NURS 663 Maryville Psych Exam 3

pharmacologic agents for PTSD - med tx is focused on diminishing intrusive thoughts, hyperarousal, and avoidance, with some success and mixed results PTSD frequent comorbidity - depressive disorder, anxiety disorders, and behavioral problems associated with ______________ sertraline and paroxetine - that __________and ______________ are approved by the Food and Drug Administration (FDA) in the treatment of PTSD in adults, there is scant evidence to support its use for the core symptoms of PTSD in youth Risperidone and aripiprazole - FDA approval for use in children and adolescents with aggression, severe behavioral dyscontrol, and severe psychiatric disorders Antiadrenergic agents - treat dysregulation of the noradrenergic system in adults and youth with PTSD clonidine and guanfacine - Alpha2-agonists examples Alpha2 agonists - decrease norepinephrine release, such as, are propranolol - centrally acting β-antagonists example prazosin - α-1-antagonists example propranolol use - hypothesized to improve hyperarousal and intrusive thoughts through attenuation of norepinephrine postsynaptically prazosin use - nightmares associated with trauma Modify PTSD sx - Off-label medications including antidepressants, atypical antipsychotics, adrenergic modulators/sympatholytics, and anticonvulsants/mood stabilizers clonidine and propanolol - nightmares and exaggerated startle response: some evidence in adults, but children case report only guanfacine and clonidine - __________ may reduce nightmares in children with PTSD and ____________may diminish symptoms of reenactment of traumatic events in children Mood-stabilizing agents - divalproex, carbamazepine, topiramate, and gabapentin have been utilized for adults with PTSD with modest improvement; some clonidine with dosage ranges of 0.05 to 0.1 mg twice daily - may provide some relief for the symptoms of hyperarousal, impulsivity, and agitation in young children with PTSD; in children some evidence benzodiazepines - no controlled trials supporting use in children Trauma-Focused CBT - 10-16 treatment sessions, including 9 components itemized in the acronym PRACTICE PRACTICE elements - Psychoeducation on typical reactions to PTSD. Parenting skills- praise, time-out, reinforcement Relaxation- muscle, breathing, cognitive tech Affective Expression and Modulation- ID feelings Cognitive Coping and Processing Cognitive Triangle Trauma Narrative:developed over time by child, In Vivo Exposure and Mastery of Trauma Reminders- how to deal with reminders Conjoint Child-Parent Sessions- this component may involve several sessions in which the child and parent share their understanding Enhancing future safety-family changes EMDR - exposure and cognitive reprocessing interventions are paired with directed eye movements, alternating tones or tapping CBITS - Cognitive Behavioral Interventions for Trauma in Schools CBITS description - intervention that administers treatment in the school setting for children who screen positive for PTSD and whose parents agree to treatment in school. CBITS elements - Consists of 10 weekly group sessions 1-3 individual imaginal exposure sessions 2-4 optional sessions with parents 1 parent education session. Similar to trauma-focused CBT, incorporates psychoeducation, relaxation, training, cognitive coping skills, gradual exposure to traumatic memories SPARCS - Structured Psychotherapy for Adolescents Responding to Chronic Stress SPARCS description - -Consists of a group intervention, -16 sessions -focus on the needs of adolescents (12-19 years old) chronic trauma and PTSD. -Utilizes cognitive behavioral techniques, and -incorporates many of the components of TF-CBT -Includes mindfulness techniques and relaxation. TARGET - Trauma Affect Regulation:Guide for Education and Therapy TARGET description - -affect regulation therapy, -combines CBT components, such as cognitive procession, with affect modulation. -adolescents (13-19) exposed to maltreatment and/or chronic traumatic exposure to such things as community violence or domestic violence. -12 sessions, which focuses on past or current situations. TARGET efficacy - --Like SPARCS treatment, gradual exposure may occur in the context of recounting past trauma but is not a core component of treatment. --Reduces anxiety, depression, and PTSD --Promising treatment for girls with h/o delinquency, especially to reduce anger and to enhance optimism and self efficacy. Crisis intervention/Psychological Debriefing - 1. several sessions immediately after an exposure to a traumatic event; encouraged to describe the traumatic event in the context of a supportive environment. 2. Psychoeducation is provided and guidance about the management of initial emotional reactions may be provided. 3. No controlled studies have yet provided evidence that this intervention leads to a more positive outcome PTSD criteria add'l info - 1. Over 6 years old 2. Sx over 1 month duration, or dx criteria may not have occurred until at least 6 months after the trauma 3. Constricted emotions can show up suddenly after major life event, stressor, or accumulated stressors that challenge defenses. 4. Can hide in somatic complaints or co-occur with depression, substance abuse, anxiety or after head injury PTSD differential diagnosis: Medical - hyperthyroidism, caffeinism, migraine, asthma, seizure disorder, and catecholamine or serotonin-secreting tumors. Some prescription medications and even some OTC medications may have similar effects, such as antiasthmatics, sympathomimetics, steroids, SSRIs, and antipsychotics, diet pills, antihistamines, and cold medicines PTSD differential diagnosis - anxiety disorders, such as separation anxiety disorder, obsessive-compulsive disorder (OCD) or social phobia, depressive disorders, bereavement trauma, disruptive behavior d/o PTSD-associated psychosis - does not respond well to neuroleptic (antipsychotic) medication; may respond better to psychosocial interventions. The hallucinations and delusions connect to the traumatic situation and perpetrators. Older kids show symptoms like adults. PTSD criteria - Trauma: occured, witnessed, learned about Harm or threat of harm to self, loved one 1. Re-experiencing traumatic event 2. Sustained high level of anxiety, hyperarousal / hypervigilance / exaggerated startle 3. Avoid activities, people, places, situations, objects that arouse memories 4. A numbing of responsiveness, concentration 5. Re-exp. flashbacks, nightmares, intrusive memories 6. Inability to remember aspects of the trauma 7. Chronic negative emotional state, decreased interest / participation in significant activities 8. Depression, survivor's guilt, relationship problems, panic attacks 9. Substance abuse 10. Anger, aggressive, reckless, thrill-seeking, or self-destructive behavior PTSD stats - 20 to 76% _________ children in inpt psych units endorse hallucinations. Psychosis is present in up to 75 to 95% of those diagnosed with dissociative disorders. Traumatized C/A - 1. Hear perpetrators frightening them, making derogatory remarks, or announcing / threatening new victimization. 2. See the perpetrator, smell them, fear victimizer will follow them, or feel they will come hurt them again. 3. Hear command hallucinations (by the perpetrator) telling them to harm themselves or others. 4. Hallucinations (PTSD type) are frequently nocturnal. Occur in 9% of abused children. 5. Nightmares are frightening, recurrent PTSD under 6 yo - alterations in arousal and reactivity associated with the traumatic event(s) including: irritable behavior and anger outbursts, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. PTSD under 6 yo add'l - 1. May have enuresis after they were toilet trained 2. Developmental regression-Stop speaking or forget how to talk - 3. Become very clingy 4. Act out trauma through play or re-enactment 5. Egocentric theory of causality: blame self ODD - oppositional defiant disorder ODD criteria - A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from the categories, and exhibited during interaction with at least one non-sibling ODD categories - Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, with adults. 5. Often actively defies or refuses to comply with requests from authority figures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. ODD add'l criteria - children younger than 5 years, the behavior should occur on most days for a period of at least 6 months 5 years or older, the behavior should occur at least once per week for at least 6 months ODD severity - Specify number of settings for severity: Mild: one setting (e.g., at home, at school, at work, with peers). Moderate: at least two settings. Severe: three or more settings Conduct Disorder (CD) - A. Repetitive/persistent pattern of behavior in which basic rights of others or major societal norms/rules are violated B. at least 3 of following 15 criteria in past 12 mo, with at least 1 criterion present in the last 6 mo CD aggression - 1. Bullies, threatens, or intimidates others 2. Initiates physical fights 3. Used a weapon that can cause serious physical harm to others (bat, brick, knife, gun etc.) 4. Physically cruel to people 5. physically cruel to animals 6. Steals while confronting a victim (mugging, purse snatching, armed robbery, extortion, etc.) 7. Forced someone into sexual activity CD prop destruction - 8. Has deliberately engaged in fire setting with intention of causing serious damage 9. Has deliberately destroyed others' property (other than setting fire) CD: Deceitfulness or theft - 10. Breaks into someone else's house, bldg, or car 11. Often lies to obtain goods or favors or to avoid obligations ("cons" others) 12. Has stolen items of nontrivial value without confronting a victim (shoplifting, forgery etc; no B & E) CD serious rule violation - 13. Often stays out at night despite parental prohibitions, beginning before age 13. 14. Has run away from home overnight at least twice from home, or once without returning for a lengthy period 15. Is often truant from school, beginning before age 13. CD onset - childhood before 10 yo adolescent after 10yo Over 18 yo: antisocial personality disorder CD with limited prosocial emotions - Lack of remorse or guilt Callous-lack of empathy Unconcerned about performance Shallow or deficient affect Reactive attachment disorder - --children: received grossly negligent care and do not form a healthy emotional attachment with their primary caregivers before age 5. --absence of emotional warmth during the first few years of life can negatively affect a child's entire future Attachment - --develops when a child is repeatedly soothed, comforted, and cared for, and when the caregiver consistently meets the child's needs --creates love and trust others, to become aware of others' feelings and needs, to regulate his or her emotions, and to develop healthy relationships and a positive self-image RAD criteria A - Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers: 1. The child rarely or minimally seeks comfort when distressed. 2. The child rarely or minimally responds to comfort when distressed. RAD criteria B - A persistent social and emotional disturbance characterized by at least two of the following: 1. Minimal social and emotional responsiveness to others. Limited positive affect. 2. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interaction with adult caregivers. RAD criteria C - The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care.) 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g. institutions with child-to-caregiver-ratios.) RAD add'l - The criteria are not met for autism spectrum disorder. The disturbance is evident before age 5 years. The child has a developmental age of at least 9 months. Specify if: Persistent: The order has been present for more than 12 months. Specify current severity: specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels DMDD - disruptive mood dysregulation disorder DMDD developed to - Addresses concerns of over diagnosing or over treating bipolar disorder in children DMDD def - Pattern of mood dysregulation, chronic and persistent irritability, and frequent extreme behavioral dyscontrol in children who do not present with typical, classic, distinct episodes of mania or hypomania. Should not be made for the first time before age 6 years or after age 18 years. Onset of sx of temper outbursts and chronic irritable/ angry mood has to be before age 10 DMDD criteria - A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. outbursts inconsistent with developmental level. C. outbursts occur three or more times per week. D. The mood persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). DMDD dx - 1. can' t coexist with ODD, IED, or bipolar disorder, 2. can coexist with MDD, ADHD, conduct disorder, and SUD. 3. IF meet criteria for both ________and ODD, then give DX of _________________ DMDD add'l - 1. dx not be made for the first time before age 6 years or after age 18 years. 2. age of onset of Criteria A-E is before 10 years 3. never been a distinct period lasting more than 1 day during which the full symptom criteria, for a manic or hypomanic episode have been met PTSD neuropsych - 1. noradrenergic and endogenous opiate systems, as well as the HPA axis, are hyperactive in at least some 2. increased activity/responsiveness of the autonomic nervous system, AEB elevated HR rates and BP and by abnormal sleep architecture 3. increased 24-hour urine epinephrine concentrations in veterans 4. increased urine catecholamine concentrations in sexually abused girls 5. platelet α2- and lymphocyte β-adrenergic receptors are downregulated in _______ possibly in response to chronically elevated catecholamine concentrations PTSD HPA axis - 1. low plasma and urinary free cortisol concentrations. 2. More glucocorticoid receptors are found on lymphocytes 3. challenge with exogenous corticotropin-releasing factor (CRF) yields a blunted corticotropin (ACTH) response PTSD other neuropsych - 1. hippocampus received increased attention, although the issue remains controversial. 2. Structural changes in the amygdala, an area of the brain associated with fear, have also been demonstrated ODD neuropsych - 1. No specific laboratory tests or pathological findings 2. may share some characteristics with people with high levels of aggression, such as low central nervous system serotonin 3. Brain imaging studies suggest may have subtle differences in the part of the brain responsible for reasoning, judgment and impulse control ODD heredity - tends to occur in families with a history of Attention Deficit Hyperactivity Disorder (ADHD), substance use disorders, or mood disorders such as depression or bipolar disorder. Explanatory models of ODD/CD - focus on executive functions (EFs) Hot EF - 1. comprises motivational, affective, and emotional aspect of cognition 2. The amygdala, anterior cingulate cortex, insula, and orbitofrontal cortex are responsible for ____ EF functioning Cold EF - 1. focuses on inhibition, planning, working memory, and flexibility, which are basically top-down control mechanisms of cognition 2. dorsolateral prefrontal cortex and cerebellum control _____ EF CD neuropsych - 1. decreased gray matter in limbic brain structures, and in the bilateral anterior insula and left amygdala compared to healthy controls 2. Neurotransmitter studies suggest low level of plasma dopamine β-hydroxylase, an enzyme that converts dopamine to norepinephrine, leading to a hypothesis of decreased noradrenergic function 3. juvenile offenders have found high plasma serotonin levels in blood cerebrospinal fluid (CSF) - blood serotonin levels correlate inversely with levels of 5-HIAA in the _______________and that low 5-HIAA levels in __________correlate with aggression and violence aggressive children - had significantly greater relative right frontal brain activity at rest comparitively. Frontal resting brain electrical activity has been hypothesized to reflect the ability to regulate emotion RAD neuropsych - 1. no single specific laboratory test is used to make a diagnosis, 2. Many have disturbances of growth and development 3. If incoming early sensory input is inadequate or creates pandemonium, neural org will reflect this disarray. 4. Lower brain region disorganization automatically compromise higher brain regions Attachment Neuropsych - 1. right hemispheres forge neural connections between infants subcortical, bodily-based affective states with conscious emotional states in the higher brain regions of the right hemisphere; 2. these circuits are vital to emotional processing, empathy and development of self 3. Right hemisphere and limbic system develop rapidly during the first year and responsible for habitual responses to stress Play - vital to brain development Brain stem - 0-9mo, critical role in regulation of arousal, sleep, heart rate, body temp, fear states Diencephalon - 6mo-2yrs fine motor skills, promoting sensory integration, controlling motor functioning and facilitating flexibility in relational exchanges. Limbic system - 1-4yrs regulate emotions, interpret non-verbal information, experience empathy for others, feel a sense of social connectedness, tolerate distress and differences Cortex - 3-6yrs, highest and most complex, abstract cognitive processing and integration of social-emotional information. Violence - seems to originate in the prefrontal cortex DMDD neuropsych - 1. no study has yet been conducted specifically on children meeting the diagnostic criteria for ________ 2. abnormally reduced activation in neural regions associated with emotional salience, spatial attention, and reward processing in response to frustration tasks 3. facial affect recognition task, the participants' level of irritability correlated with amygdala activity across all intensities for all emotions (happy, fearful, and angry faces) in the _________ group 4. Event-related potential study: impairment in reward processing may be more salient than just excessive reactivity to loss for ______________ Acute stress disorder dx timeline - 3 days to one month PTSD timeline - greater than one month Drug route SUD - inhaled, snorted, or injected, thus entering the brain in a sudden explosive manner, are usually much more reinforcing than when those same drugs are taken orally--slower absorb Dopamine (DA) - 1. has long been recognized as a major player in the regulation of reinforcement and reward 2. mesolimbic pathway from the ventral tegmental area (VTA) to the nucleus accumbens seems to be crucial for reward Drugs of abuse - 1. cause DA release in the mesolimbic pathway 2. increase dopamine in a manner that is more explosive and pleasurable than that which occurs naturally. 3. activation caused by drugs of abuse can eventually cause changes in reward circuitry that are associated with a vicious cycle vicious cycle of drug preoccupation, - craving, addiction, dependence, and withdrawal ETOH w/d - 1. tremulousness 2. psychotic and perceptual symptoms (e.g., delusions and hallucinations), 3. seizures, and 4. the symptoms of delirium tremens (DTs), called alcohol delirium in DSM-5. 5. general irritability, 6. gastrointestinal symptoms (e.g., nausea and vomiting), and 7. sympathetic autonomic hyperactivity 8. alert but may startle easily. ETOH w/d autonomic hyperactivity - anxiety, arousal, sweating, facial flushing, mydriasis, tachycardia, and mild hypertension ETOH w/d time - Tremulousness develops 6 to 8 hours after the cessation the psychotic and perceptual symptoms begin in 8 to 12 hours seizures in 12 to 24 hours, and DTs anytime during the first 72 hours; watch for the for the first week of w/d; unpredictable ETOH MOA - Activates 5 HT3, GABA, dopamine, and serotonin receptors in CNS and inhibits glutamate receptors and voltage gated Ca channels. Potent CNS depressant. ETOH long term effects - Wernicke's encephalopathy is completely reversible with treatment, only about 20 percent of patients with Korsakoff's syndrome recover BCA 0.05 % - thought, judgment, and restraint are loosened and sometimes disrupted. BCA 0.1% - voluntary motor actions usually become perceptibly clumsy BCA 0.1 to 0.15 - In most states, legal intoxication ranges BCA 0.2 % - the function of the entire motor area of the brain is measurably depressed, and the parts of the brain that control emotional behavior are also affected BCA 0.3% - a person is commonly confused or may become stuporous BCA 0.4 to 0.5 % - the person falls into a coma. At higher levels, the primitive centers of the brain that control breathing and heart rate are affected, and death ensues secondary to direct respiratory depression or the aspiration of vomitus. ETOH Tolerance - Persons with long-term histories of can tolerate much higher concentrations than can _________-naïve persons; their tolerance may cause them to falsely appear less intoxicated than they really are ETOH intoxication sx - 1. Slurred speech 2. Dizziness 3. Incoordination 4. Unsteady gait 5. Nystagmus 6. Impairment in attention or memory: anterograde amnesia 7. Stupor or coma 8. Double vision benzodiazepines w/d - anxiety, dysphoria, intolerance for bright lights and loud noises, nausea, sweating, muscle twitching, and sometimes seizures Benzos w/d states - recurrence: return of the original anxiety sx rebound: worsening of the original anxiety sx rue withdrawal emergence of new sx Benzo w/d mood and cognition - Anxiety, apprehension, dysphoria, pessimism, irritability, obsessive rumination, and paranoid ideation Benzo w/d sleep - Insomnia, altered sleep-wake cycle, and daytime drowsiness Benzo w/d phys s/sx - Tachycardia, elevated blood pressure, hyperreflexia, muscle tension, agitation/motor restlessness, tremor, myoclonus, muscle and joint pain, nausea, coryza, diaphoresis, ataxia, tinnitus, and grand mal seizures Benzo w/d perception - Hyperacusis, depersonalization, blurred vision, illusions, and hallucinations Hyperacusis - debilitating hearing disorder characterized by an increased sensitivity to certain frequencies and volume ranges of sound. difficulty tolerating everyday sounds Benzo w/d timeline - onset of withdrawal symptoms usually occurs 2 to 3 days after the cessation of use, but with long-acting drugs, the latency before onset can be 5 or 6 days Benzo MOA - Stimulation of the inhibitory GABAergic activity, either by endogenous ligands or _______ or results in sedation, amnesia and ataxia, while attenuation of the GABAergic system leads to arousal, anxiety, restlessness, insomnia and exaggerated reactivity Benzo immediate risks - large margin of safety when taken in overdoses lethal dose to effective dose is about 200 to 1; minimal respiratory depression. Flumazenil - reverse the adverse psychomotor, amnestic, and sedative effects of ______ receptor agonists, including _____________, zolpidem, and zaleplon Heroin/opioids w/d - Dysphoria, craving, irritable, autonomic hyperactivity; tachycardia, tremor, and sweating. Piloerection ("goose-bumps"), especially if ("cold turkey"). So horrible that opioid abusers stop at nothing to get opioid to relieve sx of w/d. What starts as quest for euphoria ends as a quest to avoid withdrawal heroin w/d clonidine - can reduce signs of autonomic hyperactivity during withdrawal and aid in the detoxification process. heroin w/d timeline - Starts 6-12 hours, Peak 1-3 days, Subsides in a week - May not be the same for everyone. methadone w/d timeline - starts 24-48, peaks in the first few days and lasts 2-4 wks vicodine w/d timeline - starts 8-12hrs peaks 12-48 hrs and lasts 5-10 days mu-opioid receptors - μ--are involved in the regulation and mediation of analgesia, respiratory depression, constipation, and drug dependence Heroin - the most commonly abused opioid, is heroin MOA - more lipid soluble than morphine. This allows it to cross the bloodbrain barrier faster and have a more rapid and pleasurable onset than morphine. more addictive. Heroin add'l - 1. 90 percent of persons with ________________ dependence have an additional psychiatric disorder. 2. most common: major depressive disorder, alcohol use disorders, antisocial personality disorder, and anxiety disorders. 3. 15 % attempt to commit suicide at least once κappa-opioid receptors, - κ--with analgesia, diuresis, and sedation; delta-opioid receptors - Δ--with analgesia. endorphins - are involved in other addictions, such as alcoholism, cocaine, and cannabinoid addiction. naltrexone - opioid antagonist--has shown value in mitigating alcohol addiction. Heroin immediate risk - 1. Overdose: respiratory depression. 2. intoxication includes maladaptive behavioral 3. changes and specific physical sx altered mood, psychomotor retardation, drowsiness, slurred speech, and impaired memory and attention in the presence of other indicators Cocaine/stimulants - Persons aged 18 to 25 (0.9 percent) had the highest rate of past year use/abuse Follow cocaine use disorder - development of mood disorders and alcohol-related disorders Precede cocaine use disorder - anxiety disorders, antisocial personality disorder, and ADHD comorbid with cocaine use disorder - major depressive disorder, bipolar II disorder, cyclothymic disorder, anxiety disorders, and antisocial personality Cocaine w/d immediate - "crash" occurs with symptoms of anxiety, tremulousness, dysphoric mood, lethargy, fatigue, nightmares (accompanied by rebound rapid eye movement [REM] sleep), headache, profuse sweating, muscle cramps, stomach cramps, and insatiable hunger