Doc 8.docx

Cyclothymia: Chronic presentation of hypomanic & depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Mood disorders are abnormalities of mood, which include depression, mania, or both. Mania: Persistently elevated, expansive, or irritab...

Cyclothymia: Chronic presentation of hypomanic & depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Mood disorders are abnormalities of mood, which include depression, mania, or both. Mania: Persistently elevated, expansive, or irritable mood. Symptoms: inflated self-esteem, increased goal-directed activity or energy (grandiosity), decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas, distractibility, psychomotor agitation, & propensity to be involved in high-risk activities. May lead to significant functional impairment & may include psychotic features or necessitate hospitalization. Mood related symptoms are characterized as having either too little (+) affect or too much (-) affect Which NTM are affected by mood disorders? Dopamine, norepinephrine, & 5HT Too little positive affect= known as dopamine (DA) norepinephrine (NE) Dysfunction Too much negative affect= also known as 5-hydroxytryptamine (5HT) norepinephrine (NE) dysfunction When dopamine levels are low= loss pleasure, interest, alertness, and even self-confidence.  When dopamine levels are high= hallucinations you see in schizophrenia and psychosis.  Norepinephrine= Responsible for flight, fight, or fright High levels of NE= antsy, nervous, and affect ability to focus.  Serotonin= play a role in relaxation, comfort, and decrease stress. Serotonin regulates sleep, arousal, libido, aggression, and pain perception. What are symptoms of decreased positive affect? depressed mood, loss of joy, lack of interest, loss of energy, decreased alertness, decreased self-confidence, appetite changes. What NTM is responsible for decreased positive affect? DA and NE dysfunction What are symptoms of increased negative affect? depressed mood, guilt, fear, anxiety, hostility, irritability, loneliness, appetite changes. What NTM is responsible for increased negative effect? 5HT and NE dysfunction What is Bipolar Disorder? a chronic condition characterized by extreme fluctuations in mood, energy, & ability to function How is bipolar disorder diagnosed? Diagnosed when a client has one or more episodes of mania or hypomania with a h/o one or more major depressive episodes. What is Bipolar type 1- at least 1 episode of mania for at least 1 week OR any duration if hospitalization due to symptoms is required. What is Bipolar type 2- Diagnosis requires current or past hypomanic episode & a current or past major depressive episode. Symptoms last at least 4 days but < 7 days. What is Cyclothymia- chronic presentation of hypomania & major depressive symptoms that do not meet the criteria for a major depressive or manic/ hypomanic episode What is mania? Characterized by persistency elevated, expansive, or irritable mood. What are mania symptoms? Inflated self- esteem, increased goal- directed activity or energy, grandiosity, decreased need for sleep, excessive talkativeness, flight of ideas, and propensity to be involved in high-risk activities. Manic: Many have only experienced 1 manic episode in their lifetime. Hypomanic: Not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization. Anger & irritability are common. Clients often enjoy the elevation of mood & are reluctant to report these symptoms, making bipolar more difficult to diagnose if the client presents in the depression phase. Depressed Mixed: Agitation is commonly seen in mixed. Signs & symptoms include pacing & fidgeting in mild cases. In severe cases, uncooperative, threatening, or aggressive behaviors. Treatment of agitation: Rapid acting oral antimanic including a loading dose of divalproex, oral formulations of atypical antipsychotics, conventional antipsychotics (Haldol or loxapine), or benzodiazepines (lorazepam). Selecting initial treatment should follow a stepwise approach First step in selecting initial treatment is to assess client safety, comorbidities, & treatment adherence Second step in selecting initial treatment includes: initiate/optimize therapy, choose monotherapy/ combination, optimize dose, & check for adherence The third step in selecting initial treatment includes: Add on/ switch therapy: Use alternate 1st line agent/add-on additional 1st line agent & if 1st line agent are not effective, may switch to 2nd line agent. 5 factors associated with nonadhearence 1. Medication factors: adverse effects & low treatment doses 2. Manifestation of bipolar dz: mixed episodes, rapid cycling, hallucinations, & bipolar disorder 1 3. Comorbidities: Substance abuse & obsessive-compulsive disorder 4. Demographics: Male, younger, lower educational level, & single 5. Other: Poor insight, Negative, attitude, & low self-esteem. Lithium: (1st line tx for new onset bipolar) Lithium alerts transport in the nerve & muscle Carbamazepine (Tegretol) action Glutamate voltage gated NA & Ca++ channel blocker (Glu-CB) Carbamazepine (Tegretol) Consider genotyping pt. with Asian ancestry; the HLA-B 2501 allele increased risk of SJS. Lamotrigine (Lamictal) Affects Na channel ion transport & enhances the activity of y-aminobutyric acid (GABA) Lamotrigine (Lamictal) This drug is equal in efficacy to lithium Lamotrigine (Lamictal) Educate pt. & assess for rash at each visit. Lamotrigine (Lamictal) There is a risk for rare SJS rash & multiorgan failure. Lamotrigine (Lamictal) Take at HS d/t sedation SE Valproic acid (Depakene) DA, NE, & 5-HT receptor antagonists. Valproic acid (Depakene) Affects ion transport & enhances the activity of y-aminobutyric acid (GABA) Valproic acid (Depakene) If using with lamotrigine decrease valproate levels by ½. Aripiprazole IM after oral trial establishes tolerability Aripiprazole Appropriate for pt. who struggle with adherence Lithium is effective tx for manic episodes, to prevent reoccurrence & to a lower degree is effective in depressive episodes. Lithium is well established to help prevent suicide in clients with mood disorders Lithium has a narrow therapeutic window & requires lab draws A patient and a family member presents to the PMHNP. The client states they do not understand why they had to come here today but after further imploration, the family member tells the practitioner that the client has been extremely irritable lately, has not slept in 3 days, can’t seem to think straight, and states he stole a bike from the store. The PMHNP suspects bipolar disorder. Which type does the patient most likely have? Bipolar type 1 The PMHNP is seeing a new patient who reports feeling very depressed, irritable, and distracted. Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication? Have you ever experienced symptoms such as increased self-esteem, increased activity, or a decreased need for sleep? Which brain region is affected when a patient is experiencing racing thoughts and grandiosity? Nucleus accumbens Rational: Prefrontal Cortex (PFC): Concentration, Mental fatigue, & Mood Prefrontal cortex & Amygdala: Guilt, suicidality, worthlessness Prefrontal cortex (PFC): Risk-taking & Talkative/pressured speech Nucleus Accumbens & PFC: Racing thoughts, grandiosity:  PFC & Amygdala​: Mood  Striatum: Physical fatigue & Motor/agitation Nucleus Accumbens: Pleasure interests, racing thoughts, & grandiosity Hypothalamus: Sleep, appetite Thalamus & Hypothalamus​: Decreased sleep/arousal