NR547 Midterm Exam Study Guide 2024

differential diagnosis - The provider's initial hypothesis -a working list of potential problems that can be associated with the initial or chief complaint -Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) • provides guidance for identifying psychiatric diagnoses Psychiatric assessment: History taking – -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? 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? 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? 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? 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? Screening and Psychiatric Rating Scales - Evidence-based screening tools and psychiatric rating scales -can help the provider identify symptoms and assess their severity and can assist with the evaluation of response to treatment 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? No action is necessary as the client is not currently considering suicide. Provide a brief suicide safety assessment. Alert the client's primary care physician. Provide a STAT safety and full mental health evaluation. - 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. Diagnostic Testing when diagnosing mental health disorders - -Diagnostic tests and labs are most used to rule out physical conditions that may cause psychiatric symptoms and to evaluate the effects of treatment Basic Laboratory Interpretation - Complete Blood Count Comprehensive Metabolic Panel (CMP) Thyroid Function Tests Vitamin B12 Level Vitamin D Level Toxicology Screen Urinalysis (UA) Basic Laboratory Interpretation: Complete Blood Count - -measures RBCs, WBCs, hemoglobin, hematocrit, and platelets -includes a differential of the WBCs -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 • Ex: rule out anemia as a cause for depressive symptoms and fatigue • Ex: rule out infection as a cause of acute mental status changes RBCs: 4.5-6.0 million/microliter Hemoglobin: 12-18 grams/100 mL Hematocrit: 38%-48% Reticulocytes: 0%-1.5% WBCs (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 Basic Laboratory Interpretation: Comprehensive Metabolic Panel (CMP) - common blood test used to determine general health status -fluid and electrolyte balance, status of the body's metabolism, liver function, and kidney function -used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels -rule out medical conditions that could cause symptoms • Ex: changes in mood or cognition 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 Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: 120mg/dl Cholesterol, serum: REC200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl -Kidney Tests • Creatinine, serum 0.6-1.2mg/dl • Urea nitrogen, serum (BUN) 7-18mg/dl -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 Basic Laboratory Interpretation: Thyroid Function Tests (TFTs) - used to rule out thyroid disorders as a cause for symptoms • 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 Normal TFT levels TSH: 0.4-4.5 mIU/L T3: 100-200 ng/dL T4: 5-11 ug/dL Basic Laboratory Interpretation: Vitamin B12 Level - Deficiency of vitamin B12 can affect mood and other brain functions -psychiatric symptoms associated with B12 deficiency include depression, mania, psychotic symptoms, and cognitive impairment normal: 190-950 picograms/mL • 200-300/mL indicates a borderline level with a possible need for additional testing Basic Laboratory Interpretation: Vitamin D Level - affects functions such as neurotransmission, neuroprotection, & neuroimmunomodulation -high prevalence of vitamin D deficiency in clients with psychiatric disorders such as schizophrenia, depression, seasonal affective disorder, and cognitive impairment -Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis, and poor brain development 25-hydroxy vitamin D blood test: normal 20-50 ng/mL, less than 12 ng/mL indicates a deficiency Basic Laboratory Interpretation: Toxicology Screen - -rule out substance use as a cause for symptoms -used before starting therapy involving controlled substances -used to monitor medication adherence -used in the diagnosis of substance use disorder Basic Laboratory Interpretation: Urinalysis (UA) - Urinary tract infections are associated with a variety of neuropsychiatric symptoms -acute mental status changes • UA may be used to rule out a UTI as the cause. Treat or Refer: Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L. - 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. Treat or Refer: Leo is a 49-year-old who presents with fatigue. His hemoglobin is 15 g/dL and hematocrit is 42%. - 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. Treat or Refer: Terri is a 79-year old who presents with confusion. She has positive urine leukocyte esterase. - 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. Treat or Refer: Julio is a 66-year-old who presents with depression. His vitamin D level 11 ng/mL. - 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. Treat or Refer: Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. - 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. Treat or Refer: Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. - Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated. Treat or Refer: Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is 32. - Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Symptom-Directed Treatment - Psychiatric medication is generally prescribed in a transdiagnostic manner in which symptoms rather than diagnoses guide clinical practice Social Determinants of Health (SDOH) - the conditions in which individuals are "born, grow, live, work, and age" that contribute to the development of both physical and psychiatric pathology over the course of one's life" SDOH: social and structural factors that impact mental health - • Discrimination, racism, social exclusion • Adverse early life experiences • Poor education • Unemployment, underemployment, job insecurity • Poverty • Neighborhood deprivation • Food insecurity • Poor housing quality and housing instability Legal and Ethical Considerations - Protecting the privacy and confidentiality of client records is a legal obligation and may help reassure the client The SNAPPS Method - Summarize the history and findings Narrow the differential dx to 2-3 possibilities Analyze the differential by comparing & contrasting the possibilities Probe the preceptor by asking questions about alternative approaches or uncertainties Plan the management of the client's health issues Select an issue from the case for self-directed learning Prioritizing Client Complaints and Questions - Use client-centered communication techniques -Strategies • Acknowledge the client's list of questions and concerns and review the list with the client with a statement such as, "I see you have a list of concerns; let's look at it together." • Mutually negotiate what to cover during the visit, use of positive language • Be honest about the time allotted for the visit while planning jointly how to use that time • Plan for follow-up, Set a mutual agenda and time frame for the next visit, Review which issues have been addressed, and which ones will be addressed at the next visit. Document this plan as a reminder for the next visit Parts of the Initial Psychiatric Interview - Identifying data Source and reliability Chief complaint Present illness Past psychiatric history Substance use/abuse Past medical history Family history Developmental and social history Review of systems Mental status examination Physical examination Formulation DSM-5 diagnoses Treatment plan Psychiatric Review of Systems - Mood -Depression: Sadness, tearfulness, sleep, appetite, energy, concentration, sexual function, guilt, psychomotor agitation or slowing, interest. A common pneumonic used to remember the symptoms of major depression is SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidality). -Mania: Impulsivity, grandiosity, recklessness, excessive energy, decreased need for sleep, increased spending beyond means, talkativeness, racing thoughts, hypersexuality. -Mixed/Other: Irritability, liability. Anxiety -Generalized anxiety symptoms: Where, when, who, how long, how frequent. -Panic disorder symptoms: How long until peak, somatic symptoms including racing heart, sweating, shortness of breath, trouble swallowing, sense of doom, fear of recurrence, agoraphobia. -Obsessive-compulsive symptoms: Checking, cleaning, organizing, rituals, hang- ups, obsessive thinking, counting, rational vs. irrational beliefs. -Posttraumatic stress disorder: Nightmares, flashbacks, startle response, avoidance. -Social anxiety symptoms -Simple phobias, for example, heights, planes, spiders, etc. Psychosis -Hallucinations: Auditory, visual, olfactory, tactile. -Paranoia. -Delusions: TV, radio, thought broadcasting, mind control, referential thinking. -Patient's perception: Spiritual or cultural context of symptoms, reality testing. Other -Attention-deficit/hyperactivity disorder symptoms. -Eating disorder symptoms: Binging, purging, excessive exercising process of DSM-5 differential diagnosis - 1) ruling out Malingering and Factitious Disorder 2) ruling out a substance etiology 3) ruling out an etiological medical condition 4) determining the specific primary disorder(s) 5) differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions 6) establishing the boundary with no mental disorder most common mental illness in the United States - Anxiety disorders -Anxiety impacts approximately 18% of the adult population and 25% of children ages 13-17 each year Obsessive-compulsive disorder (OCD) - characterized by persistent, uncontrollable thoughts or actions that occur over an hour or more per day -one of the top 20 illness-related disabilities worldwide first line medication treatment: Generalized anxiety disorder - -SSRIs -SNRIs -Buspirone -Drug Therapy at least 12 months first line medication treatment: Panic disorder - -Paroxetine -Sertraline -Fluoxetine -Drug therapy 6-9 months first line medication treatment: Obsessive compulsive disorder - -Fluoxetine -Fluvoxamine -Sertraline -Paroxetine -Clomipramine (TCA) -Drug therapy for at least 1 year first line medication treatment: Social anxiety disorder - -Sertraline -Paroxetine -Drug therapy takes 4 weeks to see effects first line medication treatment: Post-traumatic stress disorder - -Paroxetine -Sertraline Positron emission tomography (PET) scans have shown reduced in patients with anxiety - serotonin binding COPD, asthma, diabetes Generalized anxiety disorder (anxiety) - neurological condition -characterized by persistent, uncontrollable worrying that causes emotional distress -show symptoms on most days, for a period of at least six months -common symptoms of anxiety include restlessness, irritability, muscle tension, fatigue, and sleep disturbances -GAD is twice as common in women as in men Patients with anxiety disorders often show increased activity in the and - amygdala and prefrontal cortex Risk factors for developing anxiety: - -genetic predisposition (family history of anxiety) -being female -recent life stressors -chronic physical illness -lack of support during childhood Anxiety Disorders - Generalized Anxiety Disorder (GAD) Social Anxiety Disorder Panic Phobias Agoraphobia Adjustment Disorder with Anxiety GAD often presents with physical symptoms, including: - restlessness or edginess fatigue difficulty concentrating irritability muscle tension sleep disturbance , , and - major depression, such as as well as medical conditions Anxiety is often comorbid with 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 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? - 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. Social Anxiety Disorder - AKA social phobia -condition in which typical, everyday social interactions cause significant anxiety, self-consciousness, fear of embarrassment, or a feeling of being judged negatively by others -may worry about the presence of physical symptoms that others may notice such as trembling or blushing -derealization, or a feeling of "spacing out," may occur -Causes likely include a combination of genetic and environmental factors -past year: 7% of adults and 9% of adolescents -DSM-5-TR defines social anxiety disorder as an individual's fear of acting in a way that might cause judgment by others -anxiety is persistent, lasting greater than six months Usually, social anxiety disorder causes distress and anxiety in specific social situations such as: - -making small talk with others -meeting new people -performing in front of others (called performance anxiety) Panic attack - brief episode of acute anxiety during which an individual develops an intense fear of negative outcomes accompanied by a feeling of imminent danger -can be unpredictable -feelings are often accompanied by physiological symptoms • symptoms typically peak within ten to twenty minutes, some may last for hours Symptoms of Panic Attacks: - -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 Panic disorder - occurs when a person experiences repeated panic attacks -Anxiety about future attacks may lead to behavioral changes • avoid situations that might trigger attacks 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? - 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. phobia - 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 -often occur after experiencing or witnessing a traumatic event -typically develop in childhood -Types of phobias: • natural or environmental (lightning, water, tornado) • injury (dentist, injections) • animal (specific animals, insects) • situational (enclosed spaces) • other (loud noises, clowns) 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 Agoraphobia - 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 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? - 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. Adjustment Disorder with Anxiety - DSM-5 classifies adjustment disorder as a trauma- and stressor-related disorder -presents with nervousness, worry, or jitteriness -Adjustment disorder occurs in the presence of a specific and identifiable stressor • common stressors include loss of employment, getting married, a new disability, or a natural disaster • Symptoms begin within three months of the stressor and typically last no more than six months 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 - 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. 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 h - 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. 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? - generalized anxiety disorder panic disorder panic attack 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 rating scale: GAD-7 - General Anxiety Disorder-7 -answer question with several days (+1), more than half days (+2), nearly every day (+3) • Feeling nervous, anxious, or on edge • Not being able to stop or control worrying • Worrying too much about different things • Trouble relaxing • Being so restless that it's hard to sit still • Becoming easily annoyed or irritable • Feeling afraid as if something awful might happen 0-4: No anxiety disorder 5-9: Mild anxiety disorder 10-14: Moderate anxiety disorder 15-21: Severe anxiety disorder Anxiety rating scale: HAM-A - Hamilton Anxiety Scale -mild (+1), moderate (+2), severe (+3), very severe (+4) • Anxious mood • Tension • Fears • Insomnia • Intellectual • Depressed mood • Somatic (muscular) • Somatic (sensory) • Cardiovascular symptoms • Respiratory symptoms • Gastrointestinal symptoms • Genitourinary symptoms • Autonomic symptoms • Behavior at interview 0-17: Mild anxiety 18-24: Mild to moderate anxiety 25-30: Moderate to severe anxiety 31-56: Severe anxiety HAMILTON ANXIETY RATING SCALE (HAM-A) - developed in the late 1950s to assess anxiety symptoms, both somatic and cognitive. -provides limited coverage of the "worry" required for a diagnosis of generalized anxiety disorder and does not include the episodic anxiety found in panic disorder. -score of 14 has been suggested as the threshold for clinically significant anxiety -scores of 5 or less are typical in individuals in the community -Reliability is fairly good based on internal consistency, interrater, and test-retest studies. -Validity appears good based on correlation with other anxiety scales but is limited -used extensively to monitor treatment response in clinical trials of generalized anxiety disorder and may also be useful for this purpose in clinical settings. Medical Diagnoses that Mimic Anxiety - -Certain medications and substances may cause symptoms of anxiety -Anxiety symptoms may also present as part of another primary mental disorder • Depression, substance abuse, and schizophrenia can all have anxiety components -Baseline labs help rule out a medical diagnosis or other condition • CMP, TFT, toxicology screen Which of the following medical conditions is likely to present with symptoms that mimic anxiety? hypothyroidism hyperthyroidism dysrhythmias irritable bowel syndrome anemia diabetes type 2 migraine headache covid-19 rheumatoid arthritis menopause - hyperthyroidism dysrhythmias irritable bowel syndrome migraine headache rheumatoid arthritis 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. Which of the following medications or substances commonly cause symptoms that mimic anxiety? bupropion nasal decongestants metoprolol levothyroxine Insulin albuterol cocaine alcohol caffeine morphine - bupropion nasal decongestants metoprolol levothyroxine albuterol cocaine alcohol caffeine 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. GAD anxiolytic treatment - Pros -decreased adverse effects -decreased drug interactions Cons -limited effectiveness Time to efficacy -2-4 weeks Agents -buspirone GAD SSRIs/SNRIs treatment - Pros -highly effective Cons -increased drug interactions -risk of hyponatremia Time to efficacy -up to 6 months Agents -Escitalopram (Lexapro) -Paroxetine (Paxil) -Duloxetine (Cymbalta) GAD Benzodiazepine treatment - Pros -highly effective -rapid onset -can be used PRN Cons -multiple adverse effects -fall risk -risk of misuse Time to efficacy -immediate Agents -Alprazolam (Xanax) -Clonazepam (Klonopin) GAD nonpharmacologic tx - Relaxation or meditation Art or music therapy Yoga or other exercise Acupuncture Prayer or spiritual counselling -High-intensity aerobic exercise is a good complement to first-line therapy Silexan - branded extract of lavender -available by prescription in many countries and over the counter as CalmAid through the Nature's Way product line in the U.S. -pharmacologic properties are similar to many CAM therapies -research supports its efficacy for GAD Social Anxiety Disorder (SAD) treatments - cognitive behavioral therapy, medications, or a combination of both -Medications for SAD: • First try SSRI & SNRIs • Then Benzodiazepines • Then MAOIs (SSRI/SNRI must be out of system) Performance anxiety (beta-blockers) - Beta-blockers are recommended for clients who have an awareness of physiological symptoms such as tachycardia or tremor associated with performance anxiety -Beta-blocker or benzodiazepine 30-60 min before performace Panic tx - -Exposure therapy -Cognitive behavioral therapy -Medications • SSRIs • Benzodiazepines in emergencies -Combination of modalities Tx plan to support dx of Adjustment Disorder with Anxiety - -Psychosocial support • Provide reassurance and emotional support to the patient. -Lifestyle modification: Mindfulness • Mindfulness or relaxation training can assist clients with controlling excessive feelings of worry or anxiety. -Lifestyle modification: Limit alcohol • Alcohol can increase anxiety levels -Lifestyle modification: Sleep hygiene • Regular, consistent sleep patterns of 7-8 hours per night can reduce feelings of anxiety. -Pharmacologic therapy: Sertraline • An SSRI, such as sertraline, may be indicated to help Phoebe cope with her feelings of anxiety. Patients with a hx of childhood trauma: cuts response and remission rate of SSRIs - in half CUS - chronic unpredictable stress anhedonia - inability to experience pleasure rumination - compulsive fretting; overthinking about our problems and their causes -responds to atypical antipsychotics Neurotransmitters involved in anxiety: - Norepinephrine- excitatory Serotonin- quick turnover GABA-inhibitory Other Brain Chemicals HPA axis-cortisol Corticotrophin Releasing Hormone- CRH Brain-Derived Neurotrophic Factor-BDNF Differential Diagnoses for anxiety: - Obsessive-compulsive disorder. Panic disorder Major depressive disorder Social phobia Phobias Adjustment disorder with anxiety Social Anxiety Disorder Substance-related disorders Medical Disorders DSM-5 criteria for GAD - excessive anxiety and worry occurring more days than not for at least six months. The person finds it difficult to control and experiences at least three symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance First-line psychotropic medications used to treat anxiety disorders are: - selective serotonin reuptake inhibitors (SSRIs) that act on the serotonin system and indirectly on the GABA system -There are also non-benzodiazepine anxiolytics that may help manage anxiety symptoms, including buspirone, gabapentin, and propranolol -Also, Clonidine or Guanfacine may be used with children -Treatment is usually continued for 6 to 12 months -SNRI's and SSRI's have become the first-line pharmacological intervention separation anxiety disorder - fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate -persistent fear or anxiety about harm coming to attachment figures and events that could lead to loss of or separation -reluctance to go away -nightmares and physical symptoms of distress Selective mutism - characterized by a consistent failure to speak in social situations in which there is an expectation to speak (e.g., school) even though the individual speaks in other situations. -significant consequences on achievement in aca-demic or occupational settings -interferes with normal social communication Substance/medication capable of producing substance/medication-induced anxiety disorder - Alcohol Caffeine Cannabis Phencyclidine Other hallucinogen Inhalant Opioid Sedative, hypnotic, or anxiolytic Amphetamine-type substance (or other stimulant) Cocaine Other (or unknown) substance Obsessive-Compulsive and Related Disorders - -obsessive-compulsive disorder (OCD) -body dysmorphic disorder -hoarding disorder -trichotillomania (hair-pulling disorder) -excoriation (skin-picking) disorder -substance/medication-induced obsessive-compulsive & related disorder -obsessive-compulsive & related disorder due to another medical condition -other specified obsessive-compulsive & related disorder (e.g., nail biting, lip biting, cheek chewing, obsessional jealousy, olfactory reference disorder [olfactory reference syndrome]) -unspecified obsessive-compulsive & related disorder OCD - -presence of obsessions and/or compulsions -Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted -compulsions are repetitive behaviors or mental acts that an indi-vidual feels driven to perform in response to an obsession or according to rules that must be applied rigidly psychosis - disruptions in thoughts and perceptions leading to a disconnection from reality -symptoms may include abnormal behaviors and sensations, including catatonic behavior -may be acute or chronic -Although psychosis is categorized as a psychiatric disorder, it commonly occurs as a secondary condition due to underlying endocrine, vascular, immunologic, or metabolic problems -Drugs, other substances, or other psychiatric conditions such as depression or mania may also cause symptoms Psychosis: Clinical Presentation - divided into several clinical domains -positive • occur when clients experience things in addition to reality • hearing voices or seeing things that are not there -negative • involve a loss of something • loss of ability to experience pleasure or loss of motivation -cognitive • disorganization in thoughts, memories, focus, or attention -affective • the client's feelings and emotions -motor • may include abnormalities in gait, balance, and coordination, irregular muscle contractions, or tremors Psychosis: Positive Symptoms - Hallucinations Delusions Thought disorder Hostility Excitability Psychosis: Motor Symptoms - Motor delay Dyscoordination EPS -Parkinsonism -Dyskinesia Psychosis: Affective Symptoms - Depression Anxiety Suicidality Psychosis: Cognition symptoms - Attention Working memory Verbal memory Visual memory Executive functioning Processing speed Social conditioning Psychosis: Negative Symptoms - Affective flattening Alogia Anhedonia Amotivation Asociality Hallucinations: - perceptual experiences in the absence of external stimuli -Auditory • may include command hallucinations -Visual -Tactile: feeling sensations in the body in the absence of stimuli -Olfactory: smelling things that are not there -Gustatory: tasting things that are not there Delusions: - fixed false, irrational beliefs -persecution: delusions r/t being threatened, victimized, or spied on -reference: delusions r/t receiving personal messages from tv, radio, or actions of others -somatic: delusions r/t the body, including illness or the presence of foreign objects • may believe there are objects in their body (may think they are infested with insects.) -grandeur: delusions r/t beliefs of special abilities or powers -control: delusions that actions & thoughts are controlled by others Symptoms of Psychosis: Thought Disorder - impairment in the process of thinking and difficulty organizing thoughts in a logical pattern. -incoherent speech -loose associations -meaningless words -perseveration Symptoms of Psychosis: Disorganized Behavior - disordered or impaired behavior or communication -childlike silliness -unpredictable agitation -inappropriate clothing for the weather -poor hygiene psychosis neurobiological factors: genetics - -Many genes play a role in the likelihood that an individual will develop schizophrenia as do epigenetic factors • Heritability for schizophrenia may be as high as 79% • links gene-environment interaction to the diagnosis of schizophrenia psychosis neurobiological factors: Environmental Triggers - Regular Cannabis Use Exposure to Early Life Trauma -Sexual Abuse -Emotional Abuse -Emotional Neglect -Bullying psychosis neurobiological factors: Neuroanatomy Several areas of the brain are associated with the symptoms of schizophrenia. When brain circuitry in the prefrontal cortex malfunctions, patients may experience symptoms. Match the brain area with malfunctioning circuitry with the symptoms produced: Area of brain: Mesocortical and ventromedial prefrontal cortex Dorsolateral Orbitofrontal and connections to the amygdala Symptoms: aggressive, impulsive symptoms negative and affective symptoms cognitive symptoms - Mesocortical and ventromedial prefrontal cortex: negative and affective symptoms Dorsolateral: cognitive symptoms Orbitofrontal and connections to the amygdala: aggressive, impulsive symptoms psychosis neurobiological factors: Neural networks - Dopamine pathways explain the positive and negative symptoms seen in schizophrenia and psychosis -as well as the side effects associated with antipsychotic medications schizophrenia is a diagnosis commonly associated with - psychosis psychosis neurobiological factors: Neural signaling - Dopamine Role in Psychosis -leading hypothesis is that psychosis and schizophrenia are associated with a dysfunction of the neurotransmitter dopamine (DA) • Traditionally, schizophrenia and psychosis symptoms have been associated with a surplus of dopamine, since medications that block dopamine, specifically D2, have been found to reduce the positive symptoms of schizophrenia -schizophrenia symptoms are related to "out of tune" dopamine -Dopamine dysfunctions are also involved in other conditions that cause psychosis, such as severe depression, certain medical disorders, and substance abuse Esme is a 22-year-old client who presents to the clinic with her mother. Esme appears quiet and withdrawn with very little emotional expression. Her mother reports that for the last couple of years, Esme has gradually disengaged from all her friends. After graduating from high school, she left for college but started hearing voices telling her that she was ugly and stupid. She stopped attending class or completing her work. When asked directly about her symptoms, Esme provides very short, one-to-two-word responses in a monotone voice. Which of the following symptoms is Esme exhibiting? Select all that apply. anosognosia alogia avolition asociality blunted affect depersonalization catatonia anhedonia hallucinations delusions - alogia avolition asociality blunted affect hallucinations Rationale: Esme is experiencing the following symptoms of psychosis: alogia: short answers, using few words to communicate avolition: lack of initiative, withdrawal from work/school asocialtiy: lack of relationships, reduced social interactions blunted affect: decreased facial expressions and voice inflections hallucinations: perceptual experiences in the absence of external stimuli Esme has not provided enough information to support the following symptoms at this time: anhedonia: inability to experience pleasure anosognosia: functional inability to recognize illness depersonalization: a perception that the body is floating, changing, or detached catatonia: lifeless, trance-like state with lack of response or movement delusions: fixed false, irrational beliefs Types of Psychotic Disorders - -Schizophrenia -Schizoaffective Disorder -Schizophreniform Disorder -Brief Psychotic Disorder -Delusional Disorder -Catatonia Schizophrenia - -affects between 0.25% & 0.75% of the population in the U.S. -one of the top 15 leading causes of disability worldwide -at risk of premature mortality due to co-occurring medical conditions that are often undiagnosed or undertreated • Common comorbidities include heart and liver disease and diabetes -increased risk for suicide -typically symptoms begin to manifest before age 25 and persist throughout the lifespan -Prodromal Phase: usually develop before the first psychotic episode Schizophrenia Prodromal Phase - -usually develop before the first psychotic episode -over a few days to a few months and may persist for a year or more before the onset of overt psychotic symptoms -Symptoms that occur in the prodromal phase of the illness are typically negative and may be overlooked due to their similarity to other conditions, such as depression -signs and symptoms: • interest in abstract ideas, philosophy, and occult or religious questions • noticeably strange behavior, abnormal affect, unusual speech, bizarre ideas, and odd perceptual experiences Schizophrenia Course - typically involves exacerbations and remissions -after the first psychotic episode, clients may recover and function somewhat normally for a long time before relapsing -pattern of illness during the first five years after the diagnosis generally indicates the client's course -Each relapse leads to further decline in client functioning -Over time, positive symptoms tend to become less severe while negative symptoms may increase in severity Psychosis Screening tools - -Brief Psychiatric Rating Scale (BPRS) -Positive and Negative Syndrome Scale (PANSS) -Clinician-Rated Dimensions of Psychosis Symptom Severity Scale Brief Psychiatric Rating Scale (BPRS) - -used to assess clients who present with symptoms of psychosis. -consists of 24 categories, each scored between 1-7. -scale varies, scores may be broadly interpreted with higher numbers indicating more severe illness -may be used over time to evaluate treatment. Positive and Negative Syndrome Scale (PANSS) - -clinician-rated tool to identify and differentiate the presence of (+) and (-) symptoms of psychosis -commonly used in research settings Clinician-Rated Dimensions of Psychosis Symptom Severity Scale - -can help the provider to determine the degree of impairment from (+), (-), and cognitive symptoms -Each item is scored & interpreted independently -may be used to monitor tx success & the need for additional follow-up Schizoaffective Disorder - involves symptoms of both schizophrenia and a mood disorder, such as bipolar disorder -associated with depression • often misdiagnosed as MDD -Dx req at least 2 psychotic episodes, each lasting 2 weeks or more • One without depressive or manic symptoms Minh is a 19-year-old who presents to the emergency department after a suicide attempt. She is medically stable. She states that she has experienced auditory hallucinations for the past 3-4 weeks and "could not take them anymore." She also complains of depressed mood, loss of interest in activities, and feelings of hopelessness for the past few months. Her toxicology reports on admission were negative. Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), what is the most appropriate diagnosis for Minh? include ICD-10 code: - schizoaffective disorder depressive type F25.1 Rationale: Minh presents with major depressive episode concurrent with hallucinations. This disturbance is not attributable to a substance. The most appropriate diagnosis for Minh is schizoaffective disorder depressive type F25.1 Schizophreniform Disorder - characterized by schizophrenia-like symptoms that last for more than 1 month but less than 6 months -differentiated from schizophrenia based on the length of time symptoms have been present Holden is a 14-year-old who presents to the clinic with his parents. His mother notes that he has stopped showering, seems disinterested in activities in which he had previously engaged and in peer interaction, and echoes words that others have said. These behaviors have increased over the past two months. Holden's urine toxicology is negative. Based on the DSM-5-TR, does Holden meet diagnostic criteria for schizophreniform disorder? yes no Unable to determine - No Rationale: Holden's behaviors have lasted for at least one month, but less than six months. His behaviors are not attributable to a substance. Holden displays two of the five required symptoms for the diagnosis of schizophreniform disorder. He displays catatonic behavior with echolalia and has negative symptoms of asociality and avolition. He does not, however, display one of the three required behaviors for diagnosis: delusions, hallucinations, or disorganized speech. An alternate diagnosis should be considered.