NR 547 Differential Dx Midterm

Hamilton Rating Scale HAM-A scoring Mild, moderate, severe

0 (not present) 4 (severe) Total score ranges from 0-56 <17: indicated mild severity 18-24: mild to moderate severity 25-30 moderate to severe

What 14 questions are on HAM-A?

1) Anxious mood 2) Tension 3) Fears 4) Insomnia 5) Intellectual 6) Depressed mood 7) somatic (muscular) 8) Somatic (sensory) 9) cardiovascular symptoms 10) Respiratory symptoms 11) gastrointestinal symptoms 12) Genitourinary symptoms 13) Autonomic symptoms 14) Behavior at interview

Performance-only SAD Tx for Recurring performances

1) CBT 2) Beta blocker or Benzodiazepine 30-60 min before performance

What are risk factors for developing anxiety?

1) family Hx 2) being female 3) recent life stressors 4) chronic physical illness 5) lack of support during childhood

A commonly used method is the "SNAPPS" method, which follows a mnemonic consisting of six steps. This method is often used for client presentations to preceptors. The six steps includ

1.Summarize the history and findings 2.Narrow the differential diagnosis to two or three possibilities 3.Analyze the differential by comparing and contrasting the possibilities 4.Probe the preceptor by asking questions about alternative approaches or uncertainties 5.Plan the management of the client's health issues 6.Select an issue from the case for self-directed learning

Social Determinants of Health (SDOH)

1: Discrimination, racism, social exclusion 2: Adverse early life experiences 3: Poor education 4: Unemployment, underemployment, job insecurity 5: Poverty 6: Neighborhood deprivation 7: Food insecurity 8: Poor housing quality and housing instability

Anxiolytic time to efficacy?

2-4 weeks

According to NIMH approximately ___% of US adults will experience GAD in the past year and approximately ____% of the US adults will experience GAD at some point in their lifetime

3, 6

Ella is a 17-year-old who presents to the clinic with her mother. Her mom reports that Ella will not go to the basement in their home, and she is concerned about the behavior. During the interview, Ella confirms that even thinking about going to the basement causes her extreme anxiety because she knows that there are spiders in the basement. She has had her phone taken away in the past because she will not go to the basement to gather her laundry, but she states, "I will take the punishment because it is better than being around those spiders." She states she has been afraid of spiders for as long as she can remember Which of the following is the most appropriate ICD-10-CM code for Ella? 40.2 Specific phobias 40.218 Specific phobia - animal F40.298 Other specified phobia F40.9 Phobia, phobic

40.218 Specific phobia - animal Rationale: Ella meets diagnostic criteria for F40.218 Specific Phobia: Animal.

Pt's with GAD show persistent, uncontrollable worrying that causes emotional distress and show symptoms on most days for a period of how long?

6 months

In the past year SAD has impacted approximately ____% of adults and _____% of adolescents

7, 9

Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. A) Begin Treatment B) Refer

A) Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated.

Leo is a 49-year-old who presents with fatigue. His hemoglobin is 15 g/dL and hematocrit is 42%. A) Begin Treatment B) Refer

A) Begin treatment. Rationale: The hemoglobin and hematocrit are within normal limits. This client's complaint of fatigue is not due to anemia. Begin treatment based on a complete evaluation.

Harold is a 32-year-old who presents to the clinic with complaints of fatigue, difficulty concentrating, and difficulty falling asleep at night. He states he worries about finances, his performance at work, and his relationship, and his worries have been "almost constant" for 8 months. He denies substance use and recently had a normal physical exam. He feels that his relationship is suffering due to his constant worry. Based on the DSM-5-TR, does Harold meet diagnostic criteria for generalized anxiety disorder? A) Yes B) No

A) Yes Rationale: Harold meets the following diagnostic criteria for generalized anxiety disorder: He has three symptoms associated with worry, including fatigue, difficulty concentrating, and sleep difficulties. He has experienced anxiety more days than not for over 6 months, and his worries are impacting his relationship.

Sigourney is a 47-year-old who presents to the clinic with complaints of anxiety. She states that certain situations seem to trigger her anxiety, including using the subway, attending concerts and movies, and going to the corner bodega. She states that these types of situations make her fear that she will be trapped in the event of an emergency. To cope, she has been walking rather than using public transportation and using an online ordering app for grocery delivery. She has not been to a concert or movie theater in years and feels that she has lost some friends because of her reluctance to attend. Based on the DSM-5-TR, does Sigourney meet diagnostic criteria for agoraphobia? A) Yes B) No

A) Yes Rationale: Sigourney meets the following diagnostic criteria for agoraphobia: she has marked anxiety about using public transportation and being in enclosed spaces and crowds. She fears a situation because she worries about her ability to escape. She has changed her behaviors to avoid situations that cause her anxiety, and she has caused social impairment in her life.

Callie is an 18-year-old college student who reports to the healthcare provider that she feels anxious "about everything." Her restlessness and irritability have impacted her relationship with her significant other. She reports no significant past medical or mental health history. She states that her anxiety started about 8 months ago when she decided to transfer from her local community college to a large state university to pursue a law degree. During the law program's orientation attended by 300 students, she learned that only 100 students would be selected out of 300 applications for the fall admission. She began feeling inferior that she would not be one of the students accepted. She also started thinking about "plan B," assuming that her grades are not "good enough" to get her selected for the program. She told the PMHNP that she was preparing for the rejection because she does not measure-up to the other applicants since none of her other family members had ever been to college and she would be better off going back to the community college. Callie decided to leave the orientation to choose another major other than law. Which is the most appropriate anxiety disorder diagnosis for Callie? A) generalized anxiety disorder B) panic attack​ C) panic disorder​ D) social anxiety​

A) generalized anxiety disorder Rationale: Callie has persistent symptoms of anxiety accompanied by restlessness and irritability. The thoughts are unrealistic since she has pre-determined that she is not good enough for the law program without evidence to support that feeling. She also compares herself to strangers where she automatically assumes that they are better prepared for the program than she is. She decides not to apply to the law program based on these unsubstantiated thoughts.

Which of the following should be included when providing client education about medication regimens? Select all that apply.

A)Explain how the medication targets the symptoms, specific benefits, and expected time course. (Correct answer) B)Identify potential side effects, duration of side effects, and adverse effects. (Correct answer) C)Explain the instructions, dosing, and special requirements. (Correct answer) D)Use teach-back methods to ensure client understanding. (Correct answer)

Which of the following medications or substances commonly cause symptoms that mimic anxiety? A)bupropion B)nasal decongestants C)metoprolol D)levothyroxine E)Insulin F)albuterol G)cocaine H)alcohol I)caffeine J)morphine

A)bupropion (Correct answer) B)nasal decongestants (Correct answer) C)metoprolol (Correct answer) D)levothyroxine (Correct answer) F)albuterol (Correct answer) G) cocaine (Correct answer) H)alcohol (Correct answer) I)caffeine (Correct answer) Rationale: Medications with side effects mimicking anxiety disorder include nasal decongestants, antidepressant medications, synthetic thyroid hormones, beta-adrenergic agonists, and hormones such as androgens and estrogens. Substances with effects that may mimic anxiety include cocaine, ecstasy, marijuana, psychoactive compounds, and caffeine.

Coping mechanism for agoraphobia

Although some clients with agoraphobia are completely homebound, many clients cope by actively avoiding situations that create anxiety; for instance, a person who fears public transportation may choose to live within walking distance to employment and shopping. Clients may be able to function better when a support person comes with them

Pt's with anxiety often show increase activity in where?

Amygdala and prefrontal cortex

Increased brain activity in prefrontal cortex is a sign of?

Anxiety

What is the most common mental illness in the US? And what percentage does it affect adult and children?

Anxiety disorders are the most common mental illness in the United States. Anxiety impacts approximately 18% of the adult population and 25% of children ages 13-17 each year (Anxiety & Depression Association of America [ADAA], n.d.). People who experience anxiety have a higher incidence of work and school absenteeism and higher use of medical resources, such as emergency department and provider visits than the general population

Fabrizia is a 27-year-old graphic designer who presents to the clinic two months after an emergency department visit for complaints of chest pain, palpitations, nausea, and dizziness. Her electrocardiogram (ECG) and cardiac enzyme panels showed no abnormalities. She states that the symptoms began while she was watching a movie with her boyfriend and lasted about 15 minutes. She has never experienced anything like this in the past, but since the episode, she has worried occasionally about the symptoms recurring, as her father died of a heart attack at age 45. Based on the DSM-5-TR, does Fabrizia meet diagnostic criteria for panic disorder? A) Yes B) No

B) No Rationale: Fabrizia meets diagnostic criteria for a panic attack, but not for panic disorder. During her panic attack, she reported having four cardinal symptoms associated with a panic attack. She has only had one panic attack, and although she has expressed worry about symptoms recurring, it is not persistent concern or worry.

Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L. A) Begin Treatment B) Refer

B) Refer Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH levels are within normal limits.

Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. A) Begin Treatment B) Refer

B) Refer Rationale: Clients with hyperthyroidism have elevated T3 levels. Hyperthyroidism is associated with anxiety symptoms. Client can be reevaluated for anxiety once hyperthyroid treatment has been initiated and T3 levels are within normal limits.

Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is 32 A) Begin Treatment B) Refer

B) Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion.

Julio is a 66-year-old who presents with depression. His vitamin D level 11 ng/mL. A) Begin Treatment B) Refer

B) Refer Rationale: Vitamin D deficiency is associated with depressive symptoms. The PMHNP may refer or treat vitamin D deficiency depending on the level of comfort of the provider.

Apply the Ask Suicide-Screening Questions (ASQ) Suicide Risk Screening Tool (Links to an external site.) to the scenario below. A 52-year-old client presents to the emergency department following a car accident. The emergency department (ED) physician is concerned that the client may have intentionally crashed her car and requests a stat PMHNP consult. In speaking with the PMHNP, the client describes persistent feelings of sadness and hopelessness. She states that she often wonders if her husband would be happier if she wasn't around anymore since she's never happy and sometimes thinks about what it would be like to just take a handful of sleeping pills and go to sleep forever. The client reports a previous suicide attempt when she was 16 but denies that she is considering killing herself right now. Based on the client's ASQ score, what is the most appropriate response? A) No action is necessary as the client is not currently considering suicide. B)Provide a brief suicide safety assessment. C)Alert the client's primary care physician. D)Provide a STAT safety and full mental health evaluation.

B)Provide a brief suicide safety assessment. Rationale: While the client's responses do not indicate a need for a stat full safety and mental health evaluation, the client requires a brief suicide safety assessment to determine whether a full mental health evaluation in necessary. It is also important to notify the client's physician or the clinician responsible for the client's care.

Terri is a 79-year old who presents with confusion. She has positive urine leukocyte esterase. A) Begin treatment B) Refer

B)Refer Rationale: A positive Urine Leukocyte Esterase indicates the presence of a urinary tract infection (UTI) , which may cause confusion. Refer this client for treatment of the UTI.

Which of the following medical conditions is likely to present with symptoms that mimic anxiety? A) hypothyroidism B)hyperthyroidism (C C)dysrhythmias (Correct answer) D) irritable bowel syndrome (Correct answer) E) anemia F) diabetes type 2 G)migraine headache (Correct answer) H) Covid-19 I) rheumatoid arthritis (Correct answer) J) menopause (Correct answer)

B)hyperthyroidism C)dysrhythmias D) irritable bowel syndrome G)migraine headache I) rheumatoid arthritis J) menopause Rationale: Medical conditions that commonly present with symptoms that mimic anxiety include endocrine disorders including hyperthyroidism and adrenal dysfunction cardiac disorders including angina and dysrhythmias, GI conditions including irritable bowel syndrome and GERD, inflammatory conditions including lupus and rheumatoid arthritis, neurological disorders including migraine headaches and seizures, and respiratory conditions including asthma and COPD. Changes in the menstrual cycle, including PMS and menopause, may also cause symptoms that mimic anxiety.

Performance- only SAD Tx for one or rarely recurring performance?

Beta blocker or Benzodiazepine 30-60 min before performance

Anxiolytic agents?

Buspirone

Complete the case study below by utilizing the HAM-A scale. Rashard, a 54-year-old, presents for a walk-in visit with the PMHNP due to increased anxiety and requests an early refill of his clonazepam. He reports his brother died a week ago and he is very anxious. He has taken all the clonazepam #20 tabs that the PMHNP refilled 3 weeks earlier. The client understands that his benzodiazepine is to be used as needed and only for severe anxiety, but he said he used it all because he "just couldn't cope." He reveals that he was hospitalized after the death of his father 7 years ago and does not want that to happen again; he wants to avoid the hospital. Upon assessment, the client has difficulty sitting still, his leg is swinging continuously, and he taps his fingers; he is constantly shifting in his chair. His anxiety symptoms include feeling short of breath, heart racing, and some chest pain, "jumping out of his skin" at sudden noises, and feeling like something terrible will happen. He works from home and is having great difficulty completing tasks. He is having difficulty with his memory. He lives on a farm and must take care of the sheep and goats every day. He enjoys being outside with the animals. He says the baby goats playing makes him smile, but nothing else brings him joy. He has no appetite and has difficulty both falling and staying asleep. The client wakes up feeling anxious, and the feeling lasts all day. He states he only experiences relief when he takes clonazepam. Based on the HAM-A, what is Rashard's current level of anxiety? A) mild anxiety B) mild to moderate anxiety C)moderate to severe anxiety D)severe anxiety

C) moderate to severe anxiety Rationale: The HAM-A is a clinician-rated anxiety screening tool. Based on Rashard's interview and examination, his positive findings score as follows: Anxious mood - 4 (daily worry, fearful anticipation) Tension- 4 (startle, tense, trembling daily) Fears- 3 (daily fear something will happen) Insomnia- 3 (nightly sleep issues) Intellectual- 2 (poor memory) Depressed mood- 3 (daily loss of interest, lack of pleasure) Cardiovascular symptoms- 3 (tachycardia, chest pain) Respiratory symptoms- 2 (pressure or constriction in chest, dyspnea) Behavior at interview- 3 (fidgeting, restlessness, or pacing) Rashard's total HAM-A screening score is 28, indicating moderate to severe anxiety.

Jeremy is a 44-year-old male who works as a department head for a local grocery store chain that is down-sizing due to economic reasons. Top level management has announced that there will be restructuring of the company where many of the employees are no longer deemed essential. Because of the automatic self-check-out systems, there is no longer the need to employ as many cashiers as possible. Jeremy has been given the task of notifying his employees of this major change in staffing. He plans to share these decisions at next week's staff meeting. From the moment Jeremy received this directive, he started to feel fearful of the possibility of announcing the decision to downsize as well as deciding on who would be eliminated. On the day of the staff meeting, his employees were present. As he started the staff meeting, he began to feel nausea. He even noticed his heart pounding. When he was questioned by an employee on how it would be decided who would be "let go" he experienced even more intense nausea accompanied by heart pounding and the inability to formulate an organized answer to the question. He quickly excused himself from the room in order to pull himself together and to organize his thoughts. ​Which is the most appropriate anxiety disorder diagnosis for Jeremy? A) generalized anxiety disorder B) panic disorder C) panic attack D) social anxiety

C) panic attack Rationale: Jeremy's anxiety is associated with a stressful situation (delivering the bad news) and a fear that something bad will happen (staff's reaction to the announcement). He experiences physical symptoms of heart pounding, nausea, dizziness, and inability to formulate an organized answer to the question. The setting is also in a familiar place among colleagues where no real threat exists.

Normal CMP levels Misc. Calcium, serum (Ca 2+) Glucose, serum Fasting: 2-h postprandial: Cholesterol, serum: Total Protein Albumin

Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl Cholesterol, serum: REC<200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl

Kidney Tests Creatinine, serum Urea nitrogen, serum (BUN)

Creatinine, serum 0.6-1.2mg/dl Urea nitrogen, serum (BUN) 7-18mg/dl

Sari is a 34-year-old female who is engaged to be married in one month. This will be her second marriage. She has been divorced for three years. Her fiancé, who is also divorced, has arranged for Sari to meet his three teenagers. Sari learns through a mutual friend of hers and the fiancé, that his teenagers, although hesitant, are willing to meet her. On the day of the arranged meeting, Sari is asked to arrive to the restaurant to meet the teens prior to the fiancé's arrival because he has been held up at a meeting. Sari agrees but starts to feel uneasy about it. She is concerned that they will not accept her because of her previous divorce and the fact that she is not their mother although they were willing to meet her. The closer she got to the restaurant, the more uneasy she felt to the point of disorientation. Just before entering the restaurant, she turned around and called her fiancé to inform him that her car broke down and she would be very delayed in arriving to the restaurant. The fiancé arranges to leave his meeting early to meet the teens. ​ Which is the most appropriate anxiety disorder diagnosis for Sari? A) generalized anxiety disorder B) panic disorder C) panic attack D) social anxiety

D) Social Anxiety Rationale: Sari feels like she will be judged by the teens because she is not their mother. She avoids the situation by creating an excuse for not meeting them at the restaurant. The feelings are unwarranted since the teens agreed to meet with Sari.

Anxiety is usually comorbid with?

Depression, COPD, asthma, and diabetes

Differential Dx

Diagnostic reasoning is the process of questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are drawn are based on evidence. This is a critical step for providers who are trying to uncover a cause, or diagnosis, for their clients' signs and symptoms. The provider's initial hypothesis is known as the differential diagnosis. The differential diagnosis, or differential, is a working list of potential problems that can be associated with the initial or chief complaint. Establishing a differential diagnosis is a critical step in providing safe, quality care. This evolving process of clinical reasoning and decision making involves examining the client's presentation, clinical data, and when appropriate, screening and diagnostic test results to distinguish one disease from another and arrive at the correct diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)provides guidance for identifying psychiatric diagnosest

Medical History/Screening for General Medical Conditions

Do you have a primary care provider? Do you have any medical illnesses? Are you currently taking any medications or herbal supplements? Do you have any allergies to medications? Have you ever been hospitalized for any reason? Have you ever had surgery?

What may individuals with SAD resort to?

Drugs or alcohol to reduce social inhibitions

Adjustment Disorder with Anxiety examples

Examples of common stressors include loss of employment, getting married, a new disability, or a natural disaster.

Panic disorder Tx plan

Exposure therapy Cognitive behavioral therapy Medications Combination of modalities Treatment may include exposure therapy, cognitive behavioral therapy, medications, or a combination of modalities. SSRIs are a safe, economical pharmacologic treatment for panic disorder. ​Benzodiazepines may be used in emergencies

First line of Tx for Obsessive compulsive disorder

Fluoxetine Fluvoxamine Sertraline Paroxetine Clomipramine (TCA) Drug therapy for at least 1 year

Functional neuroimaging studies of GAD show?

Functional neuroimaging studies of GAD show increased activation of the amygdala and reduced activation in the prefrontal cortex, indicating heightened activation of the fear response with diminished capacity for reasoning

Greta who is clingy to her mom when meeting adults but does not have anxiety in peer setting. Would this meet DSM-5 criteria?

Greta displays anxiety when meeting adults in a social situation. Her anxiety is expressed as clinging to her mother and not speaking. The anxiety has been present for several years; however, Greta does not have anxiety in peer settings. Therefore, she does not meet DSM-5 criteria for social anxiety disorder

Risk Factors for SAD

HX of abuse or Neglect Close relative with SAD

Family Psychiatric History

Has any relative of yours ever been hospitalized for a mental health issue? Has any blood relative of yours ever been diagnosed with a mental health issue? Has any blood relative of yours had a history of seizures or dementia/Alzheimer's?

The Psychiatric History

Have you ever been hospitalized for any mental health issues? Have you ever had counseling or psychotherapy? Have you ever taken medications for your mental health in the past? Are you currently on any medications for mental health or sleep?

Holistic Care: Culture, Values, and Health Beliefs

Holistic approaches to mental health care consider all aspects of the individual, not just the symptoms and diagnosis. A holistic approach not only addresses psychiatric and medical considerations, it recognizes that social, spiritual, lifestyle, and behavioral elements also impact mental health. Psychiatric symptoms may be secondary to environmental factors or life events. Clients' culture, values, and health beliefs may affect how mental health diagnoses are manifest or described and may impact treatment choices. Healing and rehabilitation are most likely to occur when providers address client needs holistically and involve clients in treatment planning.

History of Present Illness

How long have you been feeling this way? Did something happen in your life that may have triggered these emotions? How is this current situation impacting your life?

Benzodiazepines time to efficacy?

Immediate

Thyroid Function Tests

In psychiatric diagnosing, TFTs are used to rule out thyroid disorders as a cause for symptoms. Common symptoms related to thyroid disorders include anxiety, restlessness, depression, mood swings, sleeping difficulties, difficulties with concentration, short-term memory lapses, and lack of mental alertness.

What is Silexan?

Is a branded extract of lavender. OTC in the US. Similar to CAM therapies

What is Exposure and response prevention (ERP)

Is a specific CBT for clients with OCD. Provides exposure to obsessive thoughts and learned behaviors to choose not to complete a compulsive behavior

Liver Tests Alanine aminotransferase (ALT), serum: Aspartate aminotransferase (AST), Bilirubin, serum (adult) Total//Direct: Phosphatase (alkaline), serum:

Liver Tests Alanine aminotransferase (ALT), serum: 8-20 U/L Aspartate aminotransferase (AST), serum: 8-20 U/L Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl Phosphatase (alkaline), serum: 20-70 U/L

SAD causes distress in what kind of social situations?

Making small talk with other Meeting new people Performing in front of other (called performance anxiety)

Normal CMP Levels Electrolytes Sodium (Na+): Postassium (K+): Chloride (Cl-): Bicarbonate (HCO3-):

Normal CMP Levels Electrolytes Sodium (Na+): 136-145 mEq/L Postassium (K+): 3.5-5.0 mEq/L Chloride (Cl-): 95-105 mEq/L Bicarbonate (HCO3-): 22-28 mEq/L

Normal TFT levels TSH: T3: T4:

Normal TFT levels TSH: 0.4-4.5 mIU/L T3: 100-200 ng/dL T4: 5-11 ug/dL

SAD treatment plan?

Not all clients with social anxiety disorder (SAD) require treatment. Young adults may experience benefits from learning about their disorder and reflecting on how the disorder impacts their personal life to make an educated decision about treatment options. Many clients diagnosed with SAD have experienced symptoms for years and have learned to navigate the symptoms at a functional level. Treatment for SAD is rarely an emergent situation. Treatment includes cognitive behavioral therapy, medications, or a combination of both.

Obsessions vs compulsions

Obsessions: (intrusive or unwanted thoughts) "Did I forget to turn the stove off?" Fear of germs Continued thoughts of harming another person Compulsions: (repetitive behaviors in response of intrusive thoughts) Checking the lock on the door multiple times Taking several hours to eat a meal Counting Repetitive prayers

Benzodiazepines Pros vs Cons

PROS highly effective rapid onset can be used PRN CONS multiple adverse effects fall risk risk of misuse

SSRIs/SNRIs Pros vs Cons

PROS: Highly effective CONS: ↑ drug interactions risk of hyponatremia

Anxiolytic Pros vs Cons

PROS: ↓ adverse effects ↓ drug interactions CONS limited effectiveness

Physical symptoms of a panic attack include?

Palpitations, pounding heart, or accelerated heart rate Trembling or shaking Paresthesias (numbness or tingling sensations) Sensation of shortness of breath or smothering Derealization (feelings of unreality) or depersonalization (feeling detached from oneself) Feeling of choking Feeling of chest pain or discomfort Nausea or abdominal stress Feeling dizzy, unsteady, light-headed or faint Chills or heat sensations

First line of Tx for Post-traumatic stress disorder

Paroxetine Sertraline

First line of Tx for Panic Disorder?

Paroxetine Sertraline Fluoxetine Drug therapy 6-9 months

How is GAD characterized by?

Persistent, uncontrollable worry about ordinary everyday situations

OCD Tx options?

Pharmacotherapy, psychotherapy or combo Typical night dose of SSRI - common dosage fluoxetine 80mg

Vitamin B12 Level

Providers may choose to check vitamin B12 levels. Deficiency of vitamin B12 can affect mood and other brain functions. Common psychiatric symptoms associated with B12 deficiency include depression, mania, psychotic symptoms, and cognitive impairment ( A normal vitamin B12 level is between 190-950 picograms/mL. Between 200-300/mL indicates a borderline level with a possible need for additional testing.

What is the Tx of GAD ?

Pyschotherapy, medication, or both

Normal Range of: Red blood cells Hemoglobin Hematocrit Reticulocytes

Red blood cells: 4.5-6.0 million/microliter Hemoglobin: 12-18 grams/100 mL Hematocrit: 38%-48% Reticulocytes: 0%-1.5%

Positron emission tomography (PET) scans show reduced what in pt's with anxiety?

Reduced serotonin binding

What anxiety can become so severe that derealization, or a feeling of "spacing out"?

SAD

First line of Tx for Generalized anxiety disorder?

SSRIs SNRIs Buspirone Drug Therapy at least 12 months

SAD medication treatment options?

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) SAD is usually treated using anti-depressants. Benzodiazepines These psychoactive drugs are known for inducing calm. Monoamine oxidase inhibitors (MAOIs) This class of drugs are for clients who are able to undergo dietary and medication restrictions. SSRIs or SNRIs must be completely flushed from the system first.

What is the most widely studied and efficacious form of Tx of GAD?

Serotonergic antidepressants in combinations with CBT

First line of Tx for Social anxiety disorder

Sertraline Paroxetine Drug therapy takes 4 weeks to see effects

If symptoms are severe of GAD what is the line of Tx?

Short course of a benzodiazepine at the beginning of treatment may be indicated

Non pharmacologic Treatment of GAD

Some clients may consider complementary and alternative treatments. Treatments may include physical, cognitive, and spiritual activities aimed at decreasing anxiety. High-intensity aerobic exercise is a good complement to first-line therapy for GAD. Mindfulness-based stress reduction activities, such as meditation and yoga, have shown a reduction in symptoms of GAD Relaxation or meditation Art of music therapy Yoga or other exercise Acupuncture Prayer or spiritual counselling

When does Adjustment Disorder with anxiety usually appear?

Symptoms begin within three months of the stressor and typically last no more than six months.

Social and Developmental History

Tell me a little bit about your childhood and how you grew up. How was your experience in school when you were younger? Did you enjoy school? How do you support yourself with your finances? Do you have a good support system? Are you currently in a relationship? Where do you live? Who do you live with? What do you do in your free time? What activities do you enjoy?

Complete Blood Count

The CBC is a serum diagnostic test that measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. The CBC includes a differential of the white blood cells. ​A CBC is often included as part of routine health screening or to obtain information related to specific conditions. In mental health, the CBC is used to rule out medical conditions that may present with symptoms that can be attributed to both medical and psychiatric diagnoses. For example, the CBC can help rule out anemia as a cause for depressive symptoms and fatigue or rule out infection as a cause of acute mental status changes. The CBC is also used to monitor certain treatment regimens. For example, some medications, such as clozapine, require routine analysis of absolute neutrophil count and platelet levels.

Comprehensive Metabolic Panel (CMP)

The CMP is another common blood test used to determine general health status. The CMP includes several tests that provide information about fluid and electrolyte balance as well as the status of the body's metabolism, liver function, and kidney function. In psychiatric care, the CMP may be used to rule out medical conditions that could cause symptoms such as changes in mood or cognition. The CMP is also used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels.

Adjustment Disorder with Anxiety

The DSM-5 classifies adjustment disorder as a trauma- and stressor-related disorder; however, symptoms of adjustment disorder with anxiety are similar to those found in anxiety disorders. Adjustment disorder with anxiety presents with nervousness, worry, or jitteriness. Adjustment disorder occurs in the presence of a specific and identifiable stressor. The distress experienced is out of proportion to the severity of the stressor.

SSRIs/ SNRIs time to efficacy?

Up to 6 months

Urinalysis (UA)

Urinary tract infections are associated with a variety of neuropsychiatric symptoms (Lee et al., 2019). When clients present with acute mental status changes, a urinalysis may be used to rule out a urinary tract infection as the cause.

Vitamin D Level

Vitamin D affects functions such as neurotransmission, neuroprotection, and neuroimmunomodulation. Studies have indicated a high prevalence of vitamin D deficiency in clients with psychiatric disorders such as schizophrenia, depression, seasonal affective disorder, and cognitive impairment (Cuomo et al., 2019). Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis, and poor brain development. A vitamin D level can be measured via the 25-hydroxy vitamin D blood test. A normal level is between 20-50 ng/mL. A level less than 12 ng/mL indicates a deficiency.

Toxicology Screen

When diagnosing psychiatric conditions, providers may use toxicology screenings to rule out substance use as a cause for symptoms. Toxicology screenings are also used before starting therapy involving controlled substances, to monitor medication adherence, and in the diagnosis of substance use disorder.

Social Anxiety Disorder

While it is common to feel nervous in some social situations, social anxiety disorder (also called social phobia) is a condition in which typical, everyday social interactions cause significant anxiety, self-consciousness, fear of embarrassment, or a feeling of being judged negatively by others.

Normal Range of? White blood cells (total): Neutrophils: Eosinophils: Basophils: Lymphocytes: Monocytes: Platelets:

White blood cells (total): 5000-10,000/microliter Neutrophils: 55%-70% Eosinophils: 1%-3% Basophils: 0.5%-1% Lymphocytes: 20%-35% Monocytes: 3%-8% Platelets: 150,000-300,000/microliter

GAD is twice as common in ___________ than in __________

Women, men

Benzodiazepines Agents

alprazolam (Xanax) clonazepam (Klonopin)

DSM-5 defines SAD

as an individual's fear of acting in a way that might cause judgment by others Anxiety leads to avoidance of social situations which disrupts an individual's relationships and daily routines. The anxiety is persistent, lasting greater than six months. ​

SSRIs/ SNRIs Agents

escilatopram (Lexapro) paroxetine (Paxil) duloxetine (Cymbalta)

Agoraphobia

involves intense fear, anxiety, or panic out of proportion to the situation that occurs in two or more of the following specific scenarios: public transportation (bus) open spaces (parking lot or bridge) enclosed spaces (store, theater) standing in a crowd or line (crowd) being outside of their home

Panic attacks

is a brief episode of acute anxiety during which an individual develops an intense fear of negative outcomes accompanied by a feeling of imminent danger. Panic attacks can be unpredictable, often occurring in familiar places where there are no apparent threats. The feelings are often accompanied by physiological symptoms. While symptoms typically peak within ten to twenty minutes, some may last for hours

Panic disorder

occurs when a person experiences repeated panic attacks, usually accompanied by fears about future attacks. Anxiety about future attacks may lead to behavioral changes to avoid situations that might trigger attacks

Phobia

phobia is an intense fear of a specific situation or object. The fear associated with a phobia is not in proportion to the actual danger associated with the situation or object. The prevalence of specific phobias is approximately 8%. Specific phobias often occur after experiencing or witnessing a traumatic event and typically develop in childhood. Clients who have specific phobias often fear more than one object or situation. Each specific phobia is diagnosed separately

GAD often presents with physical symptoms, including:

restlessness or edginess fatigue difficulty concentrating irritability muscle tension sleep disturbance