotrigine) Neurontin (gabapentin) Topamax (topiramate) Trileptal (Oxcarbazepine)

Substance Abuse: Hallucinogens

Lysergic acid diethylamide (LSD or acid) Mescaline (peyote) Psilocybin (magic mushroom) Phencyclidine piperidine (PCP, angel dust) Bath salts: Inhaled, injected, mixed with food or drink Ecstasy (3,4-methylenedioxymethamphetamine), also called MDMA, Molly

Medications for Bipolar Disorder

Maniac Phase *Anticonvulsants/Mood Stabilizers ex. Lithium (first line) Tegretol, Depakote, etc. *Antipsychotics *Anti-anxiety drugs ex. benzodiazepines Depressive Phase *Antidepressants

Lithium

Mood Stabilizers Naturally occurring salt. Unclear action-substitute for Na+ in neurons. Affects 5HT & Glutamate. Pharmacokinetics: excretion by kidneys. Usually first line. Effective long-term prevent recurrences of mania, bipolar depression. Treats acute mania. Best agent for treating risk of suicide in bipolar depression Low therapeutic index. Must monitor therapeutic levels (0.6 - 1.2 mEq/liter) Must monitor for Lithium toxicity. Must monitor for side effects. (Polyuria, polydipsia, edema, fine hand tremor, weight gain, mild nausea, vomiting, diarrhea, arrhythmias.) Long term issues: hypothyroidism, renal impairment Teratogenic, but Lithium is safest (after 1st trimester) of all mood stabilizers. 2 major long-term risks are hypothyroidism and renal impairment

Trileptal (Oxcarbazepine)

Mood Stabilizers - Anticonvulsants. Caution in renal & hepatic impairment, pregnancy, lactation, children & older adult.

Lamictal (lamotrigine)

Mood Stabilizers - Anticonvulsants. Life-threatening rash rare. Can be minimized with slow titration to therapeutic levels.

Substance Abuse: Opiates

Opium Heroin Morphine Demerol Codeine Oxycodone

Phobias

Persistent irrational fear of specific object, event, activity -> desire to AVOID Characteristics: *Most assoc. with panic *Fear recognized as unreasonable *Dx: Prob. Pervasive

Obsessive-Compulsive Disorder

Recurrent obsessions/ compulsions (cannot be dismissed by the mind) **time consuming **marked distress or **sig. impairment Purpose of obsession/compulsion Realizes excessive/unreasonable -> Prognosis: guarded

Alzheimer's Disease: Stages

Stage 1 (mild): forgetfulness -Short term memory loss -Aware of problem -Loss of energy, drive -Mood changes -Beginning probs. IPR's Stage 2 (moderate): confusion -↑↑ short term memory loss -↑Impairment in functioning -Mood changes -May confabulate -Needs assistance Stage 3 (moderate to severe): -Total care necessary, with negativism -Advanced apraxia -Severe Agnosia -Total care necessarycaregiver burden -↑↑Mood changes -↓ reality testing -Safety issues Stage 4 (late): end stage -No longer recognizes family, doesn't recognize self in mirror -Agraphia -Forgets how to swallow & chew -Inability to walk, talk -Incontinent -Stupor, coma -Death by infection or choking

Alcohol Withdrawal

Sx's assoc. with withdrawal develop within 24-48hrs. Physical and Neuro-behavioral: Ex. Illusions can occur

Diathesis-stress model

The diathesis-stress model describes how genetic or biological factors interact with environmental stress which results in a disorder or condition. Specifically, this theory purports that an individual's biological vulnerabilities, or predispositions, to particular psychological disorders can be triggered by stressful life events. If the individual is resilient or has low biological vulnerability for a particular disorder, it would take extremely high levels of stress to trigger symptoms of that disorder. On the other hand, if the individual has high biological vulnerability to the disorder, then it would take lower levels of stress for symptoms to be exhibited.

Toxic effects of Lithium

Therapeutic levels are 0.6 - 1.2 mEq/liter. Signs of Lithium Toxicity begin at levels 1.5 mEg/L. *Advanced signs of toxicity 1.5-2 mEq/L: Blurred vision, ataxia, persistent N/V/D. *Severe toxicity 2-3.5 mEq/L: Inc. tremors, inc. urine output, muscle irritability, psychomotor retardation, mental confusion, giddiness. *Greater than 3.5mEq/l: Impaired consciousness, nystagmus, seizures, coma, oliguria/anuria & MI, cardiovascular collapse -> death can occur.

Treatment for Alcohol Dependence

To help maintain abstinence: *Naltrexone (Re Via) - Major drug used in alcoholism treatment now - 1st line! Block craving for alcohol & pleasure derived from drinking. Does not produce dependence. *Campral (Acamprosate) - Helps client abstain from alcohol. Mechanism not well understood. *Disulfiram (Antabuse): Prevents relapse. NOT FIRST LINE. Action: inhibits major enzyme that metabolizes alcohol. If a person ingests ETOH will become ill.

Dystonia

acute contractions of tongue, face, neck, and back

Cardiovascular effects

hypotension and postural hypotension, tachycardia

Parkinsonism

mask-like facies, stiff/stooped posture, shuffling gait

Akathisia

motor driven restlessness i.e. tapping foot incessantly, shifting weight, rocking

Histamine blocking

sedation, wt gain