NR 547 Final Study Guide PMHNP Exam New Latest Version Updated 2023, Exams of Nursing

Download NR 547 Final Study Guide PMHNP Exam New Latest Version Updated 2023 and more Exams Nursing in PDF only on Docsity! NR 547 Final Study Guide PMHNP Exam New Latest Version Updated 2023-2024 with All Questions and 100% Correct Answers Rico is a 30-year-old who is referred to the clinic by his wife, Tracy. Rico and Tracy have been married for eight years. She states that in the past year, his behaviors have become disquieting. He constantly accuses her of cheating on him. He often takes her phone and scrolls through her calls, texts, and social media accounts. He is suspicious about texts she receives from coworkers and other acquaintances. He starts frequent arguments with her about where she has been and who she was with, an -------- Correct Answer --------- No Rationale: Although Rico meets diagnostic criteria of preoccupation about his wife's loyalty, reads into benign events, and has suspicions of his wife's fidelity, these symptoms have developed within the past year. A diagnosis of paranoid personality disorder requires the presence of symptoms by early adulthood and in a variety of contexts. Alternate diagnostic considerations include substance use disorder, schizophrenia, or bipolar or depressive disorder with psychotic features. Crispin is a 33-year-old who presents after experiencing auditory hallucinations. He states he has heard voices "grumbling at him" about three or four times in the past week, for about 15 minutes each time. He is employed as a data analyst and works from home. He does not have hobbies or activities outside of work. He does not use alcohol, marijuana, or illicit drugs; he smokes cigarettes. He lives with his sister, who is getting married in a month; he will be moving into an apartment with a roo -------- Correct Answer --------- Schizoid personality disorder Rationale: Crispin meets DSM-5 criteria for schizoid personality disorder. He is detached from social relationships, prefers solitary activities, lacks close friends, and lacks interest in sexual experiences. He has experienced these traits since adolescence. Clients with a schizoid personality disorder may have brief periods of psychotic episodes when stressed. Heloise is a 27-year-old who presents to the clinic with symptoms of depressed mood. She states that she has been stressed by a recent wildfire that started near her community. She believes that she caused the fire to spread because she was thinking about it too much. She also says that she hears the animals crying out to her as they are succumbing to the fire. She states she has never had friends, other than her sister because she gets very anxious around other people. She was teased throughout -------- Correct Answer --------- Schizotypal personality disorder Rationale: Heloise meets diagnostic criteria for schizotypal personality disorder. She exhibits ideas of reference, magical thinking, unusual perceptual experiences, has an odd appearance and speech patterns, social anxiety, and lacks close friends. The traits have been present since she was in high school. Cluster B -------- Correct Answer --------- Cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behavior. -ANTISOCIAL • inability to conform to social norms typical of adolescent or adult behavior • may exhibit a disregard for needs, feelings, rights, or safety of others • recurring problems with the law, criminal acts such as lying, stealing, or conning others without remorse common -BORDERLINE PERSONALITY DISORDER • stand on the border between neurosis and psychosis, exhibiting unstable affect, mood, behaviors, object relations, and self-image • often engage in risky behaviors • intensely fearful of abandonment, and their relationships are often intense and unstable • Stress-related mood swings and paranoia, and suicidal behavior or threats of self- harm are common -HISTRIONIC PERSONALITY DISORDER • excitable, emotional, colorful, dramatic, flamboyant, extroverted, or attention-seeking behavior • may be easily influenced by others • often exhibit an i Seth is a 22-year-old with a court-ordered referral for assessment. He was arrested on charges of stealing from an aunt while he was house-sitting. This is the third time he has been caught stealing from the family in the past two years, but the first time that the victim pressed charges. Seth states that he isn't too worried about his stealing behaviors, because his family "has a lot of money, and they are not going to miss a little here and there." Seth has held several entry-level jobs over t -------- Correct Answer ----- ---- Seth admits to stealing from the drawer at his first fast-food job as a senior in high school. Seth's mother states that he skipped school regularly and repeatedly got into fights as a middle-schooler. Rationale: From the initial interview, Seth meets several criteria for antisocial personality disorder. He is repeatedly stealing from his family without remorse, has an inconsistent work history, and has a reckless disregard for his safety and the safety of others indicated by unsafe sexual behaviors. He is over 18. Additional information that will help confirm a diagnosis of antisocial personality disorder is evidence of conduct disorder before the age of 15. Although self-assured behavior is consistent with antisocial personality disorder, it is not a diagnostic criterion. If Seth admitted to stealing to buy drugs, further investigation is warranted to consider an alternate (or additional) diagnosis of substance use disorder. Rationale: Nora meets diagnostic criteria for dependent personality disorder. She has difficulty making decisions without input from others, has difficulty expressing disagreement, and has feelings of discomfort about being alone and caring for herself. 10 specific types of personality disorders in the DSM-5-TR: -------- Correct Answer ------- -- -Antisocial personality disorder -Avoidant personality disorder -Borderline personality disorder -Dependent personality disorder -Histrionic personality disorder -Narcissistic personality disorder -Obsessive-compulsive personality disorder -Paranoid personality disorder -Schizoid personality disorder -Schizotypal personality disorder Edinburgh Postnatal Depression Scale (EPDS) -------- Correct Answer --------- Screening test used to identify depression during pregnancy or in the postpartum period ASQ screening -------- Correct Answer --------- The Ask Suicide-Screening Questions (ASQ) tool is a brief validated tool for use among both youth and adults. Depression: Anxious distress Modifier -------- Correct Answer --------- Depression with unusual restlessness or worry about possible events or loss of control Depression: Mixed features -------- Correct Answer --------- Simultaneous depression and mania, which includes elevated self-esteem, talking too much and increased energy Depression: Melancholic features -------- Correct Answer --------- Severe depression with lack of response to something that used to bring pleasure and associated with early morning awakening, worsened mood in the morning, major changes in appetite, and feelings of guilt, agitation or sluggishness Depression: Atypical features -------- Correct Answer --------- Depression that includes the ability to temporarily be cheered by happy events, increased appetite, excessive need for sleep, sensitivity to rejection, and a heavy feeling in the arms or legs Depression: Psychotic Features -------- Correct Answer --------- Depression accompanied by delusions or hallucinations, which may involve personal inadequacy or other negative themes Depression: Catatonic Features -------- Correct Answer --------- Depression that includes motor activity that involves either uncontrollable and purposeless movement or fixed and inflexible posture DSM5-TR Diagnostic Criteria for Depression -------- Correct Answer --------- MDD, five or more of the symptoms below need to be present for at least 2 weeks continuously. (5/9) feeling low most of the day for most days decreased interest in activities substantial weight loss, significant change in appetite fidgeting, random movement (i.e. pacing) decreased energy sense of guilt or worthlessness lack of focus or ability to make decisions repeated thoughts of death and suicide Depressed mood and/or Loss of interest/pleasure must be present. MDD statistics -------- Correct Answer --------- An estimated 4 percent of the United States' adult population has experienced at least one major depressive episode. The condition is more prevalent in women than in men. It is three times more likely for people between the ages of 18-25 to experience depression as compared to adults 60 and over. MDD frequently occurs with other medical or psychological conditions like substance abuse, anxiety, hypothyroidism and diabetes. People who have experienced cancer, a heart attack, post-traumatic stress disorder or Parkinson's Disease are likely to be diagnosed with MDD. MDD (major depressive disorder) -------- Correct Answer --------- 5 symptoms during the same two week period that are a change from previous functioning; depressed mood and/or loss of interest/pleasure must be present; exclude symptoms clearly attributable to another medical condition Adjustment disorder with depressed mood -------- Correct Answer --------- Adjustment Disorder with Depressed Mood, also called Situational Depression, may sometimes feel nearly as bleak as MDD, but a major difference is that it does not arise out of the blue. Rather, situational depression occurs after there is a specific trauma-divorce, accident, death of loved one, a major life change... Depression Education: Older Adult -------- Correct Answer --------- Emphasize that medications should be taken as prescribed but that they may not "cure" depression; remission of symptoms is the goal but changes to therapy may need to occur to achieve remission. Medications take 4-8 weeks to alleviate symptoms in older adults. To best treat depression, concurrent nonpharmacologic interventions are indicated. The United States Preventive Services Task Force (USPSTF) recommends depression screening -------- Correct Answer --------- ·Adults 18 years of age or older and adolescents ages 12-18 years old. The American Academy of Family Physicians Recommendation -------- Correct Answer - -------- Screening for depression in the general adult population, including pregnant and post-partum women. The American Academy of Pediatrics Recommendation -------- Correct Answer --------- Maternal screening for postpartum depression at infants' 1, 2, and 4- month visits. Bright Futures program recommends annual screening in adolescent clients for emotional and behavioral problems Medicaid's child health component, the Early and Periodic Screening, Diagnosis and Treatment program -------- Correct Answer --------- screening to detect physical and mental conditions at various age intervals. If a risk is identified, the provider should follow up with diagnosis and treatment. Cause of Depression -------- Correct Answer --------- Though the exact cause is unknown, depression is influenced by genetic and environmental factors. Stressful life events, such as giving birth or experiencing emotional trauma, can contribute to the development of depression. Neurotransmitters involved in Depression -------- Correct Answer --------- An imbalance of specific neurotransmitters, including dopamine, serotonin, and norepinephrine, can influence brain activity and result in depression. lower levels of dopamine, serotonin, and norepinephrine and receptor binding Depressed patients often have decreased neurotransmitter activity in the prefrontal cortex (PFC) region of the brain. The prefrontal cortex controls attention, mood, and personality, among other functions. Symptoms of depression -------- Correct Answer --------- Depressed mood and a loss of interest or pleasure. Physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation. Clients with depression often report difficulty sleeping, lack of motivation, or trouble completing tasks. Geriatric Depression Scale (GDS): Indication for Intervention -------- Correct Answer ----- ---- The presence of depression warrants prompt intervention and treatment. The GDS may be used to monitor depression over time in all clinical settings. Any positive score above 5 on the GDS Short Form should prompt an in-depth psychological assessment and evaluation for suicidality. Patient Health Questionnaire [PHQ-9] -------- Correct Answer --------- A brief 9-item self- report questionnaire used as a screening tool to assess severity of depression; widely used by health care providers, in validity is well established, particularly for identifying severe depression. The Beck Depression Inventory (BDI) -------- Correct Answer --------- Widely used to screen for depression and to measure behavioral manifestations and severity of depression. The BDI can be used for ages 13 to 80. The inventory contains 21 self-report items which individuals complete using multiple choice response formats. The BDI takes approximately 10 minutes to complete. Validity and reliability of the BDI has been tested across populations, worldwide. Center for Epidemiologic Studies Depression Scale (CES-D) -------- Correct Answer ----- ---- Designed for use in the general population and is now used as a screener for depression in primary care settings. It includes 20 self-report items, scored on a 4-point scale, which measure major dimensions of depression experienced in the past week. The CES-D can be used for children as young as 6 and through older adulthood. It has been tested across gender and cultural populations and maintains consistent validity and reliability. The scale takes about 20 minutes to administer, including scoring. EQ-5D -------- Correct Answer --------- The EQ-5D is a standardized, non-disease specific instrument for describing and evaluating health-related quality of life. The instrument measures quality of life in five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Hamilton Depression Rating Scale (HAM-D) -------- Correct Answer --------- Mood Disorders: Depression -------- Correct Answer --------- Sadness, lethargy, inactivity and feelings of helplessness and hopelessness Genetic link Behavioral changes: slower motor reactions Cognitive changes: cognitive distortions Physical changes: alters immune functioning PQ9 Scores -------- Correct Answer --------- Depression Severity 5 - 9Mild 10 - 14Moderate 15 - 19Moderately Severe 20 - 27Severe scores current depression severity and to follow up treatment response. Bipolar I and II disorders -------- Correct Answer --------- These mood disorders include mood swings that range from highs (mania) to lows (depression). It's sometimes difficult to distinguish between bipolar disorder and depression. Cyclothymic Disorder (Cyclothymia) -------- Correct Answer --------- Involves highs and lows that are milder than those of bipolar disorder. mood disorders -------- Correct Answer --------- Psychological disorders characterized by emotional extremes that occur across a spectrum from depression to mania. Disruptive Mood Dysregulation Disorder (DMDD) -------- Correct Answer --------- This mood disorder in children includes chronic and severe irritability and anger with frequent extreme temper outbursts. This disorder typically develops into depressive disorder or anxiety disorder during the teen years or adulthood. Persistent Depressive Disorder (Dysthymia) -------- Correct Answer --------- Less severe but more chronic form of depression. While it's usually not disabling, persistent depressive disorder can prevent you from functioning normally in your daily routine and from living life to its fullest. Depressed mood, for more days than not, for ≥2 years. Impairment compared with major depressive disorder may be less severe. During the 2 years, the patient has never been without symptoms for more than 2 months at a time. Premenstrual dysphoric disorder (PMDD) -------- Correct Answer --------- Depression symptoms associated with hormone changes that begin a week before and improve within a few days after the onset of your period, and are minimal or gone after completion of your period. Depression Prevalence in older adults -------- Correct Answer --------- Depression is the second leading cause of disability in older adults after cardiovascular disease and impacts around 7% of the geriatric population Biologic factors, including changes in brain structure and neurotransmitters after a cerebrovascular accident (CVA) or with a neurodegenerative disease such as Parkinson's or Alzheimer's disease, may increase the risk of depression. Examine the image below for additional risk factors. Depression in Older Adults -------- Correct Answer --------- Depression is the second leading cause of disability in older adults after cardiovascular disease and impacts around 7% of the geriatric population. Depression often presents as a comorbidity with other physical or cognitive disease processes in older adults and may present differently than in adolescents or younger adults. Depression risk factors -------- Correct Answer --------- Chronic illness Disability/ loss of mobility Change in living situation Role transitions Loss of independence Bereavement Economic hardships Pertinent Information for an Interview: Depression -------- Correct Answer --------- socialization, including recent changes or loss ability to complete activities of daily living (ADLs) typical physical activity appetite changes weight loss or gain psychotic symptoms suicidal thoughts or ideations Independent risk factor for dementia -------- Correct Answer --------- Depression therefore it is important to evaluate cognitive function when depression is suspected. Older clients may have associated memory loss, slowed processing, or impaired executive functioning. Assessing Depression in Patients with Dementia -------- Correct Answer --------- Self- reporting scales, such as the GDS, may be inappropriate. Cornell Scale for Depression in Dementia can be used to screen not diagnose. The goal of treatment for older adults experiencing depression -------- Correct Answer --- ------ Symptom remission First Choice of Treating Depression in Older Adults -------- Correct Answer --------- SSRI & SNRI's Escitalopram, citalopram, and sertraline have fewer drug-drug interactions than other medications and are appropriate choices for initial therapy in older adults taking multiple medications. Propranolol Oral contraceptives Levodopa Isotretinoin Differentials for Depressed Mood -------- Correct Answer --------- Adjustment disorder with depressed mood Substance-/medication- or medical illness-associated and other depressive disorders Bipolar disorder Premenstrual dysphoric disorder (PMDD) Grief/bereavement Dementia Anxiety disorders Alcohol-use disorder Anorexia nervosa Hypothyroidism Medication adverse effects Cushing disease Vitamin B12 deficiency Obstructive sleep apnea (OSA) Severe depression -------- Correct Answer --------- Include those who are psychotic, suicidal, catatonic, or have severe psychomotor retardation impeding activities of daily living, or severe agitation. These patients are at increased risk for suicide, impulsive and potentially self- destructive behavior, and health complications due to poor self-care and immobility. Severe Depression w/Psychotic or Agitated Symptoms -------- Correct Answer --------- Agitated patients may also benefit from short-term treatment with a benzodiazepine, or possibly both an antipsychotic and a benzodiazepine, until definitive antidepressant therapy takes effect. Psychotic patients my need antipsychotics and antidepressants Electroconvulsive therapy (ECT) -------- Correct Answer --------- A biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient 2-3 times per week for 6-8 weeks May be used as first-line w/severe depression Mostly used after failed pharmacologic mgmt. Moderate depression treatment -------- Correct Answer --------- Moderately to severely depressed patients derive the greatest benefit from the combination of antidepressants and psychotherapy. Duration of Treatment for Depression -------- Correct Answer --------- Follow up patients 1 to 2 weeks after initiating therapy, then monthly for the next 12 weeks. Assess response with PHQ 9 Successful antidepressant therapy to the point of remission of all symptoms may be expected to take 6 to 8 weeks. A 50% decrease in symptom score constitutes an adequate response, and a 25% to 50% change in symptom score may indicate the need to modify treatment. Psychotherapy and other nonpharmacologic treatments - Depression -------- Correct Answer --------- Interpersonal psychotherapy (IPT) 12 weeks Problem-solving therapy (PST) Behavioral activation Bibliotherapy ECT Cognitive behavioral therapy (CBT) has shown greater efficacy than pharmacologic placebo across levels of severity Mild Depression Management -------- Correct Answer --------- Mild depression responds less well to antidepressant medications than severe depression. Antidepressant treatment Psychotherapy Supportive interventions: self-help books, yoga, relaxation training, light therapy, exercise, tai chi, music therapy, and acupuncture Computer-based treatment: CBT, PST, and stress management Depression unresponsive to initial therapy -------- Correct Answer --------- Switching may be appropriate if no improvement in symptoms has occurred within the first 2 weeks of treatment; however, be aware that early response may be, but is not necessarily, a reliable indicator of continued response. Severe depression, nonpregnant: psychotic, suicidal, severe psychomotor retardation impeding activities of daily living, catatonia, or severe agitation -------- Correct Answer --- ------ citalopram: 20 mg orally once daily initially, escitalopram: 10 mg orally once daily initially, fluoxetine 20 mg orally (immediate-release) once daily initially, increase gradually according to response, paroxetine 20 mg orally (immediate-release) once daily initially, increase gradually according to response, sertraline 50 mg orally once daily initially, Bipolar screening - MDQ - Mood disorder questionnaire -------- Correct Answer --------- Non-diagnostic, self-rated instrument that provides information to clients who may need additional assessment. Bipolar screening - BSS - Bipolar Spectrum Scale -------- Correct Answer --------- A self- rated instrument presented in story format that is sensitive to subtle symptoms of bipolar disorder Work-up for Mood disorder -------- Correct Answer --------- A comprehensive metabolic panel, complete blood count, thyroid function tests, or a toxicology screen. Brain imaging in the form of a computerized tomography (CT) or magnetic resonance imaging (MRI) may also be useful. A Physical exam is recommended to rule out conditions that can cause or aggravate mood disorders (e.g., hypothyroidism or hyperthyroidism, central nervous system pathology such as multiple sclerosis) and to assess for common comorbid illnesses (e.g., obesity, metabolic syndrome) Medical conditions that commonly present with symptoms that mimic mania -------- Correct Answer --------- Hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. Medications and substances with effects that mimic mania -------- Correct Answer -------- - Levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine. Drug categories used to treat bipolar disorder -------- Correct Answer --------- Lithium salts: Acts as a mood stabilizer, more effective at treating mania than depressive symptoms. Antidepressants: SSRIs may trigger manic episodes in individuals who are predisposed to them. Antipsychotics: Acts on dopamine receptors to reduce levels of excess dopamine, exhibit high affinity for D2, D3, 5-HT1A, and 5-HT2A receptors. Anticonvulsants: May be combined with other medications to treat bipolar disorder, may improve both mania and depressive symptoms. Benzodiazepines: Slows the activity of the brain resulting in a reduction of mania, anxiety, and panic disorder Young Mania Rating Scale (YMRS) -------- Correct Answer --------- A validated symptom scale with point-score ranges generally associated with degrees of severity. Measures response to treatment Brain Magnetic Resonance Imaging - Bipolar -------- Correct Answer --------- For new- onset mania or atypical presentations, MRI is recommended only to rule out an organic etiology, such as brain tumor or multiple sclerosis, although some evidence points to nonspecific whole brain and regional brain volume changes in groups of patients with bipolar disorder Bipolar - Sleep disruptions -------- Correct Answer --------- If there is a suspicion of obstructive sleep apnea, frequently comorbid with obesity, a sleep study might be recommended. Differential Diagnosis - Mood Disorders -------- Correct Answer --------- Mood disorder due to general medical condition Substance-induced mood disorder Major depressive disorder Dysthymic disorder Cyclothymic disorder Psychotic disorders Personality disorders Obsessive-compulsive disorder ADHD pharmacologic treatment for acute mania -------- Correct Answer --------- Should affect a response within 2 weeks, after which time patients should be considered non- responders to specific medication(s) at the specific dosage(s Acute management of mania or hypomania -------- Correct Answer --------- Provide initial management in a tranquil environment with reduced stimuli, and attempt verbal de- escalation lithium is effective and should be considered first line Other first-line initial options for monotherapy are divalproex sodium or an atypical antipsychotic including aripiprazole, asenapine, cariprazine, paliperidone, risperidone, or quetiapine First-line combination therapies with good evidence include combinations of lithium or divalproex sodium and an atypical antipsychotic including risperidone, quetiapine, aripiprazole, or asenapine. Aggressive management of acute mania -------- Correct Answer --------- Administration of a rapidly acting nonoral antipsychotic or benzodiazepine may be necessary. Suggested first-line options include intramuscular olanzapine, inhaled loxapine, or intramuscular lorazepam.[ Mania without agitation management -------- Correct Answer --------- First-line combination therapies with good evidence include combinations of lithium or divalproex sodium and an atypical antipsychotic including risperidone, quetiapine, aripiprazole, or asenapine expect some response to treatment within 1 to 2 weeks electroconvulsive therapy (ECT) Bipolar -------- Correct Answer --------- For patients who are more severely ill, catatonic, or not responding to several trials of medication. It may also be considered when the medication risks outweigh ECT risks (e.g., in older or medically frail patients), or if the patient prefers this option. First-line options for the acute management of bipolar I depression -------- Correct Answer --------- Quetiapine, lamotrigine, lithium, lurasidone Acute management of acute bipolar II depression -------- Correct Answer --------- Mood stabilizers and antipsychotics Quetiapine monotherapy is recommended first line - Assess response after 2 weeks of treatment; Lithium and lamotrigine are second-line options Treating Patients with rapid cycling -------- Correct Answer --------- Remove any factors that may destabilize mood: antidepressant and psychostimulant medications, alcohol or illicit drugs, excessive caffeine intake, unnecessary hormonal treatments, diet pills or over-the-counter "remedies", or untreated hypothyroidism. Rapid-cycling bipolar disorder is well known for its relative resistance to most monotherapies, usually requiring combinations of mood stabilizers. Adding a second or third mood stabilizer may be necessary. Lithium -------- Correct Answer --------- Is safe, effective, and cost-effective; bipolar disorder requires lifelong treatment, and lithium remains the definitive maintenance therapy. Decreases Suicide risk Lithium has the strongest evidence for prevention of recurrence in bipolar disorder compared with other agents and remains the treatment of choice for long-term maintenance therapy, is effective against relapse of both manic and depressive symptoms Onset of mania after age 60 years -------- Correct Answer --------- more likely associated with a general medical condition (such as stroke or other brain lesion) than with bipolar disorder. "Start low and go slow" with the dosing Patients who are Pregnant and Manic -------- Correct Answer --------- Valproate and its analogs carry a particularly high risk of birth defects and developmental disorders prescribe the lowest effective doses of monotherapy Anticonvulsant mood stabilizers used during pregnancy are associated with increased risk of fetal malformations. Prenatal vitamins including high-dose folic acid are recommended prior to conception and throughout pregnancy Lomotrigine (Lamictal) Rash -------- Correct Answer --------- Stevens-Johnson syndrome Lithium toxicity -------- Correct Answer --------- Signs and symptoms of lithium toxicity usually emerge at blood levels >1.5 mEq/L, neurologic (fine tremor, gait abnormality, hyperreflexia), gastrointestinal (nausea, vomiting, diarrhea), and cardiovascular (bradycardia, T-wave changes, conduction blocks). lithium (2.5 to 3.5 mEq/L), slurring of speech, myoclonus, and a coarsening of the tremor may occur. Lithium blood levels >3.5 mEq/L are life-threatening, as renal failure, stupor, seizures, and cardiovascular collapse are likely Medications for depression -------- Correct Answer --------- SSRIs SNRIs SDRIs TCAs MAOIs SSRIs -------- Correct Answer --------- -Action: inhibit 5-HT reuptake -Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline -Comorbidities -Half-life and interactions -Cost if a medication is not achieving efficacy: -------- Correct Answer --------- -Increase dose gradually -Switch to a different drug within the same class -Switch to drug in a different class -Add a second medication Use to protect against suicide -------- Correct Answer --------- lithium MDD and BPD genetics -------- Correct Answer --------- genetic factors contribute 31- 42% of the disease risk in MDD and 59-85% in BPD monoamine hypothesis of depression -------- Correct Answer --------- -posits that depression occurs as a result of a deficiency of one or all three monoamine transmitters • serotonin, norepinephrine, and dopamine -while mania may result from an excess *Emphasis is now shifted from the monoamines to their receptors and other downstream events such as the regulation of gene expression, growth factors, environmental factors, and epigenetic changes -------- Correct Answer --------- Three principal neurotransmitters -norepinephrine (NE), dopamine (DA), and serotonin 5HT • comprise the monoamine neurotransmitter system • implications for the pathophysiology and treatment of mood disorders • All known pharmacologic treatments for mood disorders act upon one or more of these three neurotransmitters -Many of the symptoms of mood disorders are hypothesized to involve dysfunction of various combinations of the monoamine neurotransmitters Mood disorders include ____________________ and ___________________ -------- Correct Answer --------- depressive disorders and bipolar disorders Major depressive disorder (MDD) -------- Correct Answer --------- one of the most prevalent psychiatric disorders -estimated that more than 300 million people suffer from -leading cause of disability worldwide -7.1% of adults and 13.3% of adolescents in the U.S. had at least one major depressive episode -An imbalance of specific neurotransmitters, including dopamine, serotonin, and norepinephrine, can influence brain activity and result in depression -decreased neurotransmitter activity in the prefrontal cortex (PFC) MDD dx -------- Correct Answer --------- -occurrence of at least one episode of major depression lasting at least two weeks. -must experience 5 or more of the following symptoms in two weeks to be diagnosed with a major depressive episode: • feeling low most of the day for most days • decreased interest in activities • substantial weight loss, significant change in appetite • fidgeting, random movement (i.e. pacing) • decreased energy • sense of guilt or worthlessness • lack of focus or ability to make decisions • repeated thoughts of death and suicide risk factors associated with major depressive disorder (MDD) -------- Correct Answer ---- ----- female gender older adults with multiple health problems and disabilities non-white populations family history of MDD, suicide attempts and completion, substance abuse history of abuse/neglect financial, job loss, divorce, or other life stressors low socioeconomic status lack of relationships and support systems Certain conditions are associated with depression, including: -------- Correct Answer ----- ---- epilepsy post-stroke Parkinson's disease multiple sclerosis degenerative brain disease Alzheimer's disease coronary artery disease depression in malignancy hypothyroidism hyperthyroidism hyperparathyroidism Cushing's syndrome Addison's disease diabetes mellitus key symptoms of depression: -------- Correct Answer --------- depressed mood and a loss of interest or pleasure -may also present with physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation -often report difficulty sleeping, lack of motivation, or trouble completing tasks -severe cases, depressed clients may report delusions or hallucinations -may even present as catatonia MDD by severity: mild, moderate, or severe -------- Correct Answer --------- Mild: The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis. Moderate: The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe: The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis. melancholic features -------- Correct Answer --------- Symptoms worse in the morning, excessive guilt, significant weight loss atypical features -------- Correct Answer --------- Weight gain, hypersomnia, heavy feeling in arms or legs Screening tools for depression severity -------- Correct Answer --------- -Patient Health Questionnaire (PHQ) -Beck Depression Inventory-II (BDI-II) -Hamilton Depression Rating Scale (HAM-D) -Edinburgh Postnatal Depression Scale (EPDS) in post-partum and pregnant women -Children's Depression Inventory (CDI) -Children's Depression Rating Scale (CDRS) -Geriatric Depression Scale (GDS) in older adults The United States Preventive Services Task Force (USPSTF) recommends depression screening: -------- Correct Answer --------- for adults 18 years of age or older and adolescents ages 12-18 years old. The American Academy of Family Physicians recommends screening for depression in: -------- Correct Answer --------- the general adult population, including pregnant and post- partum women. The American Academy of Pediatrics recommends maternal screening for postpartum depression at: -------- Correct Answer --------- infants' 1, 2, and 4- month visits. The American Academy of Pediatrics' Bright Futures program recommends: (screenin) - ------- Correct Answer --------- annual screening in adolescent clients for emotional and behavioral problems. Medicaid's child health component, the Early and Periodic Screening, Diagnosis and Treatment program recommends: -------- Correct Answer --------- screening to detect physical and mental conditions at various age intervals. If a risk is identified, the provider should follow up with diagnosis and treatment. -three or more of the following symptoms (APA, 2022) must be present and represent a significant change from usual behavior: • inflated self-esteem or grandiosity • decreased need for sleep • increased talkativeness • racing thoughts • distracted easily • increase in goal-directed activity or psychomotor agitation • engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees dx hypomania -------- Correct Answer --------- must experience symptoms for at least four consecutive days with symptoms present most of the day and nearly every day. -energy level is higher than normal but not as high as with mania -episodes can lead to challenges but do not tend to lead to major issues with daily functioning -episodes do not involve psychotic symptoms and are less likely to lead to hospital visits. Bipolar disorder triggers -------- Correct Answer --------- Environmental factors can trigger -Selective Serotonin Reuptake Inhibitors (SSRIs) can trigger manic episode -Stimulant drugs can be legal or illegal -Changes in circadian rhythm (could be due to shift work or change in time zones) -Life stressors Clinical presentation: Bipolar Tyle I -------- Correct Answer --------- at least one episode of mania for at least one week (or any hospitalization) -Hypomanic episodes may also occur -MDD episodes are common in bipolar I (not req for diagnosis) Clinical presentation: Bipolar Tyle II -------- Correct Answer --------- at least one major depressive episode and at least one current or past hypomanic episode, but no full mixed or manic episode -symptoms last for at least four days, but fewer than seven and include the same symptoms as mania without causing severe impairment or requiring hospitalization -Psychotic features are not present with bipolar II disorder, although irritability and anger are common. Carlo is a 24-year-old married auto mechanic who works full-time. His wife reports that he began several home repair projects about three weeks ago "out of the blue." He is painting the exterior of the home, remodeling a bathroom, and digging a new garden. He used to sleep 6-7 hours per night, but he is now sleeping about 3 ½ hours per night. Although Carlo has no history of bipolar disorder, his wife is concerned that this may be a manic episode. Her father was diagnosed with bipolar I disorde -------- Correct Answer --------- unable to determine Rationale: Carlo meets category A criteria (abnormal and persistent increased activity lasting at least one week) and two diagnostic criteria in category B for bipolar I disorder (decreased need for sleep and increase in goal-directed activity). However, three symptoms are required for diagnosis; more information is needed to determine if Carlo is experiencing additional symptoms or if his behaviors are significantly impacting his occupational or social interactions. In addition, the PMHNP should inquire about the use of medications and/or legal and illegal stimulants to determine if they may be impacting Carlo's behavior. Rapid cycling -------- Correct Answer --------- four or more episodes of depression and mania occur within one year Cyclothymia -------- Correct Answer --------- numerous episodes of hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode -at least two consecutive years during which clients are symptomatic at least half the time and not symptom-free for more than two consecutive months Tariq is a 22-year-old who presents with symptoms of racing thoughts and an inability to pay attention in his college classes. He is currently failing most of his courses. He feels like he needs to talk constantly. He calls friends at all hours and tries to engage strangers in conversation. He also reports feeling restless and tense. He has experienced these symptoms continuously for the past two weeks. His toxicology screen is negative, and he takes no medications. What is the appropriate ICD-1 -------- Correct Answer --------- F31.89 Rationale: The ICD-10 code is F31.89 bipolar 1 disorder with anxious distress. Tariq meets diagnostic criteria for Bipolar I, with symptoms including racing thoughts, difficulty paying attention, and constant talking. He is experiencing consequences from his behavior as he is failing classes. He has experienced the symptoms for two weeks. Because he also has symptoms of restlessness and increased tension, he also meets the qualifying diagnostic criteria for anxious distress. Savannah is a 32-year-old who presents with her husband. Her husband states that Savannah has spent thousands of dollars on new clothing and shoes in the past month. The clothing she has purchased is much more revealing than her typical wardrobe. She is sleeping for just a few hours per night. She is spending hours on Twitter and is constantly boasting about how many retweets she receives and how many followers she has. Two days ago, Savannah reported that the drummer of her favorite band began -------- Correct Answer --------- F31.2 Rationale: The ICD-10 code is F31.2 bipolar 1 disorder with mood-congruent psychotic features. Savannah meets diagnostic criteria for bipolar I, with symptoms of grandiosity, decreased sleep, and excessive shopping. She is experiencing impairment in social and occupational functioning. She has experienced these symptoms for a month. Because Savannah is also experiencing delusional thinking consistent with her mood, she also meets the criteria for mood-congruent psychotic features. Vladimir is a 25-year-old who presents with feelings of racing thoughts. His thoughts are centered on feelings of worthlessness. He reports feeling very fatigued and continually paces around the room. He has been irritable and easily distracted for the last two weeks. He endorses an increase in sexual behavior, including several recent episodes of unprotected sex with multiple partners. He admits to having suicidal ideations. What is the appropriate ICD-10 code for Vladimir? -------- Correct Answer --------- F31.12 Rationale: The ICD-10 code is F31.12 bipolar 1 disorder manic episode with mixed features. Vladimir meets diagnostic criteria for bipolar I disorder, with symptoms including racing thoughts, psychomotor agitation, distraction, risky behaviors, and irritability for the past two weeks. Because he also endorses fatigue, feelings of worthlessness, and suicidal ideation, he meets the criteria for a manic episode with mixed features. Screening tools for bipolar disorders: -------- Correct Answer --------- Mood disorder questionnaire -a non-diagnostic, self-rated instrument that provides information to clients who may need additional assessment. Bipolar spectrum diagnostic scale -a self-rated instrument presented in story format that is sensitive to subtle symptoms of bipolar disorder Medical Diagnoses that Mimic Bipolar Disorder -------- Correct Answer --------- - hyperthyroidism -hyperaldosteronism -brain tumor -neurocognitive disorder -delirium Rationale: Medical conditions that commonly present with symptoms that mimic mania include hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. medications or substances commonly cause symptoms that mimic mania? -------- Correct Answer --------- steroid medications hallucinogens methamphetamine marijuana Rationale: Medications and substances with effects that mimic mania include levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine. -typical physical activity -appetite changes -weight loss or gain -psychotic symptoms -suicidal thoughts or ideations Bipolar Lifespan considerations: older adults -------- Correct Answer --------- Approximately 10% of bipolar cases are diagnosed after the age of 50 -mania is more likely to be expressed as agitation or irritability rather than euphoria -more likely to experience mixed episodes -Late-onset bipolar disorder may be difficult to distinguish from dementia Geriatric Depression Scale (GDS) -------- Correct Answer --------- self-reporting tool that may be used to diagnose and treat depression 0-4: No depression No treatment indicated 5-8: Mild depression Pharmacologic or psychotherapeutic treatment may be indicated Base treatment on duration of symptoms and functional impairment 9-11: Moderate depression Pharmacologic, psychotherapeutic, or combination treatment indicated 12-15: Severe depression Pharmacologic, psychotherapeutic, or combination treatment indicated It is important to evaluate _______________ when depression is suspected -------- Correct Answer --------- cognitive function -Older clients may have associated memory loss, slowed processing, or impaired executive functioning • Depression is an independent risk factor for dementia • A Mini-Cog or other cognitive screening tool can provide a baseline assessment for clients In clients who have dementia, self-reporting scales, such as the GDS, may be inappropriate. The __________________________________ may be used as an alternative -------- Correct Answer --------- Cornell Rating Scale for Depression in Dementia goal of treatment for older adults experiencing depression -------- Correct Answer --------- achieve symptom remission -Options • pharmacotherapy • psychotherapy • psychosocial interventions Depression tx for older adult: Pharmacologic -------- Correct Answer --------- SSRIs & SNRIs -Escitalopram, citalopram, and sertraline have fewer drug-drug interactions than other medications and are appropriate choices for initial therapy in older adults taking multiple medications Depression tx for older adult: Nonpharmacologic -------- Correct Answer --------- Engagement Social support Exercise Relaxation DIGFAST -------- Correct Answer --------- mnemonic that may be helpful to assess for bipolar disorder in the clinical setting: Distractibility Impulsivity Grandiosity Flight of ideas Activity level Sleep Talkativeness Neurocognitive disorders -------- Correct Answer --------- delirium and dementia Dementia -------- Correct Answer --------- -a group of symptoms that mainly affects memory, cognition and social interactions, and the ability to do everyday tasks. -Symptoms start gradually often with no clear beginning, and are usually permanent. -Most dementias are caused by neurodegenerative diseases, most commonly Alzheimer's disease, Lewy body dementia and frontotemporal dementia • clumps of abnormal proteins to build up inside neurons, damaging them, and causing them to slowly degenerate and die -vascular dementia is another common cause of progressive dementia • brain damage occurs when the blood supply to the neurons is reduced or blocked, again causing them to malfunction or die -Cognitive Symptoms: Difficulty with complex tasks, Difficulty planning and organizing, Loss of coordination -Psychological symptoms: Personality changes, Inappropriate behaviour, Paranoia, Fear, anxiety, anger or depression. Delirium -------- Correct Answer --------- ACUTE SUDDEN CHANGE IN MENTAL STATE -typically begins suddenly with a noticeable start point. -mainly affects attention, and often resolves after a few days or weeks, although it can last longer. -acute, transient, and usually reversible brain malfunction -thought to be brought on by multiple neurotransmitter imbalances Delirium symptoms -------- Correct Answer --------- -Cognitive Symptoms: Rambling or nonsense speech, Difficulty reading and writing, Wandering attention, Becoming easily distracted, Becoming withdrawn, -Psychological symptoms: Inability to focus, Reduced awareness of the environment, Disturbed sleep -May have hallucinations -symptoms can fluctuate throughout the day causes of delirium -------- Correct Answer --------- -lack of oxygen -drugs • anticholinergics • psychoactives • opioids -withdrawal • delirium tremens -stressful situations -dehydration & electrolyte imbalance infections tell the difference between delirium and dementia -------- Correct Answer --------- onset attention do symptoms fluctuate? Alzheimer's disease -------- Correct Answer --------- -type of dementia • 60-80% of dementias -neurodegenerative disease -Hallmarks: • plaques - abnormal protein (beta-amyloid plaques) between neurons • tangles - tau protein inside neurons (neurofibrillary tangles) Alzheimer's disease brain progression -------- Correct Answer --------- -Plaques & tangles usually start forming and spread from the cortex • earliest areas affected temporal lobe (learning & memory) • as it spreads goes to frontal lobe (thinking & planning) • then more temporal (speaking & communicating) • then parietal lobe (sense of where body is in relation to objects around you) • severe & late Alzheimer's disease, plaques & tangles spread throughout most of cortex, brain shrinks (atrophy) dramatically (atrophy primarily affects hippocampus and cerebral cortex) Vascular dementia -------- Correct Answer --------- -20-30% of dementia cases -lack in blood supply to the brain -changes -stage 6: moderatly severe alzheimer's disease, help with basic daily tasks, lasts 2.5 years -stage 7: final stage, speech severely limited, decline in basic abilities, movement abilities affected Diagnosis of dementia and Alzheimer's disease -------- Correct Answer --------- -Patient History -Physical Exam -neurological eval -neuropsychological test • MMSE: scores 20-24 mild dementia, 13-20 moderate, <13 severe dementia • mini-cog test -Psychiatric evaluation -Brain scans • CT scans • MRI • reason for brain scans: ID larger masses, differential diagnosis, monitor disease progression, research purposes Other conditions that can cause dementia like symptoms -------- Correct Answer --------- anemia depression infection diabetes kidney disease etc. Treatment of dementia and Alzheimer's disease -------- Correct Answer --------- No Cure -Medications lesson symptoms -meds target neurotransmitters: • acetylcholine • glutamate -Cholinesterase Inhibitors -Memantine Cholinesterase Inhibitors -------- Correct Answer --------- acetylcholine neurotransmitter -helps neurons communicate Acetylcholinesterase -breaks down acetylcholine CHOLINESTERACE INHIBITORS -stop acetylcholinesterase from breaking down acetylcholine • allowing more acetylcholine to build up, helping neurons communicate -delay worsening dementia symptoms for 6-12 months • for about 1/2 of patients -side effects: N/V, loss of appetite Medication: -Donepezil (Aricept) -Rivastigmine (Exelon) -Galantamine (Razadyne, Razadyne ER) Memantine -------- Correct Answer --------- Glutamate -excitatory neurotransmitter -normal levels: learning & memory -too high: toxic (excitotoxicity) • cell too stimulated, may die -Memantine blocks NMDA receptor for glutamate, keeping channel closed so too many ions do not get in so cell doesn't get excitotoxicity -used to tx moderate to severe alzheimer's disease -often taken with cholinesterase inhibitors -side effects: headache, confusion, dizziness Medication: -Memantine (Namenda) heritability of AD -------- Correct Answer --------- late-onset AD showing heritability of 58- 79% and early-onset AD showing over 90% Donepezil (Aricept) -------- Correct Answer --------- -inhibits centrally active acetylcholinesterase -Side effects: • GI symptoms, headache, dizziness, muscle weakness -Precautions: • sick sinus syndrome • seizure disorder -Pearls: • Taper to avoid withdrawal effects • approved to treat moderate to severe AD at 23 mg/day dose, minimal improvement in cognitive functioning when compared to a 10 mg/day dose • added to CYP2D6 or CYP3A4, there is a possibility of peripheral side effects, and inducers of CYP2D6 and CYP3A4 may increase the rate of elimination Rivastigmine (Exelon) -------- Correct Answer --------- -acts centrally for both acetylcholinesterase and butyrylcholinesterase • potentially increasing its efficacy -side effects: • GI symptoms, weakness, dizziness, tremor -Precautions • asthma or COPD • sick sinus syndrome • GI Bleeding • weight < 50 kg -Pearls: • orally or topically (transdermal patch) • transdermal patch is used for dementia associated with Parkinson's disease Galantamine (Razadyne, Razadyne ER) -------- Correct Answer --------- -elevating acetylcholine (Ach) in the cerebral cortex, modulating the nicotinic Ach receptors to increase Ach release from existing presynaptic nerve terminals, increases glutamate and serotonin levels -Side effects: GI symptoms, headache, dizziness, fatigue -Precautions: • NSAID use • GI bleed • asthma or COPD • concurrent use with medications that slow or decrease heart rate -Contraindications • severe hepatic impairment • severe renal impairment -Pearls • two major metabolizing enzymes CYP3A4 and CYP2D6 increase galantamine concentrations or reductions in clearance and anticholinergic side effects when given concurrently with inhibitors of these enzymes Memantine (Namenda) -------- Correct Answer --------- -prevents glutamate, an excitatory neurotransmitter, from binding at the receptor site. • NMDA receptors control activity throughout the brain by regulating how much calcium enters the nerve cell -Side effects: GI symptoms, urinary freq, confusion, dizziness, headache, cough -Precautions: • concurrent use with (amantadine, rimantadine, ketamine, or dextromethorphan) • severe hepatic impairment • severe renal impairment • medications or conditions that increase the pH of the urine -Pearls: • used as monotherapy or in conjunction with ChEIs; when given with ChEIs, fall precautions are required and driving is forbidden due to delayed reactions. • Minimal inhibition of CYP450 enzymes CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, and CYP3A4 occurs, which means there are no pharmacokinetic interactions with medications metabolized by these enzymes Cognitive Domains -------- Correct Answer --------- Complex attention Executive function Learning and memory Language Perceptual motor Social cognition Rationale: The classification of severity and behavioral symptoms for Lisheng is mild without behavioral disturbance. Lisheng presents with difficulties with instrumental ADLs, such as managing money and driving, consistent with mild severity of NCD. Neither she nor her daughter indicates any behavioral disturbance, such as apathy, depression, or agitation. Clinical Presentation: Mild or Major NCDs due to AD -------- Correct Answer --------- AD - approximately 60-70% of cases of dementia AD results in substantial cognitive and functional impairment -neurodegenerative complications • loss of function and cell death Stages of AD: -------- Correct Answer --------- Stage 1 Normal Aging: No difficulty either subjectively or objectively Stage 2 Possible Mild Cognitive Impairment: Complains of forgetting the location of objects, subjective work difficulties Stage 3 Mild Cognitive Impairment: Decreased job functioning evident to co-workers, difficulty in traveling to new locations, decreased organizational capacity (developmental age 12+). Stage 4 Mild Dementia: Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty shopping, etc. (developmental age 8-12) Stage 5 Moderate Dementia: Requires assistance in choosing proper clothing to wear for the day, season, or occasion, e.g., client may wear same clothing repeatedly unless supervised (developmental age 5-8) Stage 6 Moderately Severe Dementia: Needs help putting on clothes (developmental age 5). Needs help bathing (developmental age 4). Need helps using the toilet (developmental age 3-4). Urinary incon Clinical Presentation: Other Mild and Major NCDs -------- Correct Answer --------- Additional diagnoses may be considered as differentials for a client with cognitive impairment -delirium -depression -schizophrenia -head trauma • place the client's health and safety in immediate danger and, if unrecognized, may result in poor outcomes. Tonia is a 66-year-old who presents with memory difficulty. She states she can't remember anything for longer than a few minutes. She also states that she is having difficulty making complex decisions. She also "doesn't want to do anything anymore." She has stopped attending her exercise class and lunch bunch social club because she no longer has an interest in these activities. She feels "down" every day. Her symptoms began 6 weeks ago, and she has never experienced anything like this. Which of -------- Correct Answer --------- Major depressive disorder Rationale: Tonia is most likely experiencing major depressive disorder (MDD). The hallmark features that indicate MDD are depressed mood or loss of interest in usual activities. Although memory difficulties and loss of concentration are common with MDD, they are not predominant features. Daron is a 72-year-old who presents with complaints of memory changes. He states he often walks into a store and forgets why he is there. He reports that he frequently struggles to find the right word to complete a sentence. He endorses difficulty in organizing his monthly finances, although he has not missed any bill payments. He states that he has also been feeling "down" lately. His past history includes hypertension and carotid endarterectomy. Which of the following diagnoses is most appropr -------- Correct Answer --------- Vascular neurocognitive disorder Rationale: Daron's symptoms indicate a possible diagnosis of mild vascular neurocognitive disorder. He presents with memory loss, difficulty in executive function, and feelings of depressed mood, which are frequently associated with vascular NCD. He has cardiovascular risk factors, including hypertension and a past vascular intervention. The PMHNP should ask about symptoms of TIA or CVA, and imaging studies should be conducted to confirm the diagnosis. Trent is a 75-year-old who presents with changes in cognition. He states that there are times that he cannot follow a TV show or decide what to have for dinner, and then the next day, his attention and functioning seem intact. This type of fluctuation is common. He states that he has experienced some very vivid visual hallucinations. He has had several falls in the past few months and has started to use a walker due to his instability. Which of the following diagnoses is most appropriate for Tre -------- Correct Answer ------ --- NCD with Lewy bodies Rationale: Trent's symptoms are consistent with NCD with Lewy bodies. Hallmark features include fluctuating cognitive symptoms with deficits often seen in attention and executive function, vivid visual hallucinations, and repeated falls. As the disease develops, clients may develop motor deficits similar to those seen in Parkinson disease. The PMHNP should conduct additional detailed cognitive testing, including assessment scales to measure fluctuation of symptoms and sleep symptoms, and imaging studies should be conducted to rule out other forms of NCD. Cassie is a 56-year-old professor of economics. Her partner endorses recent changes in Cassie's behavior; she refuses to throw anything away and has begun to hoard food items in the home, and has lost interest in socializing with their friends. She also appears to have difficulty finding words during conversations. She does not have complaints of memory loss. Which of the following diagnoses is most appropriate for Cassie? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy -------- Correct Answer --------- Frontotemporal neurocognitive disorder Rationale: Cassie's symptoms are consistent with frontotemporal NCD. Hallmark features include behavioral disturbances such as impulsivity, socially inappropriate behavior, hoarding, or apathy; personality changes; and decline in language abilities. Memory is typically intact. Frontotemporal NCD presents at an earlier age than many other forms of NCD. Imaging studies should be conducted to rule out other forms of NCD; frontal lobe atrophy is commonly seen on the CT scan. Dae is a 72-year-old who presents with complaints of increasing memory loss; he is having difficulty remembering things that happened recently. He states that his wife has started preparing his medications after he missed a few doses. He also complains of apathy and daytime sleepiness. Walter was diagnosed with Parkinson's disease three years ago; he has experienced motor symptoms, but the cognitive symptoms are new to him. Which of the following diagnoses is most appropriate for Dae? Major dep -------- Correct Answer --------- Neurocognitive disorder due to Parkinson's disease Rationale: Since Dae has an existing diagnosis of Parkinson's disease, he may meet the criteria for NCD due to Parkinson's disease. In addition to memory loss and decreased executive functioning, symptoms often include apathy, depressed mood, visual hallucinations, and daytime sleepiness. Isaiah is a 28-year-old who presents with difficulty concentrating. He states that he cannot follow conversations when more than one person is talking, and he is having problems at work completing multi-step tasks. He endorses feelings of irritability. He was involved in a motor vehicle crash two days ago; he hit his head on the windshield and briefly lost consciousness. He was treated and released from the emergency department after the crash. Which of the following diagnoses is most appropriat -------- Correct Answer --------- Mild neurocognitive disorder due to traumatic brain injury Rationale: Isaiah meets diagnostic criteria for mild NCD due to traumatic brain injury; he sustained a head injury with loss of consciousness and his symptoms of difficulty with complex and sustained attention began shortly after the injury. Emotional disturbances, neuropsychological exam will help identify areas of cognitive impairment and aid in the creation of a comprehensive management plan. Note, the first course of action was to eliminate any underlying medical issues that could explain the concerning behaviors. Chantoya, a 78-year-old female, is being seen for her annual wellness exam. During the exam, she reports that, over the past year, she has had trouble finding her words and expressing her thoughts and feelings. She worries that this may be indicative of a stroke or Alzheimer's disease. Chantoya has a positive medical history for significant coronary artery disease, hypertension, and dyslipidemia. She denies recent surgeries. Her vital signs and recent lab values are normal. Her physical and neur -------- Correct Answer --- ------ Reassurance Rationale: Chantoya's MoCA assessment was negative and her symptoms align with expressive aphasia which can be attributed to aging. An MRI may be warranted if major cognitive impairment or pathologies were identified in the assessments. If the MoCA assessment indicated impairment in a specific part of the brain, referral to neurology for follow-up interventions would be indicated. Normal aging processes may manifest as mild short-term memory loss, a slight loss in processing speed, and expressive aphasia (the inability to find words); No significant loss of function in the cognitive domains or the activities of daily living are seen. Possible differential diagnoses for delirium include: -------- Correct Answer --------- dementia pain CVA or TIA myocardial infarction acute systemic infection hypoglycemia hyperglycemia hypoxia hypercapnia acute urinary obstruction alcoholic ketoacidosis haptic encephalopathy renal failure electrolyte imbalance meningitis brain tumor dehydration constipation urinary tract infection Unlikely but possible diagnoses for dementia include: -------- Correct Answer --------- amnestic syndromes aphasia brain tumors thyroid imbalances Wilson's disease vitamin B12 deficiency Lyme disease tuberculosis late-stage syphilis what Diagnostic testing can be used to narrow the list of possible diagnoses for clients who present with cognitive deficits. -------- Correct Answer --------- Laboratory -blood chemistry profiles (including glucose, sodium, potassium, chlorine, bicarbonate, bun, and creatinine) -fasting blood glucose -CBC with differential -TSH -cobalamin level -folate level -ESR -CRP -urinalysis with culture -chest x-ray -HIV testing in those considered at risk -syphilis testing -urine toxicology panel (for opiates, benzodiazepines, cannabinoids, and cocaine) -collagen vascular profile (if there is evidence of systemic vascular involvement) -urinalysis for heavy metals Neuroimaging -CT to identify if there are any brain tumors or structural issues -MRI to identify atrophy, vascular lesions -neurofibrillary tangles -amyloid plaques -fluorodeoxyglucose (FDG)-positron emission tomography (PET) can provide better accuracy than MRI -amyloid PET can make an earlier and more accurate diagnosis of Alzheimer dementia Dementia: Pharmacological Interventions -------- Correct Answer --------- N-methyl-D- aspartate (NMDA) or cholinesterase inhibitors to treat symptoms related to memory and thinking -aducanumab, an intravenous drug that changes the disease progression to reduce cognitive and functional decline Aducanumab -------- Correct Answer --------- has been used with clients with mild dementia in clinical trials. This drug acts by binding to and reducing amyloid-beta plaque in the brain. A client with Alzheimer's dementia is prescribed donepezil. Which of the following is the most anticipated client outcome? cured Alzheimer's disease complete return of cognitive function prevention of further cognitive and functional decline improved memory and thinking -------- Correct Answer --------- improved memory and thinking Rationale: The effect of donepezil is to increase the availability of acetylcholine, which results in enhanced transmission and improved cognition. Donepezil does not cure Alzheimer's disease, result in a complete return of cognitive function, or prevent further decline, although it may slow progression. Personality disorders involve: -------- Correct Answer --------- -"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" per the Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) -pervasive unhealthy patterns of thinking, functioning, and behaving -usually begins by late adolescence or early adulthood and causes distress or problems in functioning -affect at least two of these areas: • Way of thinking about oneself and others • Way of responding emotionally • Way of relating to other people • Way of controlling one's behavior -Diagnosis is only applicable to individuals 18 or older • People under 18, personalities are still developing -3 clusters • A, B, C -occur in 10-20% of the general population and about 50% of psychiatric clients personality disorders should not be diagnosed unless: -------- Correct Answer --------- the symptoms are long-standing and impact functioning. Cluster A -------- Correct Answer --------- Cluster A personality disorders are characterized by odd or eccentric thinking or behavior. -PARANOID PERSONALITY DISORDER • long-standing, pervasive mistrust or suspicion of others and their motives • may refuse to take responsibility for their feelings, often assigning responsibility to others • may appear angry, irritable, or hostile, perceiving innocent remarks as personal insults or attacks -SCHIZOID • lifelong pattern of social withdrawal, introversion, and discomfort with social interaction • detachment • antagonism • disinhibition • psychoticism Personality disorders Screening Tools -------- Correct Answer --------- • Personality Diagnostic Questionnaire - 4th edition • McLean Screening Instrument • Zanarini Rating Scale for Borderline Personality Disorder • Narcissistic Personality Inventory • Elemental Psychopathy Assessment • Schizotypal Personality Questionnaire • Obsessive-Compulsive Inventory -Revised • Observer-rated structured interviews Personality Diagnostic Questionnaire - 4th edition (PDQ-4) -------- Correct Answer -------- - -a self-administered true-false survey -survey is 100 questions long -questionnaire may be helpful to ID progress in tx for clients. McLean Screening Instrument & Zanarini Rating Scale for Borderline Personality Disorder -------- Correct Answer --------- brief self-assessments to assist in diagnosing borderline personality disorder Narcissistic Personality Inventory -------- Correct Answer --------- a self-assessment for narcissistic personality disorder Elemental Psychopathy Assessment -------- Correct Answer --------- may be used to assist with the diagnosis of antisocial personality disorder Schizotypal Personality Questionnaire -------- Correct Answer --------- a self-assessment for schizotypal personality disorder. Obsessive-Compulsive Inventory -Revised -------- Correct Answer --------- a self- assessment for obsessive-compulsive personality disorder. Observer-rated structured interviews -------- Correct Answer --------- -available to assess for personality disorders -Specialized training is required to conduct these assessments. Treatment of Personality Disorders -------- Correct Answer --------- Treatment plans are typically multifaceted, combining psychotherapy and pharmacotherapy -Nonpharmacologic Treatment • primary treatment is psychotherapy; promotes insight into disorder & helps client learn to cope with symptoms, understand the impact of their behavior on others, develop more adaptive solutions in their social interactions. • behavioral therapy, group therapy, social skills training, intensive psychotherapy, psychoanalytic therapy, and dialectical behavior therapy • therapeutic approaches: occupational, recreational, and vocational therapy -Pharmacologic Treatment • can help target specific symptoms to relieve distress and reduce risky or self- destructive behaviors or conflict with others • early pharmacotherapy to stabilize affect and behavior may be warranted • reduction of symptoms may help support participation in other psychotherapeutic approaches • antidepressants, antianxiety medications, or mood stabilizers Diagnosis of antisocial personality disorder is not used in _________________ -------- Correct Answer --------- individuals younger than 18 Symptoms of personality disorders begin _________________________ -------- Correct Answer --------- -no later than early adulthood • however, some individuals may not come to clinical attention until later in life when symptoms are exacerbated by the loss of a stabilizing or supportive person in the individual's life clusters Safety Concerns: borderline personality disorder -------- Correct Answer --------- increased risk for death by suicide, self-harm, or engagement in risky behaviors. Safety Concerns: antisocial personality disorder -------- Correct Answer --------- may be at risk for harm to themselves or others. -A safety plan is a critical part of treatment for clients with safety risks • provider and client should build the plan collaboratively • should help the client ID warning signs, employ coping strategies, & should ID supportive people or resources in their lives • Means of suicide or self-harm may need to be removed from the environment. Substance use disorder occurs when: -------- Correct Answer --------- the recurrent use of a substance, such as alcohol or drugs, causes clinically significant impairment -including health problems, disability, or failure to meet responsibilities at home, work, or school Tolerance -------- Correct Answer --------- With repeated ingestion of a drug, the drug shows decreased effect. Increasing doses are required to achieve the effects noted with the original administration Dependence -------- Correct Answer --------- State of adaptation produced with repeated administration of certain drugs so that physical symptoms occur when the drug is discontinued abruptly. Addiction -------- Correct Answer --------- A change in behavior caused by biochemical changes in the brain after continued substance use characterized by preoccupation with and repeated use of a substance despite of negative outcomes. Withdrawal -------- Correct Answer --------- Physiological and psychological reactions that occur when the use of a substance is stopped abruptly. Intoxication -------- Correct Answer --------- Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. Bernita is a 64-year-old who has been using heroin for 6 years. She is currently unemployed and lives with her daughter in the city center. She does not have health insurance. prescribe the proper medication: Methadone Buprenorphine Buprenorphine plus naloxone (Suboxone) Naltrexone -------- Correct Answer --------- Methadone Methadone is a full μ-receptor agonist with a long half-life, which can prevent withdrawal symptoms for 24 hours and provide steady control of cravings throughout the day. It is only administered in methadone federally regulated opioid treatment programs (OTP). Methadone clinics incorporate psychosocial interventions and require daily attendance for the first several months, so this is a good option for a client that has the flexibility to attend daily meetings. Use of methadone in MAT for opioid use disorder helps extend client survival. When patients stop methadone, they have a high likelihood of relapsing, even 10 years after starting treatment. Antoine is a 34-year-old who has been abusing prescription oxycodone. He is employed but is on probation at work for increased absenteeism. He desires MAT but is concerned about his roommates stealing his medication to get high. prescribe the proper medication: Methadone Buprenorphine Buprenorphine plus naloxone (Suboxone) Naltrexone -------- Correct Answer --------- Buprenorphine plus naloxone (Suboxone) In combination with naloxone (Suboxone): naloxone is a mu opioid receptor antagonist and can therefore block the effects of buprenorphine; however, because naloxone has Bupropion Chlorpromazine Disulfiram Methadone Naloxone Naltrexone Varenicline -------- Correct Answer --------- Disulfiram Disulfiram creates unpleasant physical symptoms when taken with alcohol. This mild negative stimulus can help reinforce the patient's abstinence from drinking alcohol. of the 20.4 million people 12 and older who had a substance use disorder in 2019: ------- - Correct Answer --------- -14.5 million people had an alcohol use disorder -8.3 million people had an illicit drug use disorder -2.4 million people had both an alcohol use disorder and an illicit drug use disorder the opioid, ______________, and _______________ neurotransmitters are related to the brain-reward circuitry and the development of substance use disorders -------- Correct Answer --------- catecholamine, and y-aminobutyric acid neurotransmitters Substance-related disorders are divided into two groups: -------- Correct Answer --------- substance use disorders -diagnostic term for prolonged use and abuse of substances such as alcohol, cannabis, hallucinogens, opioids, sedatives, stimulants, or tobacco substance-induced disorders -include substance intoxication, substance withdrawal, and substance-induced mental disorders substance use disorders (SUDs) -------- Correct Answer --------- hallmark symptoms -Behavioral, physical, and psychological dependence -dx of SUD is indicated when a person exhibits two or more symptoms within 12 months: -Physical Symptoms • Tolerance • Withdrawal (does not apply to inhalants and hallucinogens) -Behavioral Symptoms • Craving to use • Using more than intended • Stopping or reducing use is difficult • Spending significant time devoted to the substance (using, obtaining, recovering) • Using despite acknowledging associated health problems (physical, mental) Psychological Symptoms • Using despite social, occupational, or other adverse consequences • Neglecting other responsibilities because of use • Neglecting other activities because of use • Indulging in risky or dangerous behaviors or situations because of use eleven features to determine the severity of SUD -------- Correct Answer --------- - Hazardous use -Social or interpersonal problems r/t use -neglected major roles to use -withdrawal -tolerance -used larger amounts/longer -repeated attempts to control use or quit -much time spent using -physical or psychological problems r/t use -activities are given up to use -craving substance-induced disorders -------- Correct Answer --------- -Substance Intoxication • symptoms: disturbances in perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior • Acute intoxication should only be used as the main dx when intoxication occurs without a persistent SUD -Substance Withdrawal • General features: substance-specific behavioral change, with physical and psychological symptoms, due tO cessation or intake reduction of a substance -Substance-Induced Mental Disorder • potentially severe CNS syndromes that develop because of substance abuse, medications, or toxins -Comorbidity • the occurrence of two or more psychiatric disorders at the same time • People seeking tx for alcohol, cocaine, or opioid dependence have a high prevalence of having additional psychiatric disorders • antisocial personality disorder is one of the most common comorbidities associated with illicit drug use disorder Other SUD specifiers -------- Correct Answer --------- Early Remission: Full criteria for substance use disorder were previously met, but not for the last 3 months. Sustained Remission: Full criteria for substance use disorder were previously met, but not for the last 12 months or more. Controlled Environment: The client is in a controlled environment where substance access is restricted. Maintenance Therapy: The client is taking medication therapy to treat or reduce substance use. severity of SUD -------- Correct Answer --------- -Mild substance use disorder: Two or three of the features -Moderate substance use disorder: Four or five of the features without loss of control -Severe substance use disorder: More than six of the features with loss of control Substance-Induced Mental Disorder -------- Correct Answer --------- diagnosed when the following criteria are met: -the symptoms represent a mental disorder presentation -there is evidence that the substance used is capable of causing the disorder and that the disorder developed within a month of using the substance -there is evidence that the disorder is not likely explained better by the diagnosis of an independent mental condition -the disorder does not occur exclusively during delirium -the disorder causes significant social, occupational, or other impairment in functioning Kiefer is a 22-year-old student who presents to the clinic with complaints of a depressed mood that started two weeks ago. He states that he has stopped playing intramural baseball because of his mood; this is the first time since he was a small child that he has not played a season. He endorses insomnia and fatigue and is having a difficult time concentrating. Kiefer admits to taking methylphenidate "on a pretty regular basis." His use caused him to skip classes and lose a few friends who were -------- Correct Answer --------- F15.14 Stimulant use disorder, mild Rationale: Kiefer meets diagnostic criteria for major depressive disorder; his depressed mood symptoms started during withdrawal of methylphenidate. He does not have a history of depressed mood. He meets three criteria for substance use disorder (social problems related to use, neglecting major role to use, and repeated attempts to quit). He meets diagnostic criteria for mild methylphenidate use disorder with methylphenidate-induced depressive disorder onset during withdrawal. See DSM criteria doe stimulant use disorder. SBIRT -------- Correct Answer --------- Screening, brief intervention, and referral to treatment (SBIRT) -a comprehensive and integrated public health approach to identify individuals with substance use disorders and those at risk of developing these disorders -SBIRT model can be executed in primary care settings, emergency departments, trauma centers, and other community settings -a model effective for all types of substance abuse disorders how long substances can be detected in urine -------- Correct Answer --------- -Cocaine: up to 8 hours Step 2: Symptom-Triggered Regimen -If the CIWA-Ar score is 8 or higher, administer benzodiazepine: PO lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide (Librium) for symptom-triggered therapy. -Reassess CIWA-Ar every hour. AUD Comorbidity -------- Correct Answer --------- most common comorbid disorders associated with alcohol use disorder: -bipolar -schizophrenia -antisocial personality -anxiety -depressive disorders factors that are associated with suicide for persons with alcohol use disorder -------- Correct Answer --------- -presence of a major depressive episode -weak support system -serious coexisting medical condition -unemployment -living alone AUD differential Dx -------- Correct Answer --------- -Nonpathological use of alcohol -Sedative, hypnotic, or anxiolytic use disorder -Conduct disorder in childhood and adult antisocial personality disorder Opioid Use Disorder -------- Correct Answer --------- -Opioids can be ingested orally, snorted intranasally, injected intravenously or subcutaneously -Symptoms of opioid intoxication: • euphoric high • feeling of warmth • feeling of heavy extremities • dry mouth • itchy face • facial flushing • period of sedation after the initial euphoria Opioid withdrawal symptoms -------- Correct Answer --------- -severe muscle cramps & bone aches -profuse diarrhea -abdominal cramps -rhinorrhea -lacrimation -piloerection or gooseflesh -yawning -fever -pupillary dilation -hypertension -tachycardia -temperature dysregulation. opioid use disorder Comorbidity -------- Correct Answer --------- most common comorbid disorders associated with opioid use disorder are other substance use disorders and psychiatric disorders such as mood, antisocial personality, and anxiety disorders -Users who ingest opioids by injection often have viral (i.e., HIV, hepatitis C virus) and bacterial infections -also associated with an increased risk for suicide attempts, completed suicides, accidental overdose, and deliberate overdose opioid use disorder Differential Diagnosis -------- Correct Answer --------- -Opioid-induced mental disorders -Other substance intoxication (i.e., alcohol, sedative, hypnotic, or anxiolytic) -Other withdrawal disorders _________________ is the current gold standard in the treatment of opioid use disorder with physiologic dependence for both detoxification and as a maintenance agent -------- Correct Answer --------- Methadone -can only be dispensed at an outpatient opioid treatment program _____________ is used to rapidly reverse an opioid overdose -------- Correct Answer --- ------ Naloxone -can be administered nasally, intramuscularly, subcutaneously, or intravenously Stimulant Use Disorder -------- Correct Answer --------- -Most common: amphetamines, cocaine, "bath salts," and "club drugs" -Amphetamines can be ingested orally, intravenously, and nasally -Symptoms of acute stimulant intoxication: • euphoria • rambling speech • headache • transient ideas of reference • tinnitus • paranoid ideation • auditory & tactile hallucinations Long-term stimulant use disorder can result in: -------- Correct Answer --------- chaotic behavior, social isolation, aggressive behavior, and sexual dysfunction. Stimulant withdrawal symptoms -------- Correct Answer --------- -fatigue -increased appetite -dysphoria -increased craving -possibly depressive symptoms with suicide ideation comorbid disorders associated with stimulant use disorder -------- Correct Answer -------- - most common: other substance use disorders and psychiatric disorders such as mood, psychotic, anxiety, posttraumatic stress, attention-deficit/hyperactivity, and gambling disorders Stimulant Use Disorder Differential Diagnosis -------- Correct Answer --------- -primary mental disorders -phencyclidine (PCP) intoxication -stimulant intoxication and withdrawal Treatment for stimulant use disorder -------- Correct Answer --------- detoxification and psychosocial therapy -no pharmacologic treatments for symptoms of stimulant withdrawal or to decrease stimulant use Sedative, Hypnotic, or Anxiolytic Use Disorder -------- Correct Answer --------- most common substances: benzodiazepines, benzodiazepine-like drugs (e.g., zolpidem, zaleplon), carbamates (e.g., glutethimide, meprobamate), barbiturates (e.g., secobarbital), and barbiturate-like hypnotics (e.g., glutethimide, methaqualone), all prescription sleeping medications and almost all prescription antianxiety medications Symptoms of sedative, hypnotic, or anxiolytic intoxication: -incoordination -dysarthria -nystagmus -impaired memory -gait disturbance -severe cases, stupor, coma, or death Benzodiazepine withdrawal symptoms -------- Correct Answer --------- anxiety, dysphoria, intolerance for bright lights and loud noises, nausea, sweating, and sometimes seizures Barbiturates and barbiturate-like substance withdrawal symptoms -------- Correct Answer --------- range from mild symptoms such as anxiety, weakness, sweating, and insomnia to severe symptoms such as seizures, delirium, and death. Treatment and rehabilitation for a person with a sedative, hypnotic, or anxiolytic use disorder -------- Correct Answer --------- -requires tapering to prevent withdrawal symptoms -Follow-up treatment, usually with psychiatric help and community support Cannabis Use Disorder -------- Correct Answer --------- Symptoms of cannabis intoxication: -a "high," characterized by feelings of mild euphoria, relaxation, and perceptual alterations Marijuana -------- Correct Answer --------- Marijuana Rationale: Symptoms of marijuana intoxication include bloodshot eyes with droopy lids, dry mouth, tachycardia, euphoria, relaxation, time distortion, and short-term memory impairment. Match the client's symptoms to the most likely toxicology screen results: August presents with dilated pupils, tachycardia, and a slight tremor in his cheek. He is speaking very rapidly, rambling, and appears excited and restless. PCP Methyl enedioxy methamphetamine (MDMA) Cocaine Benzodiazepine Marijuana Heroin -------- Correct Answer --------- Cocaine Rationale: Symptoms of cocaine or other stimulant intoxication include tachycardia and hypertension, dilated pupils, nausea, vomiting, fever and sweating, rapid, rambling speech, restlessness, anxiety, agitation, and confusion. Match the client's symptoms to the most likely toxicology screen results: Michaela presents with blurry vision. Her balance is impaired, and her eyes display nystagmus. Her speech is also slightly slurred. PCP Methyl enedioxy methamphetamine (MDMA) Cocaine Benzodiazepine Marijuana Heroin -------- Correct Answer --------- Benzodiazepine Rationale: Symptoms of benzodiazepine intoxication include drowsiness, dizziness, poor balance and coordination, blurry vision, difficulty concentrating, and slurred speech. Match the client's symptoms to the most likely toxicology screen results: Devina presents with aggressive, violent behavior that required physical restraints. She appears to have increased pain tolerance and is having visual hallucinations. She also presents with tachycardia and hypertension. PCP Methyl enedioxy methamphetamine (MDMA) Cocaine Benzodiazepine Marijuana Heroin -------- Correct Answer --------- PCP Rationale: Symptoms of PCP intoxication include tachycardia, hypertension, nystagmus, violent behavior, hallucinations, anesthesia, and analgesia. Symptoms may rapidly fluctuate between extreme agitation and sedation. Match the client's symptoms to the most likely toxicology screen results: Joy presents with symptoms of a panic attack. She is visibly sweating and clenching her teeth. She complains of dizziness and stiff muscles. PCP Methyl enedioxy methamphetamine (MDMA) Cocaine Benzodiazepine Marijuana Heroin -------- Correct Answer --------- Methyl enedioxy methamphetamine (MDMA) Rationale: Symptoms of MDMA intoxication include feelings of panic, depersonalization, illogical thoughts, and physical symptoms including sweating, hot flashes or chills, headache, muscle stiffness, clenching teeth, and dizziness. Match the client's symptoms to the most likely toxicology screen results: Kennedy presents with constricted pupils and lethargy. She is observed going in and out of consciousness. PCP Methyl enedioxy methamphetamine (MDMA) Cocaine Benzodiazepine Marijuana Heroin -------- Correct Answer --------- Heroin Rationale: Symptoms of heroin intoxication include constricted pupils, changes in the level of consciousness, lethargy, nausea and vomiting, itching, dry mouth, and respiratory depression. Federal Drug Administration (FDA) approved medications for substance use disorders: Alcohol use disorders -------- Correct Answer --------- acamprosate disulfiram naltrexone Federal Drug Administration (FDA) approved medications for substance use disorders: Opioid use disorders -------- Correct Answer --------- buprenorphine methadone naltrexone Federal Drug Administration (FDA) approved medications for substance use disorders: Opioid overdose prevention -------- Correct Answer --------- naloxone ethical standards to guide making ethical clinical decisions, NAADAC/NCCAP (2021) code of ethics, includes the following principles: -------- Correct Answer --------- -the counseling relationship -confidentiality and privileged communication -professional responsibilities and the workplace standards -working in a culturally diverse world -assessment, evaluation, and interpretation -e-therapy, e-supervision, and social media -supervision and consultation -resolving ethical concerns -publication and communications People receiving MAT are considered to have a _____________ -------- Correct Answer --------- disability -because of their record of having an impairment during their substance use -non-discrimination laws protect individuals with disabilities • currently using illegal drugs are not protected by federal anti-discrimination laws CAGE -------- Correct Answer --------- brief 4-question CAGE screening tool for alcoholism/drug abuse Cut down: Have you ever felt the need to cut down on your drinking or drug use? Annoyed: Have you ever been annoyed at criticism of your drinking or drug use? Guilty: Have you ever felt Guilty about something you've done when you have been drinking or high from drugs? Eye opener: Have you ever had a morning eye opener (taken drugs) first thing in the morning to get going or to avoid withdrawal symptoms?