Week 4: NR606/ NR 606 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric Mental Health II Practicum Review |Complete Guide with Questions and Verified Answers| 100% Correct- Chamberlain

Week 4: NR606/ NR 606 (Latest Update
2024/ 2025) Diagnosis & Management in
Psychiatric Mental Health II Practicum
Review |Complete Guide with Questions and
Verified Answers| 100% CorrectChamberlain
Q: What is the role of an occupational therapist in evaluating developmental differences?
Answer:
Evaluates sensory and motor skills in children.
Q: What is the role of a developmental pediatrician in evaluating developmental differences?
Answer:
Assesses overall development and behavior in children.
Q: What is the role of a neurologist in evaluating developmental differences?
Answer:
Assesses neurological functioning in children.
Q: What are some sources of information used for diagnosing developmental differences?
Answer:
Clinical observations, natural setting observations, caregiver history, self-reports.

Q: At what age can a reliable diagnosis of developmental differences be made?
Answer:
Often by the age of two.
Q: What should treatment ideally begin?
Answer:
At diagnosis.
Q: What are some components of treatment for ASD?
Answer:
Pharmacologic interventions and nonpharmacologic therapies focused on different areas of
functioning.
Q: What is the goal of applied behavior analysis (ABA) therapy?
Answer:
Enhancing new skill development through rewards-based motivational systems.
Q: What is the goal of speech and language therapy?
Answer:
Improving understanding and use of speech and language.
Q: What is the goal of occupational therapy?

Answer:
Improving life skills and using sensory integration to improve responses to sensory input.
Q: What is the goal of physical therapy?
Answer:
Improving gross motor skills.
Q: What is the goal of parent training?
Answer:
Providing educational resources, coping strategies, and communication skills for parents of
children with ASD.
Q: What is the goal of dietary therapy?
Answer:
Helping develop positive, healthy food habits in children and youth with aversions to certain
foods or textures.
Q: What is the goal of social skills training?
Answer:
Improving social skills including conversation, being a good sport, and managing teasing from
other children.
Q: What is the research on limited diets for ASD inconclusive about?
Answer:
Powered by https://learnexams.com/search/study?query=

Steps for Obtaining Informed Consent
-Assess pt ability to understand medical info, tx options, to make a voluntary decision.
-Present relevant info with accuracy and sensitivity:

diagnosis
nature & purpose of tx options
benefits, risks, burdens of all tx options, including forgoing tx
-Document informed consent conversation in the medical record, including all consent forms.

Underlying assumptions for child and adolescent psychotherapy
Developmental considerations
Family involvement
Systems involvement
Resiliency

Underlying assumptions for child and adolescent psychotherapy: Developmental considerations
-developmental level will impact how they:

reason
approach relationships
regulate emotion and behavior
communicate

-Developmental considerations

inform the diagnostic process
guide tx planning

Underlying assumptions for child and adolescent psychotherapy: Family involvement
-Family involvement in tx & decision-making

a norm in child and adolescent psychotherapy
-invite parents to share the hx of the child or adolescent’s chief complaint & prior tx, medical & developmental hx, & behavioral info privately with the therapist ahead of the session
avoid feelings of criticism or discouragement
-collaborate with parent or caregiver as a tx partner

Underlying assumptions for child and adolescent psychotherapy: Systems involvement
-Therapists must consider the systems that surround children & adolescents & promote their development

family
school
peers
the community
-Therapy can help promote the child/adolescent’s socioemotional competence
-help develop a community support system

Underlying assumptions for child and adolescent psychotherapy: Resiliency
-therapist work to promote resiliency in children & adolescents

using strength-based orientation
-supports:
functioning
self-regulation
deal with challenges they faces

Piaget’s Stages of Cognitive Development
-Sensorimotor stage: Birth-2 yrs

cognitive abilities based on reflexes
object permanence & causality

-Preoperational stage: 2-7yrs

can use mental representations, symbolic thought, & language
thinking is egocentric

-Concrete operational stage: 7-11yrs

logical operations when thinking/solving problems
thinking is concrete

-Formal operational stage: 12yrs+

Adolescent can use abstract reasoning in addition to logical operations
Child can understand theories, hypothesize, comprehend abstract ideas (love & justice)

Screening, Brief Intervention, Referral to Treatment (SBIRT)
-Screening

Quickly assesses severity of substance use & ID the appropriate level of tx

-Brief intervention

Focuses on increasing insight & awareness regarding substance use & motivation toward behavioral change

-Referral

Guidance to tx provides those identified as needing more extensive tx with access to specialty care

Medication-Assisted Treatment (MAT)
Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies.

Mental health and youth
-13% of children ages 8-15 experience a mental health condition
-50% of children ages 8-15 experiencing a mental health condition do not receive tx
-13-20% of children living in the U.S. (1 out of 5 children) experience a mental health condition in a given year
-17% of high school students seriously consider suicide
-1/2 of all lifetime cases of mental illness begin by age 14

Barriers to Mental Health Treatment in Children and Adolescents
-lack of sufficient information or access to services
-stigmas or negative perceptions towards mental health services
-many drop out before receiving effective treatment, often due to:

poverty
language barriers
living in communities with scarce resources
stressors such as
➣problems in the family
➣violence in the community
➣unstable housing
➣unemployment
➣food insecurity
-Cost
-scheduling conflicts
-long waitlists for services
-high staff turnover

Prescribing Considerations for Children and Adolescents
-physiologic factors impact pediatric med selection & dosing
-Children, more rapid metabolism than adults, may require larger dose of med per unit of body weight
-Around puberty, pharmacokinetic properties reach adult parameters

dosing after puberty may need to be decreased
-Developmental considerations
attuned to signs of adverse effects, younger children may not be able to communicate complaints

Kassia, a 5-year-old, is prescribed a stimulant medication for ADHD for the first time.
Consider Piaget’s stages, match the developmentally-appropriate education statements with the correct client:

“It’s kind of like you’ve got a great bike. The brakes just need some fixing. The medication is like fixing the brakes.”

“This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your friends and parents. Do you have any concerns about taking the medication?”

“Do you know how it’s sometimes hard for you to sit still and pay attention at school? This medicine will help you.”
“Do you know how it’s sometimes hard for you to sit still and pay attention at school? This medicine will help you.”

Rationale: Kassia is in the Preoperational Stage. This stage usually lasts from ages 2-7. Children think symbolically. They learn to use words or pictures to represent objects. They are egocentric and have difficulty seeing things from others’ perspectives. Preoperational thinking is very concrete.

Oliver, a 10-year-old, is prescribed a stimulant medication for ADHD for the first time.
Consider Piaget’s stages, match the developmentally-appropriate education statements with the correct client:

“It’s kind of like you’ve got a great bike. The brakes just need some fixing. The medication is like fixing the brakes.”

“Do you know how it’s sometimes hard for you to sit still and pay attention at school? This medicine will help you.”
“It’s kind of like you’ve got a great bike. The brakes just need some fixing. The medication is like fixing the brakes.”

Rationale: Oliver is in the Concrete Operational Stage. This stage usually lasts from age 7-11. Thinking becomes more logical and organized about concrete events. Children begin to reason inductively, from specific information to general principles. The use of simile is a helpful instructional strategy for children in this stage.

Tamika, a 15-year-old, is prescribed a stimulant medication for ADHD for the first time.
Consider Piaget’s stages, match the developmentally-appropriate education statements with the correct client:

“It’s kind of like you’ve got a great bike. The brakes just need some fixing. The medication is like fixing the brakes.”

“Do you know how it’s sometimes hard for you to sit still and pay attention at school? This medicine will help you.”
“This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which may help you get along better with your friends and parents. Do you have any concerns about taking the medication?”

Rationale: Tamika is in the Formal Operational stage. This stage typically occurs at age 12 and up. Adolescents and young adults begin to reason abstractly and can consider hypothetical problems. They begin to think more about moral, philosophical, ethical, social, and political issues.

Addressing Parental Concerns: Collaborative Treatment Plans
-tx plans for children typically made in collaboration with parents or guardians
-Collaboration between the PMHNP, clients, and families when creating the treatment plan is key to ensuring the plan meets the client’s needs and is comfortable and manageable for the family

Ethical Considerations in the Treatment of Children and Adolescents
Privacy and HIPAA
Informed Consent
Mandatory Reporting

Ethical Considerations in the Treatment of Children and Adolescents: Privacy and HIPAA
-parents have right to req access to a minor’s mental health record, including symptoms, diagnosis, tx plan

circumstances may limit that right
➣see HIPAA fact sheet

Ethical Considerations in the Treatment of Children and Adolescents: Informed Consent
-Parents may decide whether to allow tx child is unable to provide true informed consent
-children may not be able to give legal consent, should be included in discussions about med & tx whenever possible

encourage tx adherence

Ethical Considerations in the Treatment of Children and Adolescents: Mandatory Reporting
-PMHNPs mandated reporters in most states

required to report suspicions about abuse or neglect to the appropriate authorities
-federal & state statutes include stipulations related to mandatory reporting
-PMHNPs responsible for following all relevant statutes in their state of practice

most common complication during the perinatal period?
Mental health problems

maternal mental health
-Up to 1 in 5 women will suffer from a maternal mental health disorder like postpartum depression
-<15% of women receive tx
-1 in 7 will experience depression during pregnancy
-Up to 50% of women living in poverty will suffer from a maternal mental health disorder
-Maternal mental health disorders impact the whole family, not just moms
-More than 600,000 women will suffer from a maternal mental health disorder in the U.S. ever year
-Anxiety & depression have risen 37% in teen girls. This will increase the number of women suffering postpartum depression in the future
-Rates of depression are more than doubled in Black moms due to cumulative effects of stress called weathering

Ethical Considerations in Maternal Mental Health Tx
-PMHNP must carefully weigh the risks & benefits r/t starting, continuing, switching, or discontinuing med therapy during the perinatal period
-work to create tx plans that respect clients’ goals & perspectives

Prescribing Considerations in Maternal Mental Health Tx
-Pharmacologic therapy during pregnancy may be necessary to prevent maternal and fetal harm

health of the embryo or fetus depends on health of the mother
-risks and benefits of all psychoactive medications to both the pregnant client and fetus must be considered
-risks and benefits of prescribing medications for breastfeeding clients must also be considered
many drugs cross from the maternal circulation into breast milk and may pose harm to the nursing baby

Prescribing Considerations in Maternal Mental Health Tx: Pregnancy
-Nearly 50% of pregnancies are unplanned
-when prescribing for pts of reproductive age take into consideration that pregnancy may occur

initiate discussions about medication safety
-may work with the pt 6-12 months before a planned pregnancy to adjust meds as needed
-be prepared to provide guidance to pts who have already conceived
-Most meds can be continued during pregnancy
-if tx plan includes med contraindicated during pregnancy:
discuss pts intended method of birth control
contingency plan for unplanned pregnancy
-decision made to D/C medication, drugs should be tapered whenever possible
-Communication throughout the pregnancy is crucial to ensure client safety if symptoms worsen
-physiologic changes during pregnancy impact pharmacokinetics of many meds
increase blood plasma level may increase the distribution volume of certain meds
Hormonal changes in CYP450 may increase or decrease drug metabolism
Increased renal blood flow & GFR may speed the excretion

Prescribing Considerations in Maternal Mental Health Tx: Lack of Evidence
-psychoactive medications in the perinatal period

paucity of evidence regarding the true risks for the pregnant client and developing fetus
➣limited as pregnant women and newborns are frequently excluded from medication research

Prescribing Considerations in Maternal Mental Health Tx: Switching Medications During Pregnancy
-switching meds during pregnancy can create a high risk for destabilization of mental illness

puts both the client and fetus at risk for stress & trauma
increases the absolute # of substances to which the fetus is exposed
➣may increase risk for adverse outcomes
-If stable on current med regimen, typically better to continue current regimen

Allie is a 26-year-old who has been receiving treatment for bipolar I disorder for 3 years. Her symptoms have been in remission with lithium 500 mg twice daily. She also completed 12 weeks of interpersonal and social rhythm therapy (IPSRT) upon diagnosis and used the life charting methodology to track her symptoms. She calls her PMHNP and states “I just found out I’m pregnant. My partner and I were not expecting this, but we are excited! I am worried about what lithium will do to my baby. Sh
schedule an appointment for Allie and her husband to discuss a treatment plan as soon as possible

ask Allie to continue taking lithium at the current dose for now

recommend that Allie begin tracking her mood, sleep schedule, and other symptoms

Rationale: Rationale: The PMHNP should schedule an appointment as soon as possible to discuss Allie’s treatment plan during her pregnancy. Discontinuation of medications for pregnancy is associated with a relapse rate of 80-100% for clients who take mood stabilizers; therefore, the client should not abruptly cease taking lithium (Ortega et al., 2023). Clients with a diagnosis of bipolar disorder may benefit from tracking the symptoms of their illness, especially during stressful times.
Although reassurance is appropriate, the PMHNP should not minimize the potential risks of continuing medication by telling the client that no harm will come to the baby.

Discontinuation of medications for pregnancy is associated with a relapse rate of _% for clients who take mood stabilizers
80-100%

Informed consent: pregnancy
-must initiate discussion with pt regarding informed consent for tx

whether new symptoms during pregnancy or already established with care
risks of continuing current meds and the risks of stopping them
-help pt process their risk factors & tx hx to make an informed decision
-if must remain on high-risk medications such as valproic acid should be thoroughly evaluated by the multidisciplinary team including a perinatal psychiatrist
-Documentation should note whether the woman plans to continue with treatment or discontinue the medication

Kenya is a 36-year-old who has been taking fluoxetine for three years for major depressive disorder. Her symptoms are currently in remission, and she just found out that she is 7 weeks pregnant. She calls the PMHNP to discuss whether she should continue her medication during pregnancy. After the discussion, Kenya indicates that she will remain on her medication.
Which of the following should be included in the discussion and documentation of the call with Kenya? Select all that apply.

rare adve
rare adverse effect of persistent pulmonary hypertension in the neonate

common adverse effect of postnatal abstinence syndrome

potential risks of discontinuing treatment to both mother and baby

decision to continue treatment

Rationale: The PMHNP should disclose all common adverse effects and discuss serious adverse effects associated with the medication, regardless of incidence. The discussion should include the potential risks to both mother and baby if the medication is discontinued. Documentation should include the client’s decision whether to continue or discontinue treatment. Since fluoxetine is not a high-risk medication for pregnancy, the PMHNP need not refer the client to a perinatal psychiatrist for medication management.

Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Depression & Anxiety
-SSRIs are first-line treatments for depression and anxiety during pregnancy
-SNRIs, tricyclic’s, & bupropion are also considered safe tx options
-most common adverse effect with SSRIs & SNRIs is neonatal withdrawal syndrome

Symptoms: tremors, high-pitched crying, disturbed sleep (peaks 2-4 days after birth)
impacts up to 30% of babies born to mothers who take antidepressant medication
no evidence D/Cing or tapering dosages in last trimester reduces risk to infant
-Paroxetine may increase risk of atrial septal defects
-Benzodiazepines taken with caution for anxiety
risk of newborn toxicity must be considered and monitored if used
Symptoms: sedation, floppy muscle tone, potential breathing issues at birth

Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Bipolar Disorder
-Lamotrigine considered safe during pregnancy

may not be effective for manic episodes
-Lithium exposure during first trimester has small but significant risk of cardiac malformations
increases with higher doses
risks and benefits carefully considered, Consider the gestational age of the embryo and fetus
-AVOID DURING PREGNANCY
valproic acid and carbamazepine are considered teratogenic

Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Psychosis
-atypical antipsychotic medications, particularly olanzapine and quetiapine

increased risk of gestational diabetes
➣D/Cing may not decrease the risk
increased risk of large for gestational age infants
-Olanzapine increase the risk of musculoskeletal malformations in infants
-Risperidone & quetiapine are the most used antipsychotics during pregnancy
Neither cause malformations
-Antipsychotic meds may cause neonatal withdrawal symptoms
close monitoring of newborn several days after delivery

Johnita has been taking sertraline 100 mg daily for 4 years for major depressive disorder. Her symptoms have fluctuated over the past year. She is 10 weeks pregnant.
Which of the following is the most appropriate recommendation for Johnita?

continue sertraline 100 mg daily

decrease sertraline to 50 mg daily

increase sertraline to 150 mg daily

discontinue sertraline
continue sertraline 100 mg daily

Rationale: Sertraline is considered a safe medication during pregnancy. The client’s symptoms have fluctuated on her current medication dose; therefore, decreasing the dose may cause a relapse of symptoms.

Alexandra has been taking lithium 1200 mg orally in two divided doses of 600 mg each for bipolar I disorder. She has been in remission of symptoms for 14 months. She is 7 weeks pregnant.
Which of the following is the most appropriate recommendation for Alexandra?

obtain serum lithium levels before tapering the lithium dose

decrease dose to 600 mg daily

decrease dose to 900 mg daily

discontinue lithium and switch to lamotrigine
obtain serum lithium levels before tapering the lithium dose

Rationale: Lithium exposure during the first trimester has a small but statistically significant risk of cardiac malformations; the risk increases with higher dosages of the medication. Obtaining serum lithium levels before tapering the dose is indicated since Alexandra has bipolar I disorder and is stable. The development of the heart begins as early as the third week of gestation with the 4-chamber fetal heart formed by gestational week 7. By the time Alexandra is weaned the risk has passed as the heart is already formed. Although lamotrigine is considered safe during pregnancy, it may not be appropriate for clients who have experienced mania in the past.

Saoirse takes aripiprazole 30 mg daily for a diagnosis of schizophrenia. She has taken the medication throughout her pregnancy and is now 34 weeks pregnant. She is concerned about the risks of neonatal withdrawal syndrome once her child is delivered. Which of the following is the most appropriate recommendation for Saoirse?

continue taking aripiprazole 30 mg daily

taper aripiprazole dose over 2 weeks to 15 mg daily and then increase to 30 mg after delivery

discontinue aripiprazole at 38 weeks
continue taking aripiprazole 30 mg daily

Rationale: Although neonatal withdrawal syndrome can occur in newborns who are exposed to second-generation antipsychotics, reducing or discontinuing aripiprazole or switching to another antipsychotic medication may cause destabilization in the client. The infant may need a few days of additional monitoring after delivery, but the client should remain on her optimized dose.

psychotropic medications & Breastfeeding
-American Academy of Pediatrics advocates breastfeeding through the first 6 months of life
-most psychotropic medications pass into breast milk

If infant exposed to med in utero, may discuss continuing med during breastfeeding, unless has severe side effects for infant
-req new or additional prescriptions while breastfeeding
discuss whether benefits of breastfeeding outweigh the risks of exposure to the infant
bottle feeding may be the best option
-Pts must be educated to support informed choice & their preferences must be supported

Safe for Breastfeeding
-SSRIs
-Benzodiazepines
-Valproic acid
-Quetiapine

Safe for Bottle Feeding
-Lithium
-Lamotrigine
-Clozapine

Substance Use Disorders During the Perinatal Period
-Perinatal SUDs are an urgent public health crisis

increasing across all groups of childbearing people
➣rates rising rural or low-income communities & those with Medicaid coverage for maternity care
-greatest risk for life-threatening outcomes of SUDs is among people of color.
-hallmark symptoms of SUDs: behavioral, physical, and psychological dependence
-most used substance in the perinatal period is tobacco, followed by alcohol, cannabis, and other illicit drugs
use of prescription & illicit opioids also increasing
-In US: 70,000 maternal overdose deaths in 2018, 69% were r/t opioid use

Health Risks Associated with SUDs: Tobacco
No tobacco product is considered safe for use during the perinatal period
-Smoking-related pregnancy complications:

ectopic pregnancy
placental abruption
placenta previa
fetal mortality
stillbirth
preterm birth
low birth weight infants

-Smoking-related effects on neonates:

sudden infant death syndrome
birth malformations
➣oral clefts
➣neural tube defects

-Smoking-related effects on infants, children, and adolescents:

asthma
cognitive impairment
lower respiratory illness
ADHD
central nervous system tumors

Health Risks Associated with SUDs: Alcohol
-Drinking while pregnant costs the US $5.5 billion
-CDC: no safe time to drink during pregnancy, no safe quantity of alcohol to consume while pregnant or trying to get pregnant
-1st trimester exposure correlates with the most significant alcohol-related birth outcomes
-increased risk for miscarriage, stillbirth, congenital anomalies, low birth weight, small for gestational age, and preterm delivery
-Lifelong effects of AUD on children:

fetal alcohol spectrum disorders (FASDs)
neurodevelopmental & CNS deficits
speech & language challenges
cognitive & behavioral deficits
impaired executive functioning
psychosocial difficulties in adulthood

fetal alcohol spectrum disorders (FASDs)
Up to 1 in 20 US school children may have FASDs
-Physical Issues:

low birth weight and growth.
problems with heart, kidneys, and other organs.
damage to parts of the brain.
Leads to…
-Behavioral and intellectual disabilities:
learning disabilities and low IQ
hyperactivity
difficulty with attention
poor ability to communicate in social situations
poor reasoning and judgment skills
Can lead to…
-Lifelong issues with:
school and social skills
living independently
mental health
substance use
keeping a job
trouble with the law

Health Risks Associated with SUDs: Cannabis
-often combined with other substances
-associated with:

preterm labor
low birth weight
small for gestational age deliveries
adverse effects on fetal and adolescent brain growth
adverse effects on executive functioning skills
behavioral problems
adverse effects on academic achievement
-All forms of cannabis have adverse effects, even medical marijuana

Marijuana Possible Effects on Your Fetus
-Disruption of brain development before birth
-Smaller size at birth; higher risk of still birth
-Higher chance of being born too early, especially when a woman uses both marijuana and cigarettes during pregnancy
-Harm from second-hand marijuana smoke: Behavioral problems in childhood and trouble paying attention in school

Marijuana Possible Effects on You
-Permanent lung injury from smoking marijuana
-Dizziness, putting you at risk for falls
-Impaired judgment, putting you at risk of injury
-Lower levels of oxygen in the body, which can lead to breathing problems

Health Risks Associated with SUDs: Cocaine
-majority of women addicted to cocaine are of childbearing age
-linked with poor pregnancy-related outcomes:

premature rupture of membranes
placental abruption
preterm birth
low birth weight
small for gestational age deliveries, as well
-long-term effects in children and adolescents:
lower short-term memory
child and adolescent delinquent behavior
earlier age of sexual activity
substance use

Health Risks Associated with SUDs: Opioids
-epidemic in the U. S.
-Opioid use disorder (OUD) during pregnancy, including heroin & prescription opioids, increases risk of maternal life-threatening health problems & death by 50%
-greater risk of eclampsia, heart attack or heart failure, & sepsis
-Infants experience significant adverse effects:

neonatal abstinence syndrome (NAS)
increased risk of toxemia
low birth weight
respiratory complications
third trimester bleeding and mortality
postnatal growth deficiency
microcephaly
neurobehavioral problems
sudden infant death syndrome (SIDS)
-4x as many infants were born with neonatal abstinence syndrome (NAS) in 2014 than in 1999

neonatal abstinence syndrome (NAS)
-caused by maternal opioid use
-affects between 45% to 94% of infants exposed to opioids in utero
-accounted for $3 billion in hospital costs over the last decade

SUDs in childbearing people: Ethical and Legal Considerations
-beneficence

treat these clients with dignity and respect

-nonmaleficence

prevent or avoid harm, including harms of omission

-justice

have right to equitable access to care, resources, & nondiscriminatory healthcare

-autonomy

have right to comprehensive info about their health & healthcare
power to make decisions about their healthcare

*stigma to perinatal substance use endangers fundamental rights

SUD-related Stigma
According to the National Center on Substance Abuse and Child Welfare SUD-related stigma occurs on three levels: structural, public, and self

-Structured Stigma (institutional stigma): policies, regulations, or laws that intentionally or unintentionally lead to discrimination

can limit access to resources and other opportunities

-Public Stigma: attitudes, beliefs, & behaviors of groups or ind’s which form a stereotype

creates an emotional reaction or prejudice and results in discrimination

-Self-Stigma: the shame individuals internalize about negative stereotypes

may lead to feelings of being flawed or unworthy of love or connection
may prevent them from seeking help

A program policy that prohibits individuals from using specific forms of prescribed medication for addiction (MAT) treatment is an example of __ stigma
structural

A stereotypic belief that individuals choose to use alcohol or other drugs and blame them for their substance use disorder is an example of _ stigma
public

Madden (2019) has proposed a new category of stigma: intervention stigma
-“Individuals working in [medication-assisted treatment] MAT experience discrimination and prejudice from other healthcare professionals
-discrimination & prejudice stem at times from stigma toward addiction diagnoses

Structural Stigma in U.S. Drug Policies
-nation’s drug policies tend to follow 1 of 2 diff. aims:

offering medical care such as MAT
criminalizing behaviors associated with substance use
-Fear of legal repercussions and the involvement of children’s services may lead women to avoid reporting substance use
# of states with punitive policies/requirements for providers to report suspected prenatal drug use has more than doubled in the last decade, resulting in poor health outcomes

State Policy on Substance Use During Pregnancy
-authorizing civil commitment
-criminalizing the behavior as child abuse or neglect
-requiring providers to notify child protective services when an infant is affected by illegal substance abuse
-requiring providers to report or test for prenatal drug exposure, which is permissible evidence in child-welfare proceedings

In 2023, the Guttmacher Institute reported:
-24 states and the District of Columbia consider prenatal substance use to be child abuse
-3 states and the District of Columbia consider it grounds for civil commitment
-25 states and the District of Columbia mandate provider reporting of suspected prenatal drug use
-8 states require providers to test for prenatal drug exposure if drug use is suspected
-19 states have created or funded drug treatment programs specifically for pregnant people
-10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people

Of pregnant women who were anonymously tested for drug use, the prevalence of use was found to be similar between Black and White women, but Black women were _ times more likely to be reported to law enforcement.
10x

___ women suffer from higher SUD rates compared to other racial and ethnic groups and are disproportionately affected by criminalization laws at the federal, state, and tribal levels.
Indigenous

Consistent use of medication for OUD treatment during pregnancy is significantly lower for ____________.
women of color

substance use during pregnancy: Assessment and Screening
-The U.S. Preventative Services Task Force (USPSTF) and ACOG have recommended the Brief Intervention and Referral to Treatment (SBIRT) approach

screen for substance use during the perinatal period
-Validated screening tools for substance use during pregnancy
Substance Use Risk Profile-Pregnancy scale (SURP-P)
4P’s Plus
➣can also include validated screening questions for depression & domestic violence

SUD Treatment in the Perinatal Period
-not contraindicated
-associated with better outcomes for both the pregnant person & the fetus
-pharmacological & nonpharmacological approaches
-Goals of tx:

abstinence or reduction of substance use
prevention of adverse effects due to substance use or withdrawal on the pregnant person & fetus
reduction of high-risk behaviors associated with substance use
improved quality of life & social conditions

Perinatal Period: Alcohol Use Disorder Tx
-advise pregnant clients who use alcohol to abstain or minimize use during pregnancy and breastfeeding
-Behavioral therapy and harm reduction counseling
-little info is available of acamprosate and naltrexone safe use during pregnancy
-Inpatient tx recommended for pts at risk for moderate, severe, or complicated alcohol withdrawal

indicated by a score of >10 on the CIWA-Ar

Perinatal Period: Tobacco Use Disorder Tx
-advise clients to discontinue tobacco use during pregnancy
-perform or refer clients for psychotherapy & support
-review risk & benefits with pt, nicotine replacement therapy (NRT), bupropion, or a combination of these interventions may be initiated

Higher doses of NRT may be req in pregnant pt due to metabolic changes of pregnancy
-immediate-release preparations, gum or inhaler, can help minimize infant exposure during pregnancy & breastfeeding
-Insufficient evidence for the use of varenicline

bupropion exposure in the fetal period is associated with:
-slightly elevated rates of congenital heart defects

overall number remains low

Perinatal Period: OUD Tx
-Clients advised to avoid abrupt discontinuation of opioid use

opioid withdrawal during pregnancy can risk harm to both mother & infant
-Methadone & buprenorphine, most prescribed MAT for OUD in pregnancy
Dosing may be increased during 2nd & 3rd trimesters due to increased blood volume & metabolism
-Naltrexone not recommended
concerns of detoxification, uncertain safety profile in pregnancy
-MAT
continue tX through pregnancy, labor, delivery, postpartum period
-Breastfeeding
methadone, buprenorphine, and naltrexone are considered safe

full spectrum of perinatal mental health disorders
-can occur during pregnancy & the first year postpartum

depression
bipolar II disorder
anxiety
OCD
PTSD
psychosis
-mild to severe

Anxiety
-Increased brain activity in the amygdala & prefrontal cortex
-PET scans have also shown reduced serotonin binding in patients with anxiety
-GAD

persistent, uncontrollable worrying that causes emotional distress, symptoms on most days, for a period of at least 6 months
-Symptoms:
worrying, restlessness, irritability, muscle tension, fatigue, sleep disturbances

Risk factors for developing anxiety
-genetic predisposition (family history of anxiety)
-being female
-recent life stressors
-chronic physical illness
-lack of support during childhood

Anxiety meds
-Anxiolytic

Buspirone
➣↓ drug interactions
➣↓ adverse effects

-SSRIs/SNRIs

escilatopram (Lexapro)
paroxetine (Paxil)
duloxetine (Cymbalta)
➣highly effective
➣↑ drug interactions
➣risk of hyponatremia

-Benzodiazepines

alprazolam (Xanax)
clonazepam (Klonopin)
➣multiple adverse effects
➣risk of misuse
➣fall risk
➣highly effective
➣rapid onset
➣can be used PRN

Symptoms of Psychosis
-Hallucinations

Auditory, Visual, Tactile, Olfactory, Gustatory

-Delusions

Persecution, Somatic, Grandeur, Control

-Thought Disorder

incoherent speech, loose associations, meaningless words, perseveration

-Disorganized behavior

childlike silliness, unpredictable agitation, inappropriate clothing for the weather, poor hygiene

Depression
-Decreased brain activity in the prefrontal cortex
-symptoms that last >2 weeks
-Symptoms:

depressed or irritable mood, diminished interest in activities, significant weight or appetite changes, fatigue, feelings of worthlessness, sleep disturbances, diminished ability to concentrate
-can be influenced by genetic & environmental factors, stressful life events
giving birth or experiencing emotional trauma
-linked to neurotransmitter imbalances

prefrontal cortex controls:
attention, memory, mood, & personality

MDD
-primary feature of MDD is the occurrence of at least 1 episode of major depression lasting at least 2 weeks
-must experience 5 or more of the following symptoms in 2 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

Depression meds
-SSRIs
-SNRIs
-TCAs
-MAOIs

Selective Serotonin Reuptake Inhibitors (SSRIs)
-Action:

inhibits the reuptake of serotonin

-Ex:

citalopram
escitalopram
fluoxetine
paroxetine
sertraline

-Common Side Effects:

nausea, agitation, headache, and sexual dysfunction

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
-Action:

inhibits the reuptake of serotonin and norepinephrine

-Ex:

desvenlafaxine
duloxetine
levomilnacipran
venlafaxine

-Common Side Effects:

nausea, sweating, insomnia, tremors, sexual dysfunction

Tricyclic Antidepressants (TCAs)
-Action:

inhibits the reuptake of serotonin & norepinephrine
blocks norepinephrine, histamine, & acetylcholine receptors

-Ex:

amitriptyline
clomipramine
desipramine
doxepin

-Common Side Effects:

dry mouth, constipation, blurred vision, urinary retention sedation, weight gain, hypotension, tachycardia, and sexual dysfunction

Monoamine Oxidase Inhibitors (MAOIs)
-Action:

increases norepinephrine & serotonin by inhibiting the enzyme that inactivates it

-Ex:

isocarboxazid
phenelzine
tranylcypromine

-Common Side Effects:

sedation, dizziness, sexual dysfunction, & hypertensive crisis

Select the lab tests required for Lithium:

thyroid function
liver function tests (LFTs)
renal function
hemoglobin A1C (HbA1C)
complete blood count (CBC)
serum lithium level
thyroid function
serum lithium level
renal function

Rationale: Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6-month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months.

Select the lab tests required for Valproic acid (Depakote):

thyroid function
liver function tests (LFTs)
renal function
hemoglobin A1C (HbA1C)
complete blood count (CBC)
serum valproate level
complete blood count (CBC)
serum valproate level
liver function tests (LFTs)

Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and LFTs every 3 months for 1 year and then annually.

Select the lab tests required for Carbamazepine:

thyroid function
liver function tests (LFTs)
renal function
hemoglobin A1C (HbA1C)
complete blood count (CBC)
serum carbamazepine level
complete blood count (CBC)
liver function tests (LFTs)
renal function
serum carbamazepine level

Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Oder a CBC, LFT, and renal function every 3 months for 1 year and then annually.

Select the lab tests required for Atypical antipsychotic meds:

thyroid function
liver function tests (LFTs)
renal function
hemoglobin A1C (HbA1C)
complete blood count (CBC)
serum drug level
hemoglobin A1C (HbA1C)
complete blood count (CBC)

Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing DM II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely.

Bipolar disorder medications
-Lithium

-lamotrigine (Lamictal)

-valproic acid (Depakene)

-Second generation antipsychotics

-carbemazepine (Tegretol)

Bipolar disorder medications: Lithium
-Lithium

Action: alters cation transport in the nerve & muscle
Indication: euphoric mania, rapid cycling, maintenance therapy
Adverse Effects:
➣GI effects, tremor, polyuria
Monitor plasma levels
Use to protect against suicide

Bipolar disorder medications: lamotrigine (Lamictal)
-lamotrigine (Lamictal)

Action: affects sodium channel ion transport & enhances the activity of y-aminobutyric acid (GABA)
Indication: maintenance therapy, monotherapy
Adverse Effects:
➣benign rash (risk for rare Stevens-Johnson Syndrome rash & multi-organ failure), GI effects, dizziness, h/a
equal in efficacy to lithium
Take at bedtime due to sedation side effect

Bipolar disorder medications: valproic acid (Depakene)
-valproic acid (Depakene)

Action: affects ion transport and enhances the activity of y-aminobutyric acid (GABA)
Indication: acute mania, mixed mood, comorbid substance use, multiple prior episodes
Adverse Effects:
➣GI effects, weight gain
equal to lithium
Monitor plasma levels
If using with lamotrigine decrease valporate levels by 50%

Bipolar disorder medications: Second generation antipsychotics
-Second generation antipsychotics

Action: DA, NE, and 5-HT receptor antagonists
Indication: acute bipolar depression, acute manic or mixed episodes, bipolar maintenance/adjunct
Adverse Effects:
➣weight gain, sedation, GI effects
Monitor for extrapyramidal effects
XR form may improve adherence
injection may improve adherence

Bipolar disorder medications: carbemazepine (Tegretol)
-carbemazepine (Tegretol)

Action: glutamate voltage gated sodium & calcium channel blocker (Glu-CB
Indication: acute mania, mixed mood
Adverse Effects:
➣GI effects, sedation, hyponatremia, neutropenia, rash (Stevens-Johnson Syndrome)
Monitor plasma levels
Consider genotyping clients with Asian ancestry
➣HLA-B 2501 allele increases risk of Steven-Johnson Syndrome

Maternal mental health disorders (MMHDs)
-Nearly 20% of women experience depression during the perinatal period (affect 1 in 5 women)
-can occur anytime in the two years between conception and the first 12 months after childbirth

symptoms before pregnancy, during, or in first postpartum year
-Maternal suicide
leading cause of death in postpartum period
among leading causes of death in pregnancy
-prevalence of perinatal maternal deaths r/t substance abuse is almost as common as suicide
-Untreated MMHDs can have significant adverse effects on fetal, neonatal, childhood, & adolescent outcomes
attachment disorders, cognitive & developmental disorders, relationship strain

consequences of untreated MMHDs: Impact on the Mother

Have poor nutrition
Use substances such as alcohol, tobacco, or drugs
Experience physical, emotional, or sexual abuse
Be less responsive to baby’s cues
Have fewer positive interactions with baby
Experience breastfeeding challenges
Question their competence as mothers

consequences of untreated MMHDs: Impact on the Child

Low birth weight or small head size
Pre-term birth
Longer stay in the NICU
Excessive crying
Impaired parent-child interactions
Social-emotional, cognitive, language, motor, & adaptive behavior development
Untreated mental health issues in the home may result in an Adverse Childhood Experience, which can impact the long-term health of the child.

terms used to refer to the conditions women experience during pregnancy and the first postpartum year:
-postpartum depression (PPD)

-perinatal (or antenatal, prenatal, or postpartum) depression & anxiety

-perinatal mood disorders (PMDs) or perinatal mood & anxiety disorders (PMADs)

-maternal mental health disorders

Barriers to Maternal Mental Health Care
-inconsistencies in terminology can lead to mistreatment in maternity care
-classification of maternal mental health disorders in the (DSM-5-TR)

depressive disorder specifier “with peripartum onset” timeframe for using the specifier remains confined to the first four weeks after birth

Risk Factors for MMHDs
-Smoking
-Lack of social support
-Poor relationship quality
-Pregnancy complications
-Personal or family history of depression
-History of physical or sexual abuse
-Unintended pregnancy
-Life stress
-Chronic physical conditions
-Prior pregnancy with fetal/infant loss
-History of mental illness
-Social Determinants of Health

low monthly income, lower education levels, or unemployed status, childbearing people who are unpartnered

Maternal mortality rates are __ times higher in Black women than in white women
3-4 times
-Almost 40% of Black mothers experience maternal mental health disorders
-half as likely to receive tx

factors that may increase the risk of maternal mental health disorders in Black women
-Systemic racism
-Unemployment
-Exposure to violence
-Gaps in medical insurance
-Adverse childhood experiences
-Lack of access to high-quality medical & mental health care
-Lack of representation in the medical system
-Higher risk of pregnancy & childbirth complications

Paid Parental Leave
-U. S. is one of only two industrialized countries that does not require employers to provide paid parental leave
-Women without paid parental leave experience higher levels of distress

The “Baby Blues”
-first few days following childbirth, 50-80% of new mothers experience a period of adjustment commonly known as the “Baby Blues”
-abrupt change in hormones when placenta is delivered may contribute

exacerbated by fatigue, pain, overstimulation, lack of support, or insecurity
-may cause temporary mood swings, tearfulness, irritability, anxiety, decreased appetite, difficulty sleeping, worrying, and physical or emotional exhaustion
-resolve within a few days to a few weeks
-Management: Ask for help, Rest often, Sleep when possible, Stay active, Eat well, Self care, Get social support

MMHDs: Depression
-most common maternal mood disorder
-specifier “with peripartum onset” can be applied to depressive disorders if the onset of mood symptoms occurs during pregnancy or in the four weeks following childbirth
-Adolescents vulnerable
-symptoms: specific concerns about the baby or parenting, sense of numbness or disconnection from the baby, guilt about not being a good mother

Low mood
Fatigue
Anxiety
Negative thoughts
Feelings of guilt
Avoiding people

Erika is a 24-year-old who gave birth to her first child a month ago. She took 3 weeks of unpaid leave from her job as a restaurant server and started back to work last week. Her mother-in-law watches the baby while she and her husband are at work. Erika has significant feelings of guilt for leaving her baby to return to work. She also reports feeling a lack of energy and difficulty focusing while at work.
According to DSM-5-TR criteria, is major depressive disorder with peripartum onset the app
no

Rationale: Major depressive disorder with peripartum onset is not the appropriate diagnosis for Erika. Although Erika’s symptoms occurred within the timeframe of 4 weeks post-delivery, she presents with three symptoms: feelings of guilt, lack of energy, and difficulty focusing. DSM-5-TR guidelines require at least five symptoms to diagnose major depressive disorder.

Erika is a 24-year-old who gave birth to her first child a month ago. She took 3 weeks of unpaid leave from her job as a restaurant server and started back to work last week. Her mother-in-law watches the baby while she and her husband are at work. Erika has significant feelings of guilt for leaving her baby to return to work. She also reports feeling a lack of energy and difficulty focusing while at work.
Which of the following management strategies is the most appropriate for Erika?

-reassure
administer a screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) to further evaluate Erika’s symptoms

Rationale: Administering a screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) to further evaluate Erika’s symptoms is the most appropriate management strategy. Screening will help identify other potential symptoms of peripartum depression. High scores on the screening tool may require medication and/or psychotherapy. Although decreased energy and difficulty focusing may be a result of Erika’s recent return to work, the symptoms, combined with significant guilt, may not be normal.

Reasons for post-adoption depression:
-unrealistic expectations
-difficulties bonding with the infant or child
-complicated relationships with birthparents in open adoptions
-underestimation of the impact that adoption would have on parents’ and families’ lives
-question their legitimacy as a parent

MMHDs: Bipolar Disorder
-DSM-5-TR includes a specifier for bipolar disorder with peripartum onset

symptoms that begin during pregnancy or in the first four weeks following childbirth
-childbirth can trigger hypomanic episodes
often early in the postpartum period
may have severe depressive episode several weeks later
-Early detection of signs of hypomania is necessary to reduce suicide & infanticide risk

MMHDs: Anxiety Disorder
-Generalized anxiety disorder

difficult to distinguish from symptoms experienced by new parents
-Symptoms: irritability, difficulty sleeping, difficulty concentrating, easy fatiguability
-Themes of worry:
pregnancy and delivery complications
infant well-being
maternal or partner illness
-Risk factors: prior hx of ax

MMHDs: Psychosis
-DSM-5-TR: “brief psychotic disorder with peripartum onset” when symptoms present suddenly during pregnancy or within the first 4 weeks after birth & last at least one day but no more than one month
-preexisting bipolar disorder have highest risk
-Loss of sleep is common precipitating factor
-presents with at least 1 of the following symptoms:

delusions
hallucinations
disorganized speech
grossly disorganized or catatonic behavior
-Suicide and infanticide are primary concerns
-Hallucinations or delusions r/t the infant are common
-considered a psychiatric emergency & requires immediate hospitalization and tx

______ is considered a psychiatric emergency and requires immediate hospitalization and treatment
Perinatal psychosis

MMHDs: OCD
-Pregnancy creates risk for onset or exacerbation of OCD
-peripartum period, approximately 1.5-2x more likely to experience OCD compared to general pop.
-47% of women with OCD experience first onset during peripartum period
-Common obsessions:

fears of contaminating the baby
need for exactness
thoughts of aggression towards infant
➣fear being left alone with infant, may distance self from infant to avoid acting on the thoughts
fears of infant death
-common compulsions:
repetitive handwashing
checking the infant

MMHDs: PTSD
-1-5% experience PTSD during the perinatal period
-Risk factors:

previous trauma
hx of sexual abuse
complications with past pregnancies
traumatic births or labor experiences
instrument-assisted vaginal births or cesarean sections
peripartum depression
previous mental illness

maternal mental health disorders: Screening
-recommendations from the American College of Obstetricians and Gynecologists (ACOG)

screening at least once during the perinatal period using a validated instrument
increasing the frequency of visits when symptoms are identified
referring clients for appropriate pharmacotherapy & psychotherapy treatments

-American Academy of Pediatrics (AAP) recommends:

incorporating the Edinburgh Postnatal Depression Scale (EPDS) into infants’ 1, 2, 4, and 6-month well check visits using a cutoff score of 10 as an indicator that maternal depression may be present

Edinburgh Postnatal Depression Scale (EPDS) to screen for maternal mental health disorders
-questionnaire to identify women who may have postpartum depression
-A score of more than 10 suggests minor or major depression may be present

Further evaluation is recommended

https://perinatology.com/calculators/Edinburgh%20Depression%20Scale.htm

Shawnta is a 29-year-old who delivered her first child one month ago. She has been seeing a psychiatric mental health nurse practitioner for therapy for the past two years to work on post-traumatic stress disorder following a sexual assault. She has no other psychiatric or physical health history and no family history of mental illness. Shawnta presents for a telehealth therapy visit and notes that over the past few days, she has felt more “down” than usual. Her partner returned to work a we
plan to repeat the screening in two weeks at Shawnta’s next therapy appointment

Rationale: Mothers who score over 13 on the EPDS are likely suffering from depressive illness; however, the EPDS only indicates how the client felt during the previous week. Therefore, a follow-up assessment in two weeks is indicated.

At Shawnta’s next appointment two weeks later, she endorses increased feelings of sadness and worry, mostly surrounding the baby. Her repeat EPDS screening score is 14.
Which of the following management strategies is the most appropriate next course of action for Shawnta?

plan to repeat the screening in two weeks at Shawnta’s next therapy appointment

request that Shawnta schedule an in-person visit as soon as possible

request a joint therapy session with Shawnta’s partner

discuss antid
discuss antidepressant medications

Rationale: Shawnta’s current EPDS score of 14 indicates likely depressive disorder, which requires the PMHNP to discuss treatment options with her, which may include antidepressant medications.

treating MMHDs: Perinatal Depression
-SSRIs: first-line pharmacologic once bipolar II disorder ruled out
-tricyclic antidepressants
-omega-3 fatty acids may reduce depressive symptoms
-brexanolone:

new tx for postpartum depression
IV infusion over 60 hours at certified healthcare facility
must be enrolled in the Risk Evaluation & Mitigation Strategy Program

-Nonpharmacologic:

CBT
interpersonal therapy
electroconvulsive therapy for severe

treating MMHDs: Perinatal Bipolar Disorder
-Pharmacologic:

lithium
lamotrigine

-Nonpharmacologic:

CBT
interpersonal therapy
behavioral therapy
social rhythm therapy

treating MMHDs: Perinatal Anxiety
-Pharmacologic:

SSRIs

-Nonpharmacologic:

CBT
interpersonal therapy

treating MMHDs: Perinatal Psychosis
-Pharmacologic:

mood stabilizers
antipsychotics
antidepressants
benzodiazepines

-Nonpharmacologic:

inpatient hospitalization
electroconvulsive therapy

treating MMHDs: Perinatal OCD
-Pharmacologic:

SSRIs

-Nonpharmacologic:

CBT with psychoeducation, cognitive restructuring, and exposure with response prevention

treating MMHDs: Perinatal PTSD
-Pharmacologic:

psychotherapy is typically used as first-line
SSRIs may be used for comorbid depression

-Nonpharmacologic:

expressive writing
eye movement desensitization and reprocessing (EMDR)
CBT

leading organization in supporting individuals with maternal mental health disorders.
Postpartum Support International

, _, and __ have shown benefits across the spectrum of perinatal mental health disorders.
Yoga
massage
peer support

Elaine Cho, a 24-year-old client with no history of mental illness gave birth to a healthy baby girl. Three weeks after the birth, she felt that she was really “bouncing back.” She was energized and excited. She noticed that she did not need to sleep as much as usual. She started on a few household projects, including repainting the baby’s gender-neutral nursery bright pink and purchasing expensive new furniture and toys for the nursery despite receiving everything she needed for the baby
yes

Rationale: According to DSM-5-TR criteria, a hypomanic episode is an appropriate diagnosis for Elaine. Criteria for a manic or hypomanic episode includes:

abnormally ↑ or irritable mood (required)
grandiose thoughts
↓ need for sleep
pressured speech
racing and expansive thoughts
distractibility
hyperactivity
impulsivity/high-risk activities

After a few weeks, Elaine started to feel more tired. She started to experience episodes of guilt about being more focused on her projects than her baby. She began to have difficulty making decisions and withdrew from her friends and husband. At her 6-week follow-up with her provider, she explained that she was feeling a little down and described her symptoms. The provider administered an EPDS. Elaine’s score was 15. Since Elaine was breastfeeding, the provider prescribed sertraline.
Is this t
no

Rationale: This is not the correct treatment decision for this client. Clients with bipolar disorder may present during the depressive phase of the illness and may not report any symptoms of hypomanic or manic episodes. The provider must obtain a careful history from the client and/or family members to differentiate between bipolar disorder and depression. Bipolar disorder should be ruled out as a cause of depression before prescribing medication as certain antidepressant medications can precipitate a manic episode or induce rapid-cycling bipolar depression, which may contribute to the increased incidence of death by suicide in children and adults younger than 25.

Which of the following screening tools is most appropriate to obtain more complete information from Elaine?

Mood Disorder Questionnaire (MDQ)
Patient Health Questionnaire-9 (PHQ-9)
Young Mania Rating Scale (YMRS)
Brief Psychiatric Rating Scale (BPRS)
Mood Disorder Questionnaire (MDQ)

Rationale: The MDQ is the most appropriate screening tool to screen for bipolar disorder. The PHQ-9 is a tool used to screen for depression. The YMRS is used to monitor symptoms of bipolar disorder after diagnosis, whereas the BPRS is used to assess clients who present with symptoms of psychosis.

What is an appropriate prescription for Elaine?
lurasidone 20 mg tablet
Disp: 30
Sig: 1 tab po daily with food at dinner
Refills: 0

The client will return for follow up and medication efficacy prior to 30 days.

Rationale: Lurasidone is a 5HT2A/D2 antagonist approved for use in schizophrenia and bipolar depression. This compound exhibits high affinity for both 5HT7 receptors and 5HT2A receptors, moderate affinity for 5HT1A and α2 receptors, yet minimal affinity for H1 histamine and M1 cholinergic receptors, which is a good choice for a new mother. There is also a low risk of weight gain or metabolic dysfunction. This medication was approved for pregnancy and postpartum use. Any medication that is prescribed while nursing requires a risk benefit discussion. A review of pediatric medical records have not shown adverse outcomes in breastfed infants, however the data is limited.

Maternal Mental Health, Epigenetics, and Child Health: Lifespan Considerations
-Maternal depression & anxiety can impact:

fetal development in utero
increase risk for preterm birth & low birth weight
lead to an insecure attachment between mother & infant
suboptimal breastfeeding practices
long-term effects:
➣decreased social-emotional, cognitive, language, motor, & adaptive behavior developmental outcomes
-PTSD following trauma exposure in childbearing people
lasting detrimental impact on child health

How a caregiver’s trauma can impact a child’s development: Early development
-Mother releases cortisol

Baby absorbs cortisol through placenta
➣Can impact baby’s: HPA axis, CNS, Limbic system, ANS
-Caregiver struggles to regulate
-Attachment relationship strained
Can impact child’s:
➣Development of a core sense of self
➣Ability to integrate experiences
➣Epigenetic expressions

How a caregiver’s trauma can impact a child’s development: Adulthood
-person who had a caregiver with untreated trauma may:

Be more prone to PTSD after trauma
Struggle to repair after conflict
Struggle with relationships
Unintentionally bring out negative behaviors in others
Be emotionally detached
Be more prone to dissociate

Stigma of Maternal Mental Health Disorders
-may impact the individual’s sense of safety regarding sharing their negative or challenging experiences

may fear revealing symptoms to others out of shame, guilt, or fear that their infant may be taken away from them

and have been demonstrated to have the lowest serum concentrations among infants exposed to medication during breastfeeding
Bupropion and Sertraline

Pediatric Anxiety & Obsessive-Compulsive Disorder (OCD)
-Separation anxiety
-Social anxiety
-OCD
-Body dysmorphic disorder

Anxiety
-Increased brain activity in the amygdala & prefrontal cortex
-PET scans have also shown reduced serotonin binding in patients with anxiety
-GAD

persistent, uncontrollable worrying that causes emotional distress, symptoms on most days, for a period of at least 6 months
-Symptoms:
worrying, restlessness, irritability, muscle tension, fatigue, sleep disturbances

Risk factors for developing anxiety
-genetic predisposition (family history of anxiety)
-being female
-recent life stressors
-chronic physical illness
-lack of support during childhood

Medications for anxiety: GAD
-SSRIs
-SNRIs
-buspirone
-Drug Therapy at least 12 months

Medications for anxiety: Panic Disorder
-paroxetine
-sertraline
-fluoxetine
-Drug therapy 6-9 months

Medications for anxiety: OCD
-fluoxetine
-fluvoxamine
-sertraline
-paroxetine
-clomipramine (TCA)
-Drug therapy for at least 1 year

Medications for anxiety: Social Anxiety Disorder
-sertraline
-paroxetine
-Drug therapy takes 4 weeks to see effects

Medications for anxiety: PTSD
-paroxetine
-sertraline

Depression
-Decreased brain activity in the prefrontal cortex
-symptoms that last >2 weeks
-Symptoms:

depressed or irritable mood, diminished interest in activities, significant weight or appetite changes, fatigue, feelings of worthlessness, sleep disturbances, diminished ability to concentrate
-can be influenced by genetic & environmental factors, stressful life events
giving birth or experiencing emotional trauma
-linked to neurotransmitter imbalances

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

Medications for depression
-SSRIs
-SNRIs
-NDRIs
-TCAs
-MAOIs

Selective Serotonin Reuptake Inhibitors (SSRIs)
-Action:

inhibits 5-HT (serotonin) reuptake

-Ex:

citalopram
escitalopram
fluoxetine
paroxetine
sertraline

-Common Side Effects:

nausea, agitation, headache, and sexual dysfunction

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
-Action:

inhibits 5-HT (serotonin) reuptake
inhibit NE reuptake (↑ energy, focus)
increase DA in prefrontal cortex (↑ cognition)

-Ex:

desvenlafaxine
duloxetine
levomilnacipran
venlafaxine

-Common Side Effects:

nausea, sweating, insomnia, tremors, sexual dysfunction

Norepinephrine Dopamine Reuptake Inhibitors (NDRI)
-Action:

inhibit DA reuptake (↑alertness, motivation)
inhibit NE reuptake (↑energy)

Tricyclic Antidepressants (TCAs)
-Action:

inhibits the reuptake of serotonin & norepinephrine
blocks norepinephrine, histamine, & acetylcholine receptors

-Ex:

amitriptyline
clomipramine
desipramine
doxepin

-Common Side Effects:

dry mouth, constipation, blurred vision, urinary retention sedation, weight gain, hypotension, tachycardia, and sexual dysfunction

Monoamine Oxidase Inhibitors (MAOIs)
-Action:

increases norepinephrine & serotonin by inhibiting the enzyme that inactivates it

-Ex:

isocarboxazid
phenelzine
tranylcypromine

-Common Side Effects:

sedation, dizziness, sexual dysfunction, & hypertensive crisis

Bipolar disorder medications: Lithium
-Lithium

Action: alters cation transport in the nerve & muscle
Indication: euphoric mania, rapid cycling, maintenance therapy
Adverse Effects:
➣GI effects, tremor, polyuria• Monitor plasma levels• Use to protect against suicide

Bipolar disorder medications: lamotrigine (Lamictal)
-lamotrigine (Lamictal)

Action: affects sodium channel ion transport & enhances the activity of y-aminobutyric acid (GABA)
Indication: maintenance therapy, monotherapy
Adverse Effects:
➣benign rash (risk for rare Stevens-Johnson Syndrome rash & multi-organ failure), GI effects, dizziness, h/a• equal in efficacy to lithium
Take at bedtime due to sedation side effect

Bipolar disorder medications: valproic acid (Depakene)
-valproic acid (Depakene)

Action: affects ion transport and enhances the activity of y-aminobutyric acid (GABA)
Indication: acute mania, mixed mood, comorbid substance use, multiple prior episodes
Adverse Effects:
➣GI effects, weight gain
equal to lithium
Monitor plasma levels
If using with lamotrigine decrease valporate levels by 50%

Bipolar disorder medications: Second generation antipsychotics
-Second generation antipsychotics

Action: DA, NE, and 5-HT receptor antagonists
Indication: acute bipolar depression, acute manic or mixed episodes, bipolar maintenance/adjunct
Adverse Effects:
➣weight gain, sedation, GI effects
Monitor for extrapyramidal effects
XR form may improve adherence
injection may improve adherence

Bipolar disorder medications: carbemazepine (Tegretol)
-carbemazepine (Tegretol)

Action: glutamate voltage gated sodium & calcium channel blocker (Glu-CB
Indication: acute mania, mixed mood
Adverse Effects:
➣GI effects, sedation, hyponatremia, neutopenia, rash (Stevens-Johnson Syndrome)
Monitor plasma levels
Consider genotyping clients with Asian ancestry
➣HLA-B 2501 allele increases risk of Steven-Johnson Syndrome

pediatric anxiety disorders
-among the most diagnosed mental health disorders

9.4% of U.S. children & youth (5.8 billion)
-can result in:
academic & social impairment
persist into adulthood
comorbid mental health problems, depression most common
-Anxiety Disorders by age
1.3% of children aged 3-5 years
6.6% of children aged 6-11 years
10.5% of children aged 12-17 years

prevalence of OCD
-between 1%-4%

80% show symptoms by age 18

common symptoms of anxiety in children
-Trouble concentrating
-Fatigue
-Irritability
-Muscle tension
-Frequent urination
-Upset stomach
-Trouble sleeping
-Restlessness
-Nightmares
-Fidgeting
-Poor performance at school

clinical presentation of pediatric: GAD
-excessive or unrealistic worry about everyday life events that are out of proportion to the impact of the events
-only one physical or cognitive symptom is required for diagnosis

whereas three symptoms are required for adult diagnosis

clinical presentation of pediatric: Separation Anxiety Disorder
-Separation anxiety typically peaks between 10-18 months and ends by about 3 years (developmentally appropriate in children under 3)
-disorder occurs when a child experiences intense or prolonged worry or fear about being separated from family members or other individuals with whom the child is close

may be triggered by stress that leads to separation from a loved
diagnosed when symptoms are excessive for the developmental age and interfere with daily functioning

risk factors for separation anxiety
-recent loss of a family member
-exposure to disturbing subject matter
-female sex
-positive family history
-shy personality
-extended parental conflict or absences
-relocation due to moving

clinical presentation of pediatric: Social Anxiety Disorder or Social Phobia
-intense fear of social situations, including performing in front of others

scrutiny, embarrassment, or humiliation are possible
-clinically significant distress and interferes with daily activities
-Physical symptoms:
blushing, stammering, nausea, difficulty speaking, racing heart
-may manifest with:
tantrums, crying, clinging, freezing up, withdrawing from social situations
-Dx: symptoms consistently present in similar situations for 6 months+ & anxiety must occur in settings with peers, not just interactions with adults

clinical presentation of pediatric: Selective Mutism (SM)
-ind. unable to speak in certain social settings they find stressful

school or work
-can communicate well in other settings
home or with family
-usually starts between ages 2-4
-more common in females
-commonly comorbid with social anxiety disorder
-Dx: based on the client’s medical, developmental, & family history
Collaboration with speech-language pathologist is recommended
-Tx: psychological treatment & referral for speech & language therapy

screening for anxiety in children
-commonly used tool: Screen for Child Anxiety Related Disorders (SCARED) tool Child Version

screen for several types of anxiety disorders
➣generalized anxiety
➣panic disorder
➣separation anxiety
➣social anxiety
-total score of 25 or more points indicates a potential anxiety disorder
higher scores, more specific results

Treatment for Pediatric Anxiety Disorders
-psychotherapy

Cognitive-behavioral therapy (CBT) most common

-pharmacologic

First-line is SSRIs
Benzodiazepines used sometimes for short-term tx
➣especially for certain phobias, fear of dental/medical tx

Eliana Swan (DOB: 6/18/20XX)is a 10-year-old who has a history of dental phobia after a traumatic experience during a root canal. She must have a tooth extraction and her mother is concerned that Eliana will not be able to tolerate the procedure without “something to help her relax.” Eliana weighs 71 pounds. In the activity below, write an appropriate prescription for Eliana.
Rx: lorazepam 1.0 mg tablet PO
Disp: 1.5 tablets
Sig: Take 45 to 90 minutes before the procedure
Refills: 0

Rationale: A benzodiazepine, such as lorazepam, may be prescribed for children with specific phobias r/t dental or medical treatments. An appropriate dose of lorazepam is 0.05 mg/kg PO as a single dose 45 to 90 minutes before the procedure.

Obsessive-Compulsive Disorder
-Onset is gradual

25% cases emerge between 8-12 years
-Symptoms:
persistent, intrusive thoughts (obsessions)
repetitive behaviors performed to decrease obsession-related anxiety (compulsions)
-diagnostic criteria: obsessions & compulsions time-consuming (>1 hour per day) & disrupt normal routines, functioning, or relationships.
-Common in children: washing, checking, ordering, fear of catastrophe

small subset of children with OCD, the diagnosis is associated with ____
streptococcal infections
-acronym PANDAS

pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
➣used to identify this subset
➣lab test called the Cunningham Panel to aid in identifying children with PANDAS
➣PANDAS is treated with antibiotics while OCD symptoms are treated with a combination of CBT & SSRIs

Children with PANDAS and SSRIs:
-Children with PANDAS may be particularly sensitive to side effects of SSRIs

important to begin treatment with low doses & increase slowly

screen for OCD in children and adolescents
-commonly used tool: Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)

children & adolescents aged 6-17

Tx of OCD in children and adolescents
-First-line treatment for mild to moderate OCD is CBT

used alone or in combination with medication
➣SSRI or clomipramine
If symptoms persist after 2+ trials of an SSRI or clomipramine & failure to respond to CBT, tx may be augmented with an atypical antipsychotic

The PMHNP administers the CY-BOCS to August and his score is 13. Which of the following are the next appropriate steps for August? Select all that apply.

refer August to his pediatrician for a Cunningham Panel

recommend exposure and response prevention therapy for August

recommend psychoeducation for August’s grandmother

recommend starting an SSRI
refer August to his pediatrician for a Cunningham Panel

recommend exposure and response prevention therapy for August

recommend psychoeducation for August’s grandmother

Rationale: August’s rapid onset of symptoms consistent with OCD indicates the need to rule out PANDAS from a streptococcal infection. August’s score of 13 indicates mild OCD. Starting with exposure and response prevention therapy is an appropriate initial treatment, as is providing psychoeducation for August’s grandmother. If symptoms persist after therapy, an SSRI may be added to the treatment plan.

Body Dysmorphic Disorder (BDD)
-type of obsessive-compulsive disorder

ind. becomes preoccupied with one or more perceived flaws in physical appearance that are not visible or appear slight to others
-typically begins in adolescence
-engage in repetitive behaviors:
checking mirrors, excessive grooming, picking, seeking reassurance
-Hospitalization may be indicated for clients with severe BDD

screening tools for Body Dysmorphic Disorder (BDD)
-Body Dysmorphic Disorder Questionnaire (BDDQ)

-The BDD Yale-Brown Obsessive Compulsive Scale for Adolescents (BDD-YBOCS-A)

determine the severity of the diagnosis
Scores range from 0-to 48, >20 indicate presence of BDD, higher score = more severe

Body Dysmorphic Disorder (BDD) tx
-CBT

reduce symptoms & improving mood & quality of life
used alone or in combination with medication
➣typically an SSRI

Pediatric Mood Disorders
-unipolar depression most prevalent at 4.4%

-bipolar disorder (BPD) approx. 4%

symptoms appearing early as age 5

-disruptive mood dysregulation disorder (DMDD) 1-3%

important concerns for adolescents with mood disorders
substance use and suicide

Mood Disorders in Children & Adolescents: Unipolar Depression
-Pediatric unipolar or major depression typically presents in late childhood or early adolescence
-more than half of youth diagnosed with adolescent-onset depression are diagnosed with BPD at adult age
-Adolescent girls 3x more likely to experience depression than boys

boys higher rate of depression before puberty

Mood Disorders in Children & Adolescents: Unipolar Depression Clinical Presentation

Sadness or irritability
Academic decline
Withdrawal from friends and family
Loss of interest in things of past enjoyment
Problems with sleep
Appetite &/or weight changes
Feelings of guilt or being misunderstood
Clinging to a parent
Unexplained crying
Thoughts or actions of self-harm

Unipolar Depression Screening
-The U.S. Preventive Services Task Force (USPSTF)

depression screening in adolescents 12- 18 years
-no current recommendations for screening children younger than 12

-The American Academy of Pediatrics • Guidelines for Adolescent Depression in Primary Care (GLAD-PC)
➣recommend the Patient Health Questionnaire-9 Modified for Adolescents (PHQ-9A)

Unipolar Depression Tx
-goals & outcomes developed in collaboration with client & family
-safety plan for addressing acute crises or suicidality established at the time of diagnosis or initial tx

safety concerns are highest at this time
-psychotherapy & medication
CBT & SSRIs
➣fluoxetine, the frontline choice due to its efficacy, low cost, and side effect profile

Although SSRIs are typically well tolerated in this population, adverse effects can occur including behavioral activation which can manifest as:
-irritability, agitation, and impulsivity.

Generally, these symptoms are time-limited and can be managed with care and support.

!!!!!!!!!!This SSRI has been associated with increased suicidal thinking & actions in children & adolescents & should not typically be used to treat depression in this population!!!!!!!!!!!!!!!!!!!!
Paroxetine

SSRI tx phases:
-Acute phase: Aim is to achieve a significant reduction or disappearance of symptoms for 8-12 weeks.

-Continuation phase: Aim is to consolidate treatment gains and prevent relapse for 6 to 12 months.

-Maintenance phase: Aim is to prevent relapse by continuing treatment for those with recurrent, severe, or chronic depression.

Initiating SSRI with child or adolescent
*Start at low doses with dose increase or med change only after 4 weeks

*Symptom severity should be assessed every 1-2 weeks after initiating medication along with continuous monitoring of suicidality

Mood Disorders in Children & Adolescents: Bipolar Disorder (BPD)
-Dx of children before puberty remains controversial
-Common comorbidities: ADHD, anxiety disorders, oppositional defiant disorder, learning disorders, substance use
-Clinical Presentation: more rapidly cycling moods & mixed episodes, symptoms of both mania and depression together

Bipolar Disorder (BPD) Screening
-Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children interview tool

validated tool for use in diagnosing BPD

Treatment for pediatric BPD
-typically includes a combination of medication and psychotherapy

mood stabilizers & antipsychotic medications
➣help tx symptoms/stabilize pt so they are able to participate in psychotherapy

-Psychosocial interventions

education, skill-building, and lifestyle modifications
-Motivational interviewing: promote medication adherence
-Family-focused therapy: help youths at high risk for BPD increase the time between mood episodes through psychoeducation, communication, & problem-solving skills training
-Interpersonal and Social Rhythm Therapy (IRPT): help clients manage life with a mood disorder by promoting regularity in daily routines

Nic, a 15-year-old, was admitted to an inpatient adolescent psychiatric unit. He has been diagnosed with bipolar I disorder and has suicidal ideations.
Match the scenario with the most appropriate initial medication:

divalproex
lithium
lurasidone
lithium

Rationale: Lithium can reduce suicidality; clients who have suicidal ideations should be carefully monitored until therapeutic levels are reached.

Toni, a 17-year-old, has complaints of irritability, racing thoughts, high energy, and low mood.
Match the scenario with the most appropriate initial medication:

divalproex
lithium
lurasidone
divalproex

Rationale: Divalproex is the preferred drug for adolescents with bipolar disorder with mixed features.

Antoine, an 11-year-old, was diagnosed with bipolar depression.
Match the scenario with the most appropriate initial medication:

divalproex
lithium
lurasidone
lurasidone

Rationale: Lurasidone is an appropriate treatment for bipolar depression in adults and children over 10 years of age.

Kenzie is a 10-year-old who was diagnosed with bipolar I disorder, acute manic episode. Since she has trouble swallowing pills, she was initially started on lithium immediate release solution 12 milliequivalents per liter (mEq) three times daily. She returns to the PMHNP’s office one week after her initial diagnosis for follow-up and lab work. Kenzie’s mother reports that although her mood seems less severe, she continues to have high levels of irritability, loss of appetite, insomnia, and “mood swings”. Kenzie’s lithium level is 0.7 mEq/L.
Which of the following is the most appropriate management strategy for Kenzie?

increase lithium dosage to 16 mEq three times daily
decrease lithium dosage to 12 mEq three times daily
stop lithium and begin divalproex
increase lithium dosage to 16 mEq three times daily

Rationale: Kenzie’s lithium level is subtherapeutic; therapeutic levels are between 0.8-1.2 mEq/L for clients experiencing acute mania. Since Kenzie is still experiencing symptoms, it is appropriate to increase her dose. The maximum dosage for immediate release solution in children 7 and older weighing greater than 30 kg is 48 mEq/day given in 2-3 divided doses.

When should the PMHNP schedule a follow-up visit for Kenzie?

one day
five days
one week
two weeks
five days

Rationale: The time to efficacy for lithium is 3-5 days in children; a follow-up visit or phone call at 5 days will allow the PMHNP to reassess the efficacy of Kenzie’s new dose.

Mood Disorders in Children & Adolescents: Disruptive Mood Dysregulation Disorder (DMDD)
-first appeared in the DSM-5 in 2013
-Clinical Presentation:

chronic, persistent irritability & anger
frequently experience problems at home, school, or with peers

-DSM-5-TR criteria:

severe, recurrent (>3 times per week) outbursts of temper
mood between outbursts of temper is chronically irritable or angry most of the day, every day, and is observable to others
symptoms have been present >12 months with no more than 3 consecutive months without symptoms
symptoms are present in at least 2 of 3 settings (home, school, or with peers), severe degree in at least one setting
diagnosis cannot be made before age 6 or after age 18 years
onset begins before age 10
behaviors cannot be attributed to another mental disorder

-cannot coexist with dx of bipolar disorder, intermittent explosive disorder, or ODD

symptoms of both DMDD and ODD, the diagnosis of DMDD should be used

Disruptive Mood Dysregulation Disorder (DMDD) Screening
-The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (KSADS-PL)

validated for use in combination with the DMDD module

Disruptive Mood Dysregulation Disorder (DMDD) Tx
-psychotherapies and medication

CBT
➣used to teach children & adolescents to manage thoughts & feelings that contribute to depression or anxious feelings
-Parent training
help teach parents techniques to interact with their children, reduce aggression/irritability, improve the parent-child relationship
-intense cases, risk of harm to self or others, severe disruptions in functioning, or substance abuse:
intensive outpatient treatment
residential treatment
inpatient psychiatric treatment
-Med classes:
stimulant medications: help decrease irritability
Antidepressants: assist with irritability & other mood problems
-Atypical antipsychotics: help control severe outbursts of temper

develop schizophrenia
-Many genes play a role

as do epigenetic factors
Heritability as high as 79%
-gene-environment interaction
-Environmental Triggers:
Regular Cannabis Use
Exposure to Early Life Trauma
➣Sexual Abuse
➣Emotional Abuse
➣Emotional Neglect
➣Bullying

schizophrenia Neuroanatomy
-Mesocortical & ventromedial prefrontal cortex: negative and affective symptoms

-Dorsolateral: cognitive symptoms

-Orbitofrontal & connections to the amygdala: aggressive, impulsive symptoms

Brain Circuits Affected in Schizophrenia:
-Dopamine Pathways

explain the (+) & (-) symptoms seen in schizophrenia & psychosis

Dopamine Role in Psychosis
-leading hypothesis

psychosis & schizophrenia associated with dysfunction of neurotransmitter dopamine (DA)
➣Traditionally surplus of dopamine

Glutamate Role in Psychosis
-primary excitatory neurotransmitter
-implicated in the overactivity of mesolimbic DA pathway in schizophrenia
-Glutamate hypoactivity may result in lost activation of the mesocortical dopamine pathway leading to negative symptoms of schizophrenia

GABA is the primary _ neurotransmitter
inhibitory

Clinical domains of psychosis symptoms: Positive Symptoms
-Hallucinations
-Delusions
-Thought disorder
-Hostility
-Excitability

Clinical domains of psychosis symptoms: Motor Symptoms
-Motor delay
-Dyscoordination
-EPS, e.g.

Parkinsonism
Dyskinesia

Clinical domains of psychosis symptoms: Affective Symptoms
-Depression
-Anxiety
-Suicidality

Clinical domains of psychosis symptoms: Cognition
-Attention
-Working memory
-Verbal memory
-Visual memory
-Executive functioning
-Processing speed
-Social conditioning

Clinical domains of psychosis symptoms: Negative Symptoms
-Affective flattening
-Alogia
-Anhedonia
-Amotivation
-Asociality

Hallucinations:
-perceptual experiences in the absence of external stimuli

Auditory
Visual
Tactile (feeling)
Olfactory
Gustatory (tasting)

Delusions:
-fixed false, irrational beliefs

Persecution: delusions r/t being threatened, victimized, or spied on
Reference: delusions related to receiving personal messages from television (tv), radio, or actions of others
Somatic: delusions related to the body, including illness or the presence of foreign objects (e.g. Sometimes people believe there are objects in their bodies; for example they might think they are infested with insects.)
Grandeur: delusions related to beliefs of special abilities or powers
Control: delusions that actions and thoughts are controlled by others

Thought Disorder:
-impairment in the process of thinking & difficulty organizing thoughts in a logical pattern

incoherent speech
loose associations
meaningless words
perseveration

Disorganized behavior:
-disordered or impaired behavior or communication

childlike silliness
unpredictable agitation
inappropriate clothing for the weather
poor hygiene

Erica is a 24-year-old with a newly diagnosed schizophreniform disorder. She is a current smoker. She does not use alcohol or other drugs. She has no medical history. Which of the following would be the least appropriate initial medication for Erica?

aripiprazole
lurasidone
olanzapine
quetiapine
olanzapine

Rationale: Olanzapine requires up to 30% increased dosage for clients who smoke concurrently. Initiating a medication that does not interact with smoking is preferable.

Tony is a 56-year-old who has recently been diagnosed with schizophrenia. He takes amiodarone for a history of cardiac dysrhythmias. He does not use alcohol or other drugs. He is a nonsmoker. Which of the following is the most appropriate medication for Tony?

aripiprazole
lurasidone
quetiapine
risperidone
risperidone

Rationale: Amiodarone is a moderate CYP3A4 inhibitor. Risperidone does not interact with CYP3A4 inhibitors or inducers.

Jenny is a 22-year-old who has been prescribed aripiprazole 15 mg/day for the past 8 months. She has gained approximately 30 lbs. during treatment. Jenny’s psychiatric symptoms have been managed well on aripiprazole and she has no other adverse effects. What is the most appropriate initial intervention for Jenny?

switch to a different antipsychotic medication

prescribe metformin

refer to a bariatric specialist
prescribe metformin

Rationale: Prescribing metformin as an adjunct treatment to assist with weight loss associated with antipsychotics is appropriate. Jenny is well-managed on the current dose of aripiprazole; switching to a different medication is not indicated at this time. Referral to a bariatric specialist may be indicated if the client continues to gain weight but is not indicated as the most appropriate initial intervention.

Scott is a 33-year-old who is currently without housing. He has been unable to adhere to his prescribed oral medication regimen. The PMHNP recommends a long-acting intramuscular form of medication. Scott is willing to try but would like to receive the medication at the community clinic near the shelter where he is staying. Which medication option is the least appropriate for Scott at this time?

aripiprazole monohydrate
olanzapine
paliperidone palmitate
risperidone
olanzapine

Rationale: Olanzapine must be given in a registered health care facility with available emergency medical services. The client receiving olanzapine must be monitored for 3 hours post-injection.

Autism Spectrum Disorder (ASD)
-neurological and developmental disorder
-impacts communication, relationships with others, learning, behavior
-1-2% of population
-all racial, ethnic, and socioeconomic groups
-Males 4x more likely than females
-Factors with increased risk:

having a sibling with ASD
having older parents
having certain genetic conditions:
➣Fragile X syndrome
➣Down syndrome
very low birth weight
-spectrum disorder
wide variation in the types and severity of symptoms
➣symptoms typically appear in first 2 years of life

DSM-5-TR criteria for ASD
-persistent deficits in communication and social interaction across multiple contexts and restrictive, repetitive patterns of behavior, interests, or activities
-Symptoms must appear early in development and can cause clinically significant impairment in functioning
-severity is classified based on the level of support needed by the individual

ASD Diagnosis and Screening
-The American Academy of Pediatrics (AAP) recommends that all children be screened for ASD

Providers perform basic developmental screenings at children’s 18-month and 24-month well-child visits
demonstrate developmental differences in behavior or functioning require additional evaluation, typically performed by a team of ASD specialists
➣child psychologist, speech-language pathologist, occupational therapist, developmental pediatrician, or neurologist
-Dx based on clinical observations, observations in a natural setting, caregiver history, or self-reports

ASD different developmental screening tools available
-Screening tools:

Ages and Stages Questionnaires (ASQ)
Communication and Symbolic Behavior Scales (CSBS)
Parents’ Evaluation of Developmental Status (PEDS)
Modified Checklist for Autism in Toddlers (MCHAT)
Screening Tool for Autism in Toddlers and Young Children (STAT)
-Diagnostic tools
Autism Diagnosis Interview – Revised (ADI-R)
Autism Diagnostic Observation Schedule – Generic
Childhood Autism Rating Scale (CARS)
Gilliam Autism Rating Scale – Second Edition (GARS-2)

Early signs of ASD include:
-avoiding eye contact
-showing little interest in peers or caretakers
-limited language abilities
-frustration with minor changes in routine
-repetitive behaviors

Quentin is a 4-year-old who presents with his parents for evaluation. Before the appointment, the psychiatric mental health nurse practitioner (PMHNP) read a report submitted to the office by Quentin’s preschool teacher, who notes that he is easily distracted, often “fidgety”, and has difficulty waiting his turn. He gets frustrated when the school schedule changes and has difficulty interacting with his peers. He does not seem bothered by his lack of friends; rather, he chooses most times to play alone, and he resists playing group games with the class. When pressed to engage, Quentin becomes agitated. The teacher reports that he responds appropriately when asked a question directly, but rarely makes eye contact and avoids physical contact with others.
Based on the information provided by the teacher, which of the following diagnoses should be considered potential diagnoses for Quentin?

attention-deficit/hyper
attention-deficit/hyperactivity disorder (ADHD)
autism spectrum disorder (ASD)
social anxiety disorder
social communication disorder

Rationale: Based on the information provided by the teacher, Quentin’s current list of differential diagnoses includes ADHD, ASD, social anxiety disorder, and social communication disorder. Additional information is required to narrow the list.

Quentin’s parents express that preschool has been Quentin’s first interaction with other children. He is an only child, and his parents were able to work opposite shifts to avoid sending him to daycare during the pandemic. His mother notes that he has never been an overly affectionate child but tolerates being hugged and kissed by his parents. She reports that he has limited eye contact with both parents, and they find his emotions “hard to read.” He has always preferred playing alone to engaging with his parents in play, and his father describes his play as “methodical in that he doesn’t seem to play pretend with his toys, but instead lines them up or takes them apart. He only has interest in cars and doesn’t play with other toys.” His parents both endorse that Quentin seems to have difficulty interacting with adults who visit the home; he seems to struggle with engaging in conversation typical for a
yes

Rationale: Quentin meets the DSM-5-TR (APA, 2022) criteria for autism spectrum disorder, including persistent deficits in social communication and interaction across multiple contexts manifested as deficits in social-emotional reciprocity, nonverbal communication, and the ability to develop relationships. He also displays repetitive behavior patterns with his toys and difficulties with changes to routines and transitions.

Based on the information provided, which of the following specifiers are appropriate for Quentin at this time? Select all that apply.

requiring very substantial support
requiring substantial support
requiring support
with accompanying intellectual impairment
with accompanying language impairment
associated with a known genetic or other medical condition or environmental factor
associated with a neurodevelopmental, mental, or behavioral problem
with catatonia
requiring support

Rationale: Specifiers describe current symptoms and may change over time. Only one specifier is pertinent at this time. Quentin’s current presentation is consistent with ASD requiring support; his social communication deficits and inflexibility cause interference with functioning, but deficits do not cause marked distress. Quentin’s language abilities appear to be age-appropriate. Further testing should be conducted to determine whether an intellectual impairment exists. Quentin does not have known genetic or medical factors that may relate to ASD, and he does not display symptoms of catatonia. Further assessment may determine whether Quentin has an associated neurodevelopmental, mental, or behavioral problem, such as ADHD or anxiety.

ASD treatment
tx should begin at dx
-pharmacologic interventions

no med specific to ASD
meds may be used to treat symptoms of irritability, aggression, repetitive behavior, hyperactivity, problems with attention, anxiety, depression
serotonergic agents, antipsychotics, beta-blockers, alpha-2 agonists, mood stabilizers, stimulants

-nonpharmacologic

therapies focused on different areas of functioning
➣behavioral
➣developmental
➣educational
➣psychological
➣social-relational
Applied behavior analysis (ABA) therapy
Speech and language therapy
Occupational therapy
Physical therapy
Parent training
Dietary therapy
Social skills training

Joaquin, a 12-year-old with ASD, has difficulty sleeping and displays impulsive behaviors at school.
match the scenario with the appropriate med:

guanfacine
clomipramine
aripiprazole
methylphenidate
guanfacine

Rationale: Alpha-agonist medications, such as guanfacine or clonidine, may be used for clients with ASD who have hyperactivity, impulsive behaviors, and sleep problems.

Ariana, a 9-year-old with ASD, has a history of aggressive behaviors, tantrums, and motor tics.
match the scenario with the appropriate med:

guanfacine
clomipramine
aripiprazole
methylphenidate
aripiprazole

Rationale: Second-generation antipsychotic medications may be used for clients with ASD who have aggressive behaviors, tantrums, sleep disorders, or motor tics.

Seth, a 15-year-old with ASD, has a history of stereotypies including toe-walking and arm flapping.
match the scenario with the appropriate med:

guanfacine
clomipramine
aripiprazole
methylphenidate
clomipramine

Rationale: Tricyclic antidepressant medications may be used for clients with ASD who have repetitive behaviors and aggression.

Tyrek, an 11-year-old with ASD, has a history of hyperactivity and impulsive behaviors at school.
match the scenario with the appropriate med:

guanfacine
clomipramine
aripiprazole
methylphenidate
methylphenidate

Rationale: Stimulant medications may be used for clients with ASD who have hyperactivity, short attention spans, and impulsive behaviors.

Rett Syndrome
-rare neurodevelopmental disorder

typically caused by mutation in methyl CpG binding protein 2 (MECP2)
-affecting one in every 10,000-15,000 live female births worldwide
Boys born with the defect typically have severe problems when they are born & die shortly after birth
-spontaneously and is not inherited
-Characterized by:
normal growth and development early in life followed by impaired growth and development later in life
children may exhibit behaviors similar to ASD
mental & physical symptoms, loss of the purposeful use of the hands & ability to speak
Apraxia

why boys are affected worse by rett syndrome
-MECP2 gene is carried on the X chromosome.
-In girls, only one X chromosome is active in any given cell, so some cells express the mutation while others do not.
-severity of the symptoms r/t the % of cells that express an abnormal copy of the MECP2 gene.
-Because boys only have one X chromosome, there is no compensation for the gene defect

Rett Syndrome Diagnosis and Screening
-Children with symptoms of Rett syndrome

refer to neurologist or neurodevelopmental pediatrician
➣further evaluation of physical & neurological status
-clinical geneticist can help confirm the diagnosis

Rett Syndrome treatment
-No cure
-treatment can help:

slow the loss of abilities
preserve function
improve communication & socialization
-Therapy
Physical, occupational, & speech
➣assist with function, safety, communication
-Orthotics, prosthetics, braces, specialized seating, mobility equipment
encourage independence, manage bone & joint deformities
-Meds
control seizures, assist with breathing problems & motor difficulties.

Treating Rett Syndrome continued:
-Anti-seizure medications
-Spinal fusion surgery (if scoliosis develops)
-Custom seating equipment
-Augmentative communication
-Occupational therapy
-Physical therapy
-Leg braces

Tourette syndrome (TS)
-chronic neurodevelopmental disorder
-often referred to as a tic disorder
-characterized by:

abrupt, quick, recurrent, nonrhythmic motor movements or phonic vocalizations
-onset typically between 5-7 years
often increases in frequency & severity between 8-12 years
-0.52% of children 4-18 have TS
-Males more common than females
-often comorbid with other psychiatric conditions:
ADHD, OCD, learning difficulties, depression

predominant symptoms of TS
Tics
-often begin as motor tics in the neck & head area
-Tics often intensify with stress or excitement
-improve with focused or calming activities
-often decrease during late adolescence & early adulthood & may disappear in some individuals

Tourette syndrome (TS) Diagnosis
DSM-5-TR four diagnostic criteria are required for TS including:
-presence of multiple motor tics & one or more vocal tics, which may not occur concurrently
-tics may wax & wane in frequency but have persisted for more than 1 year since the first tic onset
-tic onset is before 18 years of age
-not caused by the use of a substance or other medical conditions

Tourette syndrome (TS) Screening
The Yale Global Tic Severity Scale (YGTSS)
-valid instrument used to assess tic severity and overall impairment of TS on the client’s quality of life.

John is a 7-year-old who often clears his throat while playing.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Simple vocal tics

Rationale: Simple vocal tics are caused by contraction of the diaphragm or oropharynx muscles and include frequent throat clearing, sniffs, chirps, barks, or grunting.

Clarence is an 8-year-old who blinks his eyes or makes facial grimaces when doing his homework.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Simple motor tics

Rationale: Simple motor tics are of short duration and can include eye blinks, facial grimaces, shoulder shrugs, or extension of the extremities.

Samuel is a 12-year-old who presents with repetitive head-turning and shoulder shrugging.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Complex motor tics

Rationale: Complex motor tics include a combination of simple tics that last for a longer duration.

Neil is a 10-year-old who presents with his mother after repeated episodes of barking ethnic, racial, and religious slurs at school.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Complex vocal tics: Coprolalia

Rationale: Coprolalia is a complex vocal tic characterized by abrupt, sharp bark or grunt vocalization of socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs. This type of tic is less common.

Brett is a 12-year-old who often makes sexual or taboo gestures when he gets excited.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Complex motor tics: Copropraxia

Rationale: Copropraxia is a less common complex motor tic that involves making obscene gestures.

Amy is a 14-year-old who frequently echoes what she just heard, saying that word or phrase over and over.
match the clinical scenario with the appropriate tic:

Simple motor tics
Complex vocal tics: Coprolalia
Complex motor tics
Simple vocal tics
Complex vocal tics: Echolalia
Complex motor tics: Copropraxia
Complex vocal tics: Echolalia

Rationale: Echolalia is a complex vocal tic characterized by repeating the last heard word or phrase.

Tourette syndrome (TS) Treatment
Tx necessary when tics affect child’s physical, mental, or social wellbeing
-nonpharmacological

psychoeducation (first-line)
behavioral therapies
➣comprehensive behavioral intervention for tics (CBIT)
exercise therapies
-pharmacological interventions
antipsychotics such as pimozide & aripiprazole to control tics

comprehensive behavioral intervention for tics (CBIT)
non-drug treatment consisting of three important components:
-Training patient to be more aware of tics
-Training patients to do competing behavior when they feel the urge to tic
-Making changes to day to day activities in ways that can be helpful in reducing tics.

Schizophrenia
-dx is uncommon before age 17
-Prodromal symptoms often begin gradually in mid-adolescence

subtle changes in mood, thinking, & social functioning
-Stressful life events may precipitate symptoms of schizophrenia in those already vulnerable

Childhood-Onset Schizophrenia (COS)
-diagnosed in clients younger than 13
-rare
-typically present with severe symptoms & tx challenges
-Auditory hallucinations, most common symptom in children

many children do not report due to fear the voices will harm them
-negative symptoms
often misinterpreted by parents as laziness, lack of motivation, depression
-Cognitive decline is common:
verbal memory, attention, concentration
-may cause developmental delays

Ketanji is a 7-year-old who endorses hearing her grandmother speaking to her regularly. She witnessed her grandmother die from a heart attack in the home.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
PTSD

Rationale: Children who experience trauma may have flashbacks described as auditory hallucinations.

Stephen is an 8-year-old who has difficulty with social interactions. He frequently appears withdrawn, and his speech sometimes seems disorganized.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
Autism spectrum disorder (ASD)

Rationale: Social impairment, withdrawal, and stereotyped use of language are common symptoms of ASD that may be confused with COS.

Sonia is a 12-year-old who presents with tangential speech and psychomotor agitation; she states that she will be competing as a ski jumper in the upcoming Olympics and is sure to win the gold medal.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
Bipolar I disorder

Rationale: Disorganized speech or thought processes, psychomotor agitation, and delusional thinking are common symptoms of BPD that may be confused with COS.

Elena is a 6-year-old who describes visual hallucinations of a tall, thin, shadowy man in her room.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
Anxiety

Rationale: Younger children with symptoms of anxiety may report auditory or visual hallucinations as a manifestation of the anxiety.

John is a 12-year-old who has become increasingly socially isolated over the past year. His parents’ state he is completely unmotivated and often seems “in his head”, and his sister notes that she often hears him having “frightening” conversations with himself in his room at night; he denies hallucinations.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
COS

Rationale: Social isolation and withdrawal are common prodromal symptoms in children who have COS. Children often deny hallucinations due to fears of harm or of being considered mentally ill.

Ruth is a 14-year-old who spent the night at a friend’s house. Since she returned home, she has locked herself in her bedroom. When her mother knocked on her door to check on her, she stated she can’t stop floating and she is afraid she will float away if the door opens. She admitted to her mother that she and her friend had experimented with marijuana and molly the previous night.
match the clinical scenario with the most appropriate diagnosis:

Bipolar I disorder
Substance-induced psychosis
COS
PTSD
Anxiety
Autism spectrum disorder (ASD)
Substance-induced psychosis

Rationale: Substances that may induce psychosis in teens include hallucinogens, ecstasy, methamphetamines, marijuana, and alcohol. Polysubstance use increases the risk of psychotic episodes.

Childhood-Onset Schizophrenia (COS) Treatment
-antipsychotic medication is First-line treatment
-Treatment is often lifelong
-Second-generation antipsychotics have high risk of metabolic side effects, monitor:

weight
blood pressure
fasting glucose
lipid levels
-First-generation antipsychotics, higher cumulative risk of tardive dyskinesia
reserve for pts who don’t respond to second-generation antipsychotics
-Augment medications with individual & family therapy
assist with reduction of symptoms
improved communication & conflict resolution
development of coping strategies for client & family

Symptom-Triggered Therapy
Step 1: Administer CIWA-Ar
-Administer every 4-8 hours until the score is lower than 8-10 for 24 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.

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