Midterm Exam: NR607/ NR 607 (Latest 2024/ 2025 Update) Diagnosis & Management in Psychiatric Mental Health III Complete Review (Weeks 1-4) Questions and Verified Answers| 100% Correct

Midterm Exam: NR607/ NR 607 (Latest 2024/ 2025 Update) Diagnosis & Management in Psychiatric Mental Health III Complete Review (Weeks 1-4) Questions and Verified Answers| 100% Correct | Grade A – Chamberlain

The PMHNP (Psychiatric Mental Health Nurse Practitioner) is providing care to a 29-year-old client who presents with persistent sadness and hopelessness for the last two months. She is having difficulty sleeping and has a decreased appetite. This is the patient’s first contact with with the healthcare system about her concerns.
PMHNP role:

Acute PMHNP Care
Telehealth
Case Management
Primary Care
Pharmacologic Intervention
Crisis Intervention
Partial Hospitalization/Intensive Outpatient Tx
Community-Based Care
Self-Employment
Psychotherapy
Primary Care

Rationale: This is the client’s initial contact with the healthcare system about her concerns

The client has experienced depressive symptoms. The PMHNP prescribes a selective serotonin reuptake inhibitor (SSRI).
PMHNP role:

Rationale: The PMHNP is prescribing psychopharmacotherapy for the client

The PMHNP provides the client with some mindfulness techniques to try at home.
PMHNP role:

Rationale: The PMHNP is utilizing a psychotherapeutic approach to help the client gain insight

Two weeks after starting on the SSRI, the client begins to experience suicidal ideations and develops a plan to kill herself. A friend brings the client to the emergency room. The PMHNP meets the client at the emergency room and collaborates with the physician to coordinate care.
PMHNP role:

Rationale: Suicidal ideation with a plan is a psychiatric emergency requiring immediate intervention.

The client is admitted to the psychiatric and behavioral health unit at the local hospital for a 72-hour observation where the PMHNP works with her team providing treatment. The client remains hospitalized for a week while her medications are managed. The client attends individual and group therapy sessions.
PMHNP role:

Rationale: Acute inpatient care occurs in an intensive hospital or psychiatric facility setting.

Following hospitalization, the client returns home but commutes to a treatment center for 4 hours a day 5 days per week for ongoing therapy, medication management, and psychoeducation.
PMHNP role:

Rationale: Partial Hospitalization/Intensive Outpatient Treatment occurs when a client receives intensive therapy on an outpatient basis, often used when a client do not require 24-hour care but still require intense treatment.

The PMHNP serves as the point of contact person, coordinating the treatment team, which consists of the PMHNP, a social worker, and possibly a psychologist and psychiatrist.
PMHNP role:

Rationale: Case management involves oversight and/or coordination of care.

Over the course of 2 months, the client’s condition improves. She is discharged from intensive outpatient treatment and begins weekly appointments with the PMHNP at the PMHNP’s clinic.
PMHNP role:

Rationale: Community-based care is provided in a non-hospital community setting.

A global pandemic limits face-to-face mental health visits, the PMHNP determines that the patient requires ongoing mental health treatment. The PMHNP arranges to meet with the client via weekly interactive video sessions.
PMHNP role:

Rationale: Telehealth services utilize telecommunication technology to deliver treatment to clients.

The PMHNP owns the private practice that is providing services to the client.
PMHNP role:

Rationale: The PMHNP is providing direct services through her own private practice.

Code of Ethics for Nurses
-Respect for the Individual
-Commitment to the Healthcare Consumer
-Advocacy for the Healthcare Consumer
-Responsibility and Accountability for Practice
-Duties to Self and Others
-Contributions to Healthcare Environments
-Advancement of the Nursing Profession
-Collaboration to Meet Health Needs
-Promotion of the Nursing Profession

How the PMHNP does Code of Ethics: Respect for the Individual
-approaches professional relationships with compassion, caring, & respect, acknowledging the dignity & worth of each individual.
-helps instill hope & empowers those with PMH disorders.
-affirms the worth & dignity of those with PMH disorders by advocating to overcome (-) stigmas towards PMH diagnoses to ensure access to care.

How the PMHNP does Code of Ethics: Commitment to the Healthcare Consumer
-recognizes & addresses personal attitudes & behaviors that could interfere with meeting ethical guidelines for care.
-maintains proper boundaries.
participates in self, peer, & supervisory oversight of clinical skills & practice.
-recognizes that those with brain-based mental health disorders may have maladaptive coping behaviors, which impact the individual, family, & society.

Maladaptive behavior may continue in spite of (-) consequences.
Behavioral change may involve setbacks.
-is aware of the need to balance human rights with safety, including coercive measures or forced tx when individuals are unable to maintain their own safety.

How the PMHNP does Code of Ethics: Advocacy for the Healthcare Consumer
-strives to protect the rights, health, & safety of clients.
-maintains confidentiality according to HIPAA requirements & professional boundaries in all interactions
-recognizes the power differential in the therapeutic relationship & understands that any sort of sexual activity or intimacies with current clients, their close family members, guardians, or significant others is unethical.

How the PMHNP does Code of Ethics: Responsibility and Accountability for Practice
-must be responsible & accountable for their own practice.
-must be able to articulate competencies & be aware of scope of practice professional standards guiding their own practice.
-must understand the scope of other team members’ practice in order to delegate appropriately.

How the PMHNP does Code of Ethics: Duties to Self and Others
-owes the same duties to self as to others.
-accords moral worth & dignity to oneself & others, including colleagues.
-is committed to practicing self-care, managing stress, & maintaining supportive relationships to meet personal needs outside of therapeutic relationships.
-identifies & addresses moral distress.

How the PMHNP does Code of Ethics: Contributions to Healthcare Environments
-helps maintain & improve healthcare environments and conditions of employment.
-recognizes signs & symptoms of psychiatric disorders in the workplace & reports peer observations or concerns to leadership.
-helps address problems faced by colleagues that may impact patient safety or violate public trust, including substance abuse.

How the PMHNP does Code of Ethics: Advancement of the Nursing Profession
-contributes to advancing the professing through practice, education, administration, & knowledge development.
-maintains knowledge of & apply evidence-based practice guidelines, including risk assessment & management.
-participates in continuous quality improvement.
-pursues continuing education.

How the PMHNP does Code of Ethics: Collaboration to Meet Health Needs
-promotes community, national, & international efforts to meet health needs through collaboration with other healthcare professionals.
-engages in partnerships with other specialty nurses, government agencies, professional nursing organizations, & mental health organizations to promote prevention, treatment, & recovery.

How the PMHNP does Code of Ethics: Promotion of the Nursing Profession
-advocates for environments that respect human rights, customs, & spiritual beliefs of individuals, families, & communities.
-engages in interactions & collaborations to articulate nursing values & maintain the integrity of the profession.
-participates in policy development & implementation that recognizes PMH disorders as treatable & ensures that nursing care is delivered with respect to human needs & values without prejudice.

Person A: “I can’t believe you deal with these people every day. Schizophrenics would drive ME crazy!”
PMHNP: “Actually, schizophrenia is a chronic treatable disease, much like diabetes or other physical illnesses. Patients who have mental illness deserve compassion and care.”
How the PMHNP applied ethical principles:

-Respect for the Individual
-Commitment to the Healthcare Consumer
-Advocacy for the Healthcare Consumer
-Responsibility and Accountability for Practice
-Duties to Self and Others
-Contributions to Healthcare Environments
-Advancement of the Nursing Profession
-Collaboration to Meet Health Needs
-Promotion of the Nursing Profession
Respect for the Individual

Rationale: Respect for the individual affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care.

The client presents to the emergency department with hallucinations and is threatening self-harm. The PMHNP signs an involuntary admission order for emergent psychiatric care.
How the PMHNP applied ethical principles:

Rationale: The PMHNP demonstrates a commitment to the healthcare consumer by balancing the client’s human rights with safety, including coercive measures when the client was unable to maintain their own safety.

The PMHNP is sharing sexually explicit memes with a client that she saw earlier today in a group session.
How the PMHNP applied ethical principles:

Rationale: This is an unethical scenario. The PMHNP recognizes the power differential in the therapeutic relationship and understands that any sort of sexual activity or intimacies with current clients, their close family members, guardians, or significant others is unethical.

The PMHNP has overbooked her sessions today, so she asks the registered nurse (RN) who works in her office to conduct one of her phone therapy sessions today.
How the PMHNP applied ethical principles:

Rationale: This is an unethical scenario. The PMHNP must understand the scope of other team members’ practice in order to delegate appropriately. Conducting a counseling session is outside of the RN’s scope of practice.

The PMHNP takes time for daily meditation to improve mindfulness and ease stress.
How the PMHNP applied ethical principles:

Rationale: The PMHNP is committed to practicing self-care, managing stress, and maintaining supportive relationships to meet personal needs outside of therapeutic relationships.

A PMHNP discovers her colleague is diverting scheduled medications to self-medicate anxiety. The PMHNP reports the concerns to the colleagues supervisor.
How the PMHNP applied ethical principles:

Rationale: The PMHNP recognizes signs/symptoms of psychiatric disorders in the workplace reporting peer observations to leadership. The PMHNP helps address problems faced by colleagues that impact client safety or violate public trust, including substance abuse.

The PMHNP gives a presentation at a national conference on best practices in depression treatment.
How the PMHNP applied ethical principles:

Rationale: The PMHNP contributes to advancing the professing through practice, education, administration, and knowledge development.

The PMHNP is a member of the American Nurses Association (ANA) and National Alliance on Mental Illness (NAMI) and regularly participates in workgroups that seek to expand access to care for healthcare consumers with PMH disorders.
How the PMHNP applied ethical principles:

Rationale: The PMHNP promotes community, national, and international efforts to meet health needs through collaboration with other healthcare professionals to promote prevention, treatment, and recovery.

A PMHNP speaks at a school board meeting about the need develop policies to expand mental health services for underserved students.
How the PMHNP applied ethical principles:

Rationale: The PMHNP participates in policy development and implementation that recognizes PMH disorders as treatable and ensures that nursing care is delivered with respect to human needs and values without prejudice.

Informed Consent
-for care & tx is a fundamental ethical & legal principle that respects the client’s autonomy in medical decision-making.
-Clients have the right to receive information & ask Qs about recommended txs to make decisions about their care that are consistent with their beliefs, values, & tx goals
-The Joint Commission requires providers to conduct informed consent discussions

steps required to obtain informed consent, according to the American Medical Association
-Assess client ability to understand medical info. & tx options & to make a voluntary decision.
-Present relevant info. with accuracy & sensitivity. Include:

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.

exceptions to informed consent
-incapacitation
-situations involving life-threatening emergencies in which there is no time for informed consent
-client’s voluntary waiver of informed consent
-When a client is incapable of informed consent due to the nature or severity of their mental illness

PMHNP must determine if a client has the capacity to make medical decisions

steps in evaluating a client’s capacity for decision-making.

Assess for communication barriers: language, hearing or vision impairments, dysarthria
Evaluate for reversible causes of incapacity: infection, medications or other substances, acute neurologic & psychiatric disorders
Identify values & cultural influences that may impact client decision making
Ask questions: determine the client’s ability to understand the tx & how tx applies to their situation.
Identify a surrogate if needed: healthcare advance directive, medical power of attorney, spouse, adult children, other close relatives
Document

formal assessment tool to assist in determining capacity
Aid To Capacity Evaluation (ACE)

Practice Settings for complex mental health care
-mental health settings
-primary care
-pediatrics
-family and internal medicine
-home health care
-hospitals
-schools
-prisons

Legal & Ethical Implications in the Tx of Clients with Complex Disorders
-mental illness can impair a client’s capacity to make informed decisions for themselves
-side effects of some mental health txs may lead clients to choose nonadherence to tx recommendations
-client’s psychiatric symptoms may compromise their safety or the safety of others.
-ethical dilemmas may arise when clients’ wishes differ from treatment recommendations or when interprofessional team members disagree about the best course of action in the treatment of a client

Mental Health Amercia’s 2015 position statement stipulates that:
professionals must respect the client’s fundamental rights of the client for dignity, autonomy, & self-determination while addressing concerns about the safety & well-being of the client & others.

six key core skills that are critical to ethical decision-making in mental health care

Ability to identify ethical issues
Ability to understand how one’s values, beliefs, & sense of self, including implicit biases, impact client care
Ability to recognize personal limits to knowledge & expertise & willingness to practice within limits
Ability to recognize situations that present a high risk for ethical dilemmas
Willingness to seek information & consultation in difficult ethical or clinical situations
Ability to build ethical safeguards into one’s practice

Unrepresented clients
clients without advance directives and available family or friends to make decisions
-State laws and institutional policies typically take one of three approaches in choosing a decision-maker

the physician or provider
an ethics committee
court-appointed guardian

Yolanda is a 20-year-old client who was referred to the PMHNP by her college health clinic for symptoms consistent with bipolar II disorder. She initiates the interview by stating that she is not willing to take any medications but is willing to engage in counseling or other therapies.
Which of the following is the most appropriate action?

provide additional education
document refusal of treatment
initiate treatment without informed consent
provide additional education

Rationale: The client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. If, after receiving education, the client still refuses medication therapy, it is important to document the education provided and the client’s refusal of treatment.

Kevin is a 48-year-old with a 20-year history of schizophrenia. He has decided to stop pharmacological treatment due to the intolerable adverse effects of his medications. Kevin and the provider have discussed the benefits and drawbacks of ceasing treatment, and he has agreed to weekly telephone check-ins to ensure his well-being.
Which of the following is the most appropriate action?

provide additional education
document refusal of treatment
initiate treatment without informed consent
document refusal of treatment

Rationale: The client has the capacity to consent, and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment.

Ashlei is a 19-year-old who presents to the clinic with severe anxiety symptoms. As the PMHNP begins reviewing treatment options, Ashlei interrupts and states, “Hearing about these medications increases my anxiety. Please prescribe what you think is best for me, and I will take it.”
Which of the following is the most appropriate action?

provide additional education
document refusal of treatment
initiate treatment without informed consent
initiate treatment without informed consent

Rationale: Clients may choose to waive their right to informed consent. The PMHNP should clearly document the client’s waiver.

Geoff is a 32-year-old who presents to the clinic with anhedonia, fatigue, feelings of worthlessness, and a lack of focus. He admits to thinking about death but denies suicidal ideations or a plan. He has been taking sertraline 50 mg daily and wishes to stop taking the medication as it does not seem to be helping.
Which of the following is the most appropriate action?

provide additional education
document refusal of treatment
initiate treatment without informed consent
provide additional education

Rationale: The client has the capacity to provide consent and the situation is not emergent; however, the client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. At this time, the dose should be increased to achieve efficacy. If, after receiving education, the client still refuses medication therapy, the PMHNP should document the education provided and the client’s refusal of treatment.

Fritz is a 25-year-old who has been brought to the emergency department by the police after threatening a server at a restaurant. The PMHNP on call has treated Fritz for schizophrenia in the past. He has a history of poor treatment adherence. While in the emergency department, he admits to auditory hallucinations. He becomes agitated and begins throwing items around the examination room.
Which of the following is the most appropriate action?

provide additional education
document refusal of treatment
initiate treatment without informed consent
initiate treatment without informed consent

Rationale: The client does not have the capacity to provide consent at this time due to active hallucinations and agitation. For the safety of the client and staff, treatment should be initiated without obtaining informed consent.

Acute inpatient care
short-term treatment to provide care for acutely ill clients who are unable to meet basic needs due to a mental health condition or are at risk of harming themselves or others
-focus is crisis stabilization
-may be voluntary or involuntary

Voluntary Admission
-when a client & provider agree that client’s symptoms meet criteria for inpatient hospitalization & the client may benefit from admission
-client will sign consent form agreeing to a hospital stay in a locked unit
-not require a psychiatric hold

if client requests discharge & provider determines the client is not yet safe, the provider may initiate an emergency involuntary hold

Involuntary Admission
-when a client does not agree to hospitalization
-an evaluation by a mental health professional indicates that the client may be at high risk of harming themselves or others
-Other terms denoting an involuntary admission include involuntary commitment, psychiatric hold, or civil admission
-most states, clients can be held for up to 72 hours involuntary if deemed an imminent threat

Providers must perform & document a detailed eval & a risk assessment.

Involuntary civil commitment
-legal intervention directed by a judge to order a person with serious symptoms of continued danger to self or others, grave disability, or serious deterioration to either remain in a psychiatric hospital or attend supervised outpatient treatment for a period of time
-maximum length of inpatient commitment varies by state
-Outpatient commitment, or assisted outpatient treatment (AOT), may consist of supported housing, intensive case management, medications, and frequent therapy

tx may last for 6 to 12 months.

Approximately __% of clients with serious mental illness are committed involuntarily each year after a psychiatric hold
0.1%

Standards for Involuntary Commitment (Assisted Treatment) State-by-State
https://mentalillnesspolicy.org/national-studies/state-standards-involuntary-treatment.html

Keith is a 35-year-old who presents to the crisis clinic with his wife, who is very concerned about Keith’s recent behavior. He believes his neighbors have been spying on him using technology acquired from a secret government source. He is agitated and states, “I just have to take them out. I can’t have them looking at us anymore. I’m going to have to build a blaster to take them out.” Keith’s wife confirms that there are no weapons in the home. Keith is willing to initiate treatment but does not want to be admitted as an inpatient at this time.
Does Keith require an emergency psychiatric hold?

yes
no
varies according to state legislation
no

Rationale: Keith does not meet the criteria for an emergency psychiatric hold. Although he is experiencing active delusions, his behavior does not threaten the safety of himself or others. Education, resources, and a plan for follow-up care should be established.

Dakota is a 24-year-old who presents to the emergency department with his sister. He endorses taking a “handful” of pills after a fight with his boyfriend. He states that he regrets taking the pills, and he does not want to end his life. He denies active suicidal ideations or a plan. Dakota plans to stay with his sister for the next few days.
Does Dakota require an emergency psychiatric hold?

yes
no
varies according to state legislation
no

Rationale: Dakota does not meet the criteria for an emergency psychiatric hold. He does not have active thoughts of killing himself. He should be provided with resources for follow-up as well as information for the National Suicide Prevention Lifeline.

Rudy is a 42-year-old who was brought to the emergency department by his social worker. He was lethargic and disoriented when she found him at his “regular” spot in an encampment of unhoused individuals. Rudy was admitted for dehydration and his labs indicated severe malnutrition. Rudy has a history of schizophrenia with poor treatment adherence. He has no family in the area and has been living without housing for several years; his social worker endorsed that before this point, he had appeared healthy and had utilized available services for meals. Once medically stable, Rudy stated that he did not remember where to get food, and he was not sure how he got so sick. He does not wish to remain in the hospital.
Does Rudy require an emergency psychiatric hold?

yes
no
varies according to state legislation
varies according to state legislation

Rationale: Rudy meets the criteria for a psychiatric hold in most states. He has a history of mental illness with poor treatment adherence, has no family support, and has been unable to care for himself; he meets the criteria for a gravely disabled individual and may be detained involuntarily for further evaluation.

Nnenna is a 22-year-old who was brought to the emergency department by the police after a car crash. The police officers state that Nnenna was crying and repeating, “just let me die” and the officers were concerned for her mental wellbeing. Nnenna’s blood alcohol content is 0.12 g/mL. Upon interview, Nnenna has gross motor impairment and impaired judgment. She denies suicidal ideations, but she states it might be better for her to just die because her parents are going to be so upset after they find out about the accident. Nnenna’s boyfriend met her in the emergency department and reported that she frequently drinks excessive amounts of alcohol. He plans to stay with her in her apartment overnight if she is released.
Does Nnenna require an emergency psychiatric hold?

yes
no
varies according to state legislation
varies according to state legislation

Rationale: Nnenna meets the criteria for a psychiatric hold in some states. She is legally impaired due to alcohol consumption, and her boyfriend reports that she frequently drinks excessive amounts of alcohol. She also crashed her vehicle and states that she wants to die.

Miguel is a 64-year-old who was arrested at a nearby supermarket after pulling a knife out of his jacket pocket and threatening an employee who refused to allow him to enter without a mask. After finding a prescription bottle for lithium in his belongings, police requested a psychiatric evaluation to determine if he should be transferred to a psychiatric facility. During the interview, Miguel is alert, oriented, and calm. He appears focused and his speech is measured and clear. He states that he has been living with bipolar 2 disorder for about 30 years, takes his medications regularly, and sees a mental health professional every month.
Does Miguel require an emergency psychiatric hold?

yes
no
varies according to state legislation
no

Rationale: Miguel does not meet the criteria for an emergency psychiatric hold. Although Miguel exhibited dangerous behavior in the supermarket, he does not display symptoms of mania that would indicate that his behavior is related to his mental health diagnosis.

Bart is a 39-year-old client with no known medical or psychiatric history who was brought to the emergency department by the police after assaulting two people in a parking lot. He states that the people he attacked were demons sent to hurt him, and he was acting in self-defense when he attacked them. Bart endorses that he has been receiving messages from God for the past few days and, although he has tried to ignore the communication, he was forced to follow the commands in the messages. He states that he continues to receive messages; he becomes agitated when a phlebotomist enters the room and strikes at her, stating, “look! There’s another demon! Why don’t you believe me?”
Does Bart require an emergency psychiatric hold?

yes
no
varies according to state legislation
yes

Rationale: Bart meets the criteria for an emergency psychiatric hold. He presents a danger to others.

Khoudia is a 34-year-old who delivered her second child one month ago. She presents to the emergency department with her husband and newborn. Her obstetrician called a referral to the emergency department after completing the Ask Suicide-Screening Questions tool which indicated an acute positive screen. Khoudia endorses frequent thoughts about killing herself in the past week and states she has been overwhelmed by the baby’s care. She states she has a plan to wait until the baby is asleep and then sit inside the garage with the car running. Khoudia refuses to be admitted to the hospital because she is breastfeeding; her husband voices a plan to hide the car keys and stay awake all night to keep her safe.
Does Khoudia require an emergency psychiatric hold?

yes
no
varies according to state legislation
yes

Rationale: Khoudia meets the criteria for an emergency psychiatric hold. She presents a danger to herself; her husband’s safety plan, while admirable, is not realistic to keep her safe. The client should be provided with a breast pump and storage for breastmilk so that she may continue to breastfeed.

Psychiatric Advance Directives (PAD)
-unique legal documents that guide a client’s treatment preferences if they are having a mental health crisis and are unable to make decisions
-may contain advance instructions, a health care power of attorney, or both
-help protect a client’s autonomy by detailing their preferred medications and treatment modalities, and by giving advance consent for treatment or admission
-useful for clients who experience episodes of acute psychosis, catatonia, mania, or delirium

state laws regarding Psychiatric Advance Directives (PAD)
https://nrc-pad.org/states/

Ethical Use of Restraints and Seclusion
-Clients at risk of imminent harm to themselves or others may require temporary seclusion or restraint until their condition is stabilized
-Laws differ from state to state
-Seclusion: involuntary confinement of an individual alone in a room or area from which the ind is prevented from leaving
-Restraints can be both chemical and physical

Chemical restraints: any substance used to control a client’s behaviors
physical restraints: devices that restrict a client’s movement, both soft and leather limb restraints, Mittens.
-should only be used to ensure the immediate physical safety of the client and others
-Restraints, used as a last resort when less restrictive interventions have been ineffective

Restraints carry a risk of injury including:
extremity fractures, suffocation, and even death

Ordering Restraints and Seclusion
-face-to-face evaluation and written order are required to initiate

evaluation must be completed within one hour of the application
-Restraints cannot be ordered PRN
-q24 hr, an authorized licensed practitioner responsible for the client’s care orders must evaluate & document the continued need for restraints
-should be discontinued as soon as safely possible.

Severe mental illness afflicts __% of all U.S. adults
6% of all U.S. adults
-higher among females, young adults aged 18-25, and minority populations

Mental health professionals must respect the client’s fundamental rights of the client for , , and ______ while addressing concerns about the safety and well-being of the client and others.
dignity, autonomy, and self-determination

_________ for care and treatment is a fundamental ethical and legal principle
Informed consent

Clients _________________ may require temporary seclusion or restraint until their condition is stabilized.
at risk of imminent harm to themselves or others

Over _ of Americans live in a mental health professional shortage area
one-third
-those that live outside of a shortage area often report access & utilization barriers to mental health care

All clients experiencing psychiatric symptoms must be
-evaluated and screened with a validated suicide assessment tool
-Stabilization must be attempted

using the least restrictive interventions.

Psychiatric Emergencies
situations that involve acute disturbances in thought, mood, behavior, or social interactions that negatively impact a client’s ability to function in their environment and require immediate intervention to keep the client and others from harm

Types of Psychiatric Emergencies
-Risk of harm to others
-Risk of harm to self
-unable to meet their own basic needs for food, clothing, or shelter due to a psychological impairment
-Serotonin syndrome
-Neuroleptic malignant syndrome (NMS)
-Agranulocytosis
-Lithium toxicity
-Suicidality
-Acute psychosis
-Agitation and aggression
-Mania
-Substance-related concerns
-Decompensation r/t personality disorders
-Severe anxiety
-Medication-related emergencies

Risk factors for suicide
-Hx of substance abuse
-Physical disability or illness
-Losing a friend or family member to suicide
-Ongoing exposure to bullying behavior
-Mental health condition
-Recent death of a family member or a close friend
-Access to harmful means
-Relationship problems
-Previous suicide attempts

Ask suicide-screening questions (ASQ) suicide risk screening tool
https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf

Assessment During a Psychiatric Emergency
-gather info about pt before the exam to facilitate a rapid assessment; from family, medical records, emergency medical technicians or law enforcement, nursing staff.
-PMHNP may need to collaborate with emergency medicine team to determine if theres a physical cause for acute psychiatric symptoms

-psychiatric history

Risk assessment
Physical risk
Risk of harm to others
Deficiency needs
De-escalation
Risk of harm to self

psychiatric history: Risk assessment
-quickly determine level of risk to client & others
-minimize as much as possible

psychiatric history: Physical risk
-quick visual exam

skin color, sweating, pupil size, LOC, or obvious injuries to ensure adequate airway, breathing, & circulation. Vital signs if able

psychiatric history: Risk of harm to others
-PMHNP should not be alone while examining a client who is acutely disturbed or agitation
-Security personnel should be aware of the client’s behavior
-door should be kept open

provider positioned between client & the door for safe exit if necessary.

-early warning signs of violence

threatening comments
clenched fists
shifts in body position towards a fighting stance
loud vocalizations
agitated movements
striking inanimate objects.

-Risk assessment tools, help early identification and intervention.

AEIO (agitation/arousal, environment, intent, objects)

psychiatric history: Deficiency needs
-Pts with deficiency needs may req additional support to offset aggression
-Similar to Maslow’s hierarchy, the needs may include:

physiological (food, hydration, sleep, ability to see/hear normally)
safety (access to personal items, pain medication)
belonging (family members, physician-client relationship)
esteem (clarifying the client’s wishes)

psychiatric history: De-escalation
-first-line response to potential violence or aggression in healthcare settings
-AKA conflict resolution or crisis management
-strategies and techniques to reduce a client’s agitation or aggression

Clear, calm, empathetic, nonjudgmental communication
Respect for personal space
Non-confrontational approach
Non-threatening nonverbal communication
Response to client’s expressed problem or condition
Clear limits
Environmental controls such as minimizing light, noise, and loud conversations

psychiatric history: Risk of harm to self
-suicide warning signs

sense of hopelessness or no hope for the future
Isolation or feeling alone
Aggressiveness & irritability
Possessing lethal means
Feeling like a burden to others
Drastic changes in mood & behavior
Frequently talking about death
Self-harm, like cutting behaviors
Engaging in “risky” behaviors
Making funeral arrangements
Giving things away
Substance abuse
Making suicide threats
Negative view of self

-at risk of suicide; suicide assessment & risk eval necessary using a valid tool

Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool

Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool

Identify risk factors

Note those that can be modified to reduce risk

Identify protective factors

Note those that can be enhanced

Conduct suicide inquiry

Suicidal thoughts, plans, behavior, & intent

Determine risk level/intervention

Determine risk
Choose appropriate intervention to address & reduce risk

Document

Assessment of risk, rationale, intervention, and follow-up

Art is a 52-year-old who presents to the clinic for a routine follow-up appointment. He has a history of schizophrenia with a lack of insight, impulsivity, and previous violent behavior. As the interview begins, Art states that he has had homicidal ideations toward his brother and nephew. He states that the two men have “disrupted his thinking” by “creating a new theory of family,” and he is worried that the only solution is to kill them both. Currently, Art is calm and cooperative with disorganized thought content and fixed delusions; his appearance is slightly disheveled. He denies substance use and does not appear inebriated. He denies a specific plan to kill his brother and nephew and denies access to firearms. He endorses that he stopped taking his medications two weeks ago because he no longer needs them and does not think he needs additional assistance at this time. Which of the following is the most a
begin the involuntary admission process

Rationale: The most appropriate management strategy for Art is to begin the involuntary admission process. Art has homicidal ideations and a history of impulsivity and prior violence. He does not recognize the need for treatment. Therefore, the process for involuntary admission should be implemented. Consideration should also be made as to whether Art’s family should be notified of his threats. Because Art is currently calm and cooperative, de-escalation techniques are not necessary.

Amir is a 28-year-old who was brought to the ED by law enforcement after his mother called 911 due to his bizarre behaviors. When the police arrived, Amir was agitated and wandering the street naked. He refused to follow directions and became combative with officers when approached. He was handcuffed and transported by a squad car. Before transfer, his mother told police that Amir had a history of schizophrenia with treatment nonadherence and marijuana use.
During the ride to the ED, Amir was calm and cooperative. He was transferred to a gurney in the triage area without incident, but after transfer to an exam room, Amir began screaming and threatening the PMHNP and staff member. Amir tried to punch and spit at them when they approached the bedside.
Which of the following are the most appropriate management strategies for Amir? Select all that apply.

-begin the involuntary admission process
-use de-escalation techni
-use de-escalation techniques
-request additional staff support
-medicate with intramuscular lorazepam 0.5 mg
-remove objects from the room, such as monitors, tray tables, or other equipment, that the client may use to injure himself or others

Rationale: Amir presents a risk of harm to self and others due to his combative behavior; therefore, the most appropriate management strategies for Amir include the use of de-escalation techniques, request for additional staff support, intramuscular lorazepam 0.5 mg, and the removal of objects from the room, such as monitors, tray tables, or other equipment, that he may use to injure himself or others. Chemical restraint may be necessary. Additional staff should be requested to provide support, and de-escalation techniques should be attempted. Items the client may be used to injure himself or others should be secured or removed. Physical restraints may be necessary and should be applied by the emergency department team, not law enforcement.

Madison is a 30-year-old who was brought to the ED by police. She was apprehended at a local shopping center after several drivers called the police to report that she was shouting and making crude gestures at their cars. Madison is alert, oriented, and cooperative; she denies any past medical or psychiatric history, and no medical records are found in the system. She admits that she does not have a home, and he has been panhandling with little success. When the emergency department attending physician asked her to submit a blood and urine sample, she became agitated and verbally threatened the phlebotomist. A psychiatric consult is initiated. Which of the following are the most appropriate management strategies for Madison? Select all that apply.

-begin the involuntary admission process
-use de-escalation techniques
-request additional staff support
-medicate with intramuscular lorazepam 0.5 mg
-remove objects from
-ask Madison if she would like a meal or snack
-use de-escalation techniques
-request additional staff support

most common psychiatric emergencies PMHNPs may encounter:
Suicide

Hailey is a 20-year-old brought to the emergency department by EMS to evaluate a laceration. Her roommate found her sitting on their sofa with blood streaming down her arms and a knife beside her. Her roommate immediately called 911 and applied pressure to the wound. The triage nurse assessed the wound as superficial. After dressing the wound, the PMHNP was called to perform a psychiatric evaluation. On exam, she is awake and alert but appears withdrawn and hesitant to speak. She continues to repeat, “I don’t know why this keeps happening.” Hailey denies medical or psychiatric history; the PMHNP notes bilaterally linear scarring on her arms. Hailey admits to self-injury behaviors and states she has been using cutting as a coping mechanism for years. She confirms that she did not intend to kill herself today and has never experienced suicidal ideations. Which of the following is the most appropriate recommendati
discharge to home with resources for crisis care and recommendations for outpatient psychiatric services

Rationale: The client did not have suicidal thoughts during the self-harm episode. The self-harm episode was not lethal in nature, nor was there intent for lethality. The client should be provided psychiatric care resources for follow-up.

Mary Ellen is a 42-year-old who presents to the clinic with low energy and “feeling down.” She states she has been increasingly fatigued for the past two months since she was laid off from her job due to downsizing. She reports that she presented for care because she felt “down in the dumps” as it was her sister’s death anniversary. She had thoughts about harming herself somehow over the past few days but denied specific plans, stating, “sometimes it just seems like it would be easier not to be here.” She has a previous history of a suicide attempt as a teenager, after which she received several years of therapy; she has not received mental treatment for about 20 years. She also reports using occasional marijuana and alcohol socially; she currently appears sober. Mary Ellen lives with her husband with whom she states she has a poor relationship; he has not been supportive of her mental health needs in t
recommend voluntary admission

Rationale: Mary Ellen has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempts and has a lack of support resources. Currently, she may benefit from voluntary admission for evaluation and treatment.

Deshawn is a 32-year-old who presents to a rural ED with symptoms of worsening depression, insomnia, reduced appetite, and thoughts of jumping off a tall bridge. Deshawn has a history of major depressive disorder (MDD) and has been treated by his primary care provider for two years with sertraline 50 mg daily. Because the rural hospital has no psychiatric staff on call, the PMHNP was asked to provide a telemedicine consult. Deshawn was agreeable to meeting with the PMHNP via video conference. On the call, Deshawn endorsed depressive symptoms but stated that he did not want to die and that “jumping off a bridge would be a terrible way to go.” He denied other active plans for suicide. Which of the following are the most appropriate recommendations to the care team for Deshawn’s treatment and disposition? Select all that apply.

-discharge to home with resources for crisis care
-increase sertraline to 75 mg daily
-discharge to home with resources for crisis care
-increase sertraline to 75 mg daily
-recommend follow-up with telepsychiatry

Rationale: The client is not having active suicidal thoughts and does not have a plan; therefore, the most appropriate recommendations for Deshawn include discharge to home with resources for crisis care, increasing his sertraline dose to 75-100 mg daily, and due to the limited resources in Deshawn’s area, it is appropriate to recommend follow-up with telepsychiatry.

Antonia is a 26-year-old who presents to the ED with acute suicidal thoughts for several days. She denies a plan at this time. She has a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD), for which she takes paroxetine 20 mg daily and clonazepam 0.5 mg as needed. She endorses a suicide attempt by taking “a handful” of medications at age 16. Antonia reports recent stress in her life, including a breakup with her girlfriend and an unstable work environment. She states that she came to the ED tonight because she “wasn’t feeling like I could trust myself 100%.”
Which of the following is the most appropriate recommendation to the care team for Antonia’s treatment and disposition? Select all that apply.

-discharge to home with resources for crisis care & recommendation for follow-up
-increase sertraline to 75 mg daily
-23-hour observation in the ED with Q15 minute checks
-recom
recommend voluntary admission

Rationale: Antonia has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempt and MDD and GAD. She is also under acute stress. At this time, she may benefit from voluntary admission for evaluation and treatment.

Antonia agrees to voluntary admission for evaluation and treatment. After searching the hospital system, the PMHNP finds that there is not an available inpatient bed for Antonia and that a bed may not be available for 24 hours or longer. Antonia states that she is not willing to remain in the emergency department for that long, and she instead wants to schedule an appointment with her counselor for the next day. Antonia states that she is willing to stay with her brother and his family in their home and will give him her prescriptions so that she does not have access to the bottles.
Which of the following is the most appropriate recommendation for Antonia?

-discharge to home with resources for crisis care and recommendation for follow-up
-increase sertraline to 75 mg daily
-23-hour observation in the ED with Q15 minute checks
-involuntary admission
discharge to home with resources for crisis care and recommendation for follow-up

Rationale: Antonia’s symptoms indicate that she might benefit from voluntary admission; however, since there is no appropriate inpatient bed, keeping her indefinitely in the ED for observation is not appropriate. Antonia can be discharged to the care of her brother with a safety plan, crisis resources, and a follow-up plan.

Antonia is discharged to the care of her adult brother and his family. Her girlfriend broke up with her by text that night and posted comments about Antonia’s mental illness on social media. Antonia took her brother’s car and left his house unnoticed. After hours of binge drinking, she parked her car on the expressway ramp and laid down on the highway. She took a video of herself lying on the highway and sent it to her girlfriend just as she was fatally struck by two cars. The care team is notified of the death by suicide, and the PMHNP is asked to lead a crisis debriefing and postvention or intervention after the suicide to support Antonia’s family and friends.
…

postvention
-Responding to Grief, Trauma, and Distress after a Suicide

https://sprc.org/wp-content/uploads/2022/12/Spotlight_Postvention_ResourceSheetv03.pdf

Serotonin Syndrome
-medications cause excessive levels of serotonin to build up in the body.

antidepressants, illicit drugs, lithium, antibiotics.
-Clinical symptoms typically occur within several hours of beginning a new med or increasing dose of an existing med:

Symptoms:
-Neuromuscular abnormalities (greater in lower extremities)

Clonus
Hyperreflexia
Tremor
Seizure
-Mental changes
Agitation
Pressured speech
-Autonomic instability
Mydriasis
Tachycardia
Hypertension
Shivering
Diaphoresis
Diarrhea

Serotonin Syndrome Tx
-discontinuing the causative medication
-intensity of supportive tx depends on severity of symptoms

Mild cases typically resolve within 24 hrs
severe cases may require hospitalization for stabilization

Neuroleptic Malignant Syndrome (NMS)
-rare, life-threatening adverse effect caused by antipsychotic meds
-may occur due to:

disruption of dopamine receptors in the anterior hypothalamus
direct toxicity to muscle cells
Psychological stressors that activate the ANS may also play a role in triggering NMS
-onset of symptoms may occur 1-2 weeks after starting or changing the causative medication

-Symptoms:

mental status changes
agitation
confusion
catatonia
muscle rigidity (“lead pipe” rigidity)
hyperthermia
excessive salivation
autonomic instability (labile blood pressure & heart rate)
elevated Serum creatine kinase (CK) levels

Neuroleptic Malignant Syndrome (NMS) Tx
-immediate intervention to stabilize vital signs, reduce fever, and control agitation
-frequently admitted to ICU
-causative agent should be discontinued immediately
-symptoms typically resolve 1-2 weeks after tx is initiated

Serotonin Syndrome vs NMS
-Serotonin Syndrome

Dilated Pupils
Headache
Shivering
Dysrhythmias
Hyperreflexia
Clonus

-NMS

Drooling
Catatonia
Rapid changes in BP
Increased serum creatine kinase (CK)
Hyporeflexia

-Both

Agitation
High BP
High fever
Confusion
Rigid muscles

Agranulocytosis
-Clozapine-induced agranulocytosis (CLIA)

potentially life-threatening
occurs in less than 1% of clients prescribed clozapine
cause unknown; may be genetic
-Onset of symptoms any time following initiation of clozapine, most common after 4-5 weeks of drug therapy

-symptoms of CLIA:

fever and chills
increased heart rate
sudden hypotension
muscle weakness and fatigue
mouth ulcers
sore throat

-Diagnosis: absolute neutrophil counts (ANC) less than 100/mcL.

Agranulocytosis Tx
-immediate discontinuation of clozapine
-supportive care for infection
-consultation with hematology

Prevention of CLIA
-serial lab draws weekly during the first 18 weeks of tx with clozapine

then biweekly until one year
➣then monthly for the duration of tx

Lithium Toxicity
-Lithium has a narrow therapeutic range, too much can quickly cause toxicity

lead to acute kidney injury & death
-Lithium toxicity may occur due to:
excessive intake r/t overdose or dosage modifications
impaired excretion
➣sodium & fluid depletion from vomiting, diarrhea, fever, low sodium diet; lithium is reabsorbed by the kidneys which increases serum levels of the drug

-Early symptoms:

nausea
vomiting
diarrhea
hand tremors
slurred speech
vision changes
-Later symptoms
hyperreflexia and muscle spasms
nystagmus
dysrhythmias
confusion
delirium
-If serum lithium concentration exceeds 3.5 mEq/L
seizures
death

Lithium Toxicity Tx
-discontinuing lithium
-supportive care
-Acute overdose is treated with gastric lavage
-admitted for:

cardiac monitoring
intravenous fluids
serial lithium levels
-Hemodialysis may be required for clients with severe toxicity.

Depression
-mood disorder characterized by depressive symptoms that last longer than two weeks.
-influenced by genetic and environmental factors
-Signs and symptoms of depression include:

sad or irritable mood
feelings of hopelessness, worthlessness, or emptiness
diminished interest in activities
significant weight or appetite changes
fatigue, sleep disturbances including difficulty sleeping (insomnia) or sleeping too much
cognitive changes such as difficulty concentrating, remembering infor, or making decisions

Imbalance of what neurotransmitters can result in depression?
lower levels of:
dopamine
serotonin
norepinephrine

-Depressed patients often have decreased neurotransmitter activity in the prefrontal cortex (PFC) region of the brain

controls attention, mood, and personality

Major Depressive Disorder (MDD)
-primary feature of MDD is the occurrence of at least one episode of major depression lasting at least two weeks
-must experience 5+ of the following in 2 weeks to be dx’d 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 (pacing)
decreased energy
sense of guilt or worthlessness
lack of focus or ability to make decisions
repeated thoughts of death and suicide

Antidepressants
SSRIs
-inhibit 5-HT reuptake

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

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

Psychotic symptoms: Positive Symptoms
-Hallucinations
-Delusions
-Thought disorder
-Hostility
-Excitability

Psychotic symptoms: Motor Symptoms
-Motor delay
-Dyscoordination
-EPS

Parkinsonism
Dyskinesia

Psychotic symptoms: Affective Symptoms
-Depression
-Anxiety
-Suicidality

Psychotic symptoms: Cognition
-Attention
-Working memory
-Verbal memory
-Visual memory
-Executive functioning
-Processing speed
-Social conditioning

Psychotic symptoms: Negative Symptoms
-Affective flattening
-Alogia
-Anhedonia
-Amotivation
-Asociality

Symptoms of Psychosis: Hallucinations
-Perceptual experiences in the absence of external stimuli

Auditory: hearing things that are not there (may include command hallucinations in which voices direct the client to perform actions, often related to self-harm or violence towards others)
Visual: seeing things that are not there
Tactile: feeling sensations in the body in the absence of stimuli
Olfactory: smelling things that are not there
Gustatory: tasting things that are not there

Symptoms of Psychosis: Delusions
-Fixed false, irrational beliefs

Persecution: delusions related to being threatened, victimized, or spied on
Reference: delusions related to receiving personal messages from 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

Symptoms of Psychosis: Thought Disorder
-Impairment in the process of thinking and difficulty organizing thoughts in a logical pattern

incoherent speech
loose associations
meaningless words
perseveration

Symptoms of Psychosis: Disorganized behavior
-Disordered or impaired behavior or communication

childlike silliness
unpredictable agitation
inappropriate clothing for the weather
poor hygiene

Schizophrenia
-complex chronic disorder
-affecting approximately 3.5 million people in the United States
-healthcare costs exceeding $155 billion
-Symptoms typically emerge between late teens & early 30s
-Many experience exacerbations of psychotic symptoms interspersed with periods of remission or recovery
-response rates to antipsychotic good, tx adherence remains problematic
-Common comorbid conditions: dementia, liver disease, AIDS, heart failure, type 2 diabetes

antipsychotic medications are often effective in managing _ symptoms of schizophrenia
positive

impairments associated with chronic schizophrenia: Cognitive
-Most perform lower than average on neurocognitive tasks:

processing speed
attention
learning
memory
problem-solving

-contribute to functional impairments that impact everyday living.

impairments associated with chronic schizophrenia: Social
-Reduced social motivation, social cognition, & social competence
-Many struggle to identify or interpret others’ emotions and social signals.
-often isolated, or behaviors are incompatible with social relationships

leads to difficulties forming stable, long-term social connections

impairments associated with chronic schizophrenia: Work
-face chronic unemployment

poor educational outcomes
poor social skills
inability to manage interim steps to employment
poor physical health
-Supportive employment programs can help to learn vocational skills, find & maintain employment
without ongoing support, most fail to remain employed

impairments associated with chronic schizophrenia: Independent Living
-Cognitive and social impairments, chronic unemployment, and limited disability benefits make independent living difficult
-often face challenges with higher-level functional skills necessary to engage in advanced self-care activities

participating in medical care
managing medications
learning to drive
using transportation effectively
-live independently varies widely based on social support in the communities where they reside
-availability of housing
difficulty finding, securing, or maintaining affordable, accessible stable housing

impairments associated with chronic schizophrenia: Morbidity and Mortality
-dx of schizophrenia is associated with a risk of increased morbidity, premature mortality, & reduced life expectancy of 10-20 yrs due to poor physical health & chronic comorbid conditions
-(-) symptoms (avolition, apathy) contribute to sedentary behavior

reduced physical activity, and poor eating habits, impact development of obesity & comorbidities (diabetes, cardiovascular disease, hypertension)
-Residential & financial instability creates challenges in accessing care & medication
resulting in a cycle of relapse & hospitalization for acute management
-morbidity & mortality associated with variety of factors: alcohol, tobacco, other substance use & metabolic syndrome
-Common causes of death: suicide, cancer, cardiovascular disease

Schizophrenia Impairments Associated with Treatment: Adverse Effects (AEs)
-Antipsychotics work by blocking the action of dopamine
-associated with numerous AEs

can cause distress, reduce quality of life, lead to nonadherence to tx
-longer the tx with antipsychotics, greater the risk for AEs
-Extrapyramidal Adverse Effects
Akathisia
Dystonia
Drug-Induced Parkinsonism
Tardive Dyskinesia

extrapyramidal system (EPS)
-primary function is to help coordinate muscle movement
-EPS helps maintain posture and regulates involuntary motor movements
-Antipsychotic meds can cause AEs in the EPS due to dopamine blockage or depletion in the basal ganglia

Akathisia
-The subjective feeling of restlessness with a compelling urge to move
-May include repetitive movements:

finger tapping, rocking, crossing/uncrossing legs
-Onset is usually within four weeks of starting or increasing medication
-Management may include:
discontinuing or reducing the antipsychotic dose
switching to alternative antipsychotics
beta-blockers
benzodiazepines
anticholinergics
Mirtazapine may be used at a low dose

Dystonia
-Involuntary contraction or contortion of muscles
-May be painful and potentially dangerous if throat muscles are involved
-Typically occurs within 48 hours to 5 days of exposure
-Management may include:

discontinuing or reducing the antipsychotic dose
switching to an alternative antipsychotic
Antimuscarinic agents or diphenhydramine may help quickly relieve dystonia within minutes

Drug-Induced Parkinsonism
-Tremor, rigidity, slowed motor function in the trunk & extremities
-Presents with a mask-like face, stooped posture, slow, shuffling gait
-Management may include:

discontinuing or reducing the antipsychotic dose
switching to an alternative antipsychotic
administering anti-Parkinson agents; amantadine, antimuscarinic agents, dopamine agonists, levodopa

Tardive Dyskinesia
-Involuntary muscle movements most commonly affect the orofacial & tongue muscles, & less commonly, the muscles in the trunk & extremities
-some cases, may be irreversible
-Management may include:

discontinuing or reducing the antipsychotic dose
switching to an alternative antipsychotic
Valbenazine is FDA approved for tx of tardive dyskinesia

_ is FDA approved for tx of tardive dyskinesia
Valbenazine (Ingrezza)

AIMS
Abnormal Involuntary Movement Scale
-12 questions
-5 point rating scale

range from none to severe

Schizophrenia Impairments Associated with Treatment: Metabolic Concerns
-antipsychotic medications, especially second-generation antipsychotics are associated with:

weight gain
lipid disturbance
glucose dysregulation
-contribute to development of metabolic syndrome in approximately one-third of clients with schizophrenia
-Clozapine & olanzapine are associated with the greatest degree of metabolic dysregulation
-male sex and non-white ethnicity are associated with greater vulnerability to metabolic effects
-2 meds recently FDA approved to tx schizophrenia & reduce risk for metabolic comorbidities
Lumateperone: modulates serotonin, dopamine, & glutamine neurotransmission
Olanzapine-samidorphan: addition of samidorphan (opioid receptor blocker) mitigates weight gain commonly seen in clients taking olanzapine

Schizophrenia Impairments Associated with Treatment: Sexual Dysfunction
-Antipsychotic medication often associated with sexual dysfunction

contributes to significant distress and tx nonadherence
-Switching pts to aripiprazole or adding aripiprazole may help decrease sexual dysfunction
-Quetiapine, ziprasidone, & olanzapine below 15 mg/day are associated with lower levels of sexual dysfunction

Schizophrenia Impairments Associated with Treatment: Treatment Resistance
-Treatment-resistant schizophrenia (TRS) is defined as active, persistent symptoms that impair functioning for over 3 months after at least 6 weeks of appropriate med therapy with 2 different antipsychotic meds
-may not be diagnosed until treatment adherence has been confirmed.

Schizophrenia Impairments Associated with Treatment: Treatment Nonadherence
-Med nonadherence rates for clients with schizophrenia are comparable to med nonadherence rates associated with other chronic disorders, including coronary heart disease, diabetes, and asthma

-risk factors for antipsychotic medication non-adherence:

Client
➣History of nonadherence
➣Poor insight into the disease process
➣Substance use
➣Cognitive impairment or developmental disability
➣Negative attitude
Medication
➣Adverse effects
➣Continued symptoms
Environment
➣Lack of social support
➣Lack of therapeutic alliance
➣Practical difficulties getting or taking medications
Society
➣Illness stigma
➣Stigma r/t med AEs

Long-Acting Antipsychotic Medications (LAIs) to Improve Treatment Adherence
-LAIs can:

improve client outcomes
reduce the # of hospitalizations & ED visits
reduce healthcare costs for pts with schizophrenia
-pts dont have to remember to take QD med
-more stable drug plasma level
-strong evidence supports use, but used in less than 10% of pts
-Barriers to use of LAIs:
logistical issues; cost of tx and availability of staff to provide injections
client perception of LAI
client aversion to needles

Medications available in long-acting depot injections (LAIs):

haloperidol
risperidone
paliperidone
aripiprazole
olanzapine.

__ in treatment-resistant cases.
clozapine
-Patients should be offered a clozapine trial if they have a partial or non-response to two antipsychotic trials, assuming those antipsychotic trials are an adequate dose and duration (four to eight weeks)

Talitha is a 26-year-old who presents to the clinic for a medication refill.
At age 19, during her sophomore year of college, Talitha began having auditory hallucinations. She was prescribed olanzapine which helped with symptoms. After 6 months, Talitha stopped taking the medication because she felt well and had a relapse, during which the hallucinations returned, and the “voices” became threatening. Talitha developed paranoid symptoms. She was voluntarily hospitalized and was prescribed risperidone, which helped her symptoms but caused sleep disturbances. She was switched to aripiprazole, and the voices returned. Two years ago, she was restarted on olanzapine monotherapy 15 mg daily and has been adhering to the medication regimen since. Talitha denies substance use or other psychiatric history.
During the medication refill appointment, Talitha endorses that she still hears voices, but tries to tune them out and
schizophrenia; multiple episodes, currently in partial remission

Rationale: The most likely diagnosis for Talitha at this time is schizophrenia; multiple episodes, currently in partial remission. Talitha has a history of auditory hallucinations with a first episode, remission, and relapse, which meets the specifier for multiple episodes. She endorses residual symptoms of schizophrenia, including auditory hallucinations and impairment of executive function, even with medication therapy, which meets the specifier for partial remission

Which of the following is the most appropriate pharmacologic management strategy for Talitha?

-continue olanzapine 10 mg daily
-increase olanzapine to 15 mg daily
-switch to clozapine 12.5 mg daily
-switch to olanzapine/samidorphan 15mg/10mg
switch to olanzapine/samidorphan 15mg/10mg

Rationale: The most appropriate pharmacologic management strategy for Talitha is to switch to olanzapine/samidorphan 15mg/10mg. Olanzapine may be continued with an increase in dosage; the medication has been well-tolerated and the client has had trials of other antipsychotic medications. Since Talitha has experienced weight gain with olanzapine, it may be appropriate to trial olanzapine/samidorphan to mitigate additional weight gain. Talitha does not have a history of opioid use disorder and may safely begin olanzapine/samidorphan without concerns of opioid overdose, a potentially life-threatening interaction. If Talitha does not experience full remission with an increased dose of olanzapine, the provider should consider clozapine for this client.

select the most appropriate ICD-10-CM code for Talitha’s diagnosis.
F20.89

Rationale: F20.89 Acute exacerbation of chronic schizophrenia is chosen to reflect the exacerbation

Which of the following is the appropriate evaluation/management (E/M) code for this visit?

99214
99213
99215
99205
99204
99203
99215

Rationale: Talitha is an established client with one chronic illness with exacerbation, requiring a medication change; therefore, Talitha’s visit qualifies as 99215: established client with a high level of medical decision making.

Eric is a 37-year-old who presents to the clinic with new symptoms.
Past psychiatric history: Eric was diagnosed with schizophrenia at age 22. At that time, he had symptoms of paranoia, auditory hallucinations, avolition, and social withdrawal. He was prescribed aripiprazole 10 mg with good results. Over the past 15 years, his dose has been titrated up to 15 mg daily with mild, tolerable adverse effects. Eric has no history of relapse of symptoms before this point. Eric denies substance use or other psychiatric history.
During the appointment, Eric endorses his symptoms have returned. He has begun having auditory hallucinations, and he worries that everyone around him is “out to get him.” Upon further inquiry, Eric states that his dad, with whom he lived, died six months ago and Eric no longer has reliable housing. He tries to remember to take his medications daily, but states “I don’t always have them with m
schizophrenia; multiple episodes, currently in acute episode

Rationale: The most likely diagnosis for Eric is schizophrenia; multiple episodes, currently in acute episode. Eric has had a history of auditory hallucinations which resolved. At this time the hallucinations have returned, this is a second acute episode.

Which of the following is the most appropriate pharmacologic management strategy for Eric?

-switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly
-switch to aripiprazole lauroxil 662 mg intramuscular injection once monthly
-switch to aripiprazole lauroxil 882 mg intramuscular injection once monthly
switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly

Rationale: The most appropriate pharmacologic management strategy for Eric is to switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly. Eric had good symptom control with aripiprazole, but recent life changes have made it difficult to adhere to medication therapy. Switching to a long-acting injectable is an appropriate management strategy. without concerns of opioid overdose, a potentially life-threatening interaction.

Which of the following should be discussed with Eric about using oral aripiprazole after receiving his first injection?

-continue to take oral aripiprazole for 21 days and then discontinue
-continue to take oral aripiprazole for 14 days and then discontinue
-continue to take oral aripiprazole for 7 days and then discontinue
-discontinue oral aripiprazole immediately
continue to take oral aripiprazole for 14 days and then discontinue

Rationale: After the initial injection of aripiprazole lauroxil, the client should continue to take oral medication for 14 days and then discontinue.

select the most appropriate ICD-10-CM code for Eric’s diagnosis.
F20.89

Rationale: F20.89 Acute exacerbation of chronic schizophrenia is chosen to reflect the exacerbation.

Which of the following is the appropriate E/M code for this visit?

99214
99213
99215
99205
99204
99203
99215

Rationale: Eric is an established client with one chronic illness with exacerbation. He requires adjustment in prescription drug management; therefore, Eric’s visit qualifies as 99215: established client with a high level of medical decision making.

PANSS
positive and negative syndrome scale

Skylar is a 33-year-old who presents to the clinic for a routine follow-up visit.
Past psychiatric history: Skylar was diagnosed with schizophrenia at age 19. At that time, they had symptoms of visual hallucinations, disorganized thinking, and anhedonia. They were prescribed risperidone and take 6 mg daily; the medication has been well-tolerated since then and they have experienced no relapses in symptoms.
Skylar has no new complaints during today’s visit. They state they have been taking their medications as prescribed. Skylar’s positive and negative syndrome scale (PANSS) score is comparable to their last visit. Their abnormal involuntary movement scale (AIMS) scoreLinks to an external site. is 2.
What is the most likely diagnosis for Skylar at this time?

-schizophrenia; multiple episodes, currently in partial remission
-schizophrenia; first episode, currently in partial remission
-schizophrenia; continuous
-s
schizophrenia; first episode, currently in full remission

Rationale: The most likely diagnosis for Skylar is schizophrenia; first episode, currently in full remission. Skylar has not had a relapse of symptoms since their diagnosis, which meets the specifiers for first episode in full remission.

Which of the following are the most appropriate pharmacologic management strategies for Skylar? Select all that apply.

-continue risperidone 6 mg daily
-switch to aripiprazole 10 mg daily
-discontinue all antipsychotic medications
-prescribe valbenazine 40 mg daily
-continue risperidone 6 mg daily
-prescribe valbenazine 40 mg daily

Rationale: The most appropriate pharmacologic management strategies for Skylar include continuing risperidone 6 mg daily and prescribing valbenazine 40 mg daily. Skylar has had good symptom control with risperidone, but is experiencing symptoms of tardive dyskinesia (TD) as evidenced by their AIMS score of 2; a score of 2 or greater indicates TD. The APA recommends treating moderate to severe TD symptoms associated with antipsychotic therapy with a vesicular monoamine transporter 2 (VMAT2) such as valbenazine

select the most appropriate ICD-10-CM codes for Skylar s diagnosis.
F20.9 and G24.09

Rationale:
F20.9 Schizophrenia reflects Skylar’s diagnosis that is being treated at today’s visit. On the ICD 10 webpage you will see this synonym for the code: Schizophrenia in remission.
G24.09 Other drug induced dystonia corresponds to the new diagnosis- tardive dyskinesia.

Which of the following is the appropriate E/M code for this visit?

99214
99213
99215
99205
99204
99203
99215

Rationale: Skylar is an established client with one chronic illness and a newly diagnosed second chronic illness who needs prescription drug management. The new onset TD warrants additional decision making. Therefore, Skylar’s visit qualifies as 99215: established client with high level medical decision making.

Treatment-Resistant Depression (TRD)
-subset of MDD
-characterized by a lack of improvement despite the provision of traditional and first-line therapeutic options
-criteria are 2+ unsuccessful trials of antidepressant pharmacotherapy
-Inaccurate TRD diagnosis can lead to pseudo-resistance

pts prescribed suboptimal med trials D/C their meds because of adverse side effects

Management of TRD: Nutraceuticals
-adjunctive txs that may improve symptoms in clients with TRD
-Omega-3 fatty acids

thought to tx depression by decreasing chronic inflammation
-L-methylfolate
active form of folate that crosses the blood-brain barrier
reduces inflammation, reduces loss in gray matter, & helps regulate serotonin, dopamine, & norepinephrine
-Other agents associated with improvement in depressant symptoms:
zinc
magnesium
coenzyme Q10

Management of TRD: Electroconvulsive Therapy (ECT)
-procedure that applies electrical stimulation to the brain through transdermal electrodes attached to the head to trigger seizure activity

sedated under general anesthesia & given a muscle relaxant during procedure
-Use limited to clients with:
TRD
elevated suicide risk
pts with catatonia, psychosis, bipolar disorder, or dementia that have not responded to typical tx
-typically receive ECT 2-3 times per week for 3-4 weeks
-drawbacks:
need for general anesthesia and associated monitoring
potential cognitive adverse effects including retrograde amnesia & memory loss
-Up to 50% of clients receiving ECT for TRD do not maintain remission

Management of TRD: Deep Brain Stimulation (DBS)
-surgical procedure initially used to tx pts with movement disorders

now an emerging tx modality for pts who have depression unresponsive to pharmacotherapy, psychotherapy, or ECT
-Electrodes surgically placed in specific regions of the brain & connected to an implanted subcutaneous pulse generator
Once device activated, provides continuous electrical stimulation to the specified areas of the brain, most common the subcallosal cingulate white matter
-AEs typically r/t the surgery:
infection, headache, seizure, hemorrhage
-also used to manage treatment-resistant OCD

Management of TRD: (Transcranial Magnetic Stimulation (TMS)
-non-invasive procedure that uses rapidly alternating magnetic fields to stimulate the brain
-may also be used to tx chronic pain, schizophrenia, motor symptoms of Parkinson’s disease, multiple sclerosis, stroke
-most effective for pts experiencing acute symptoms within 1 year of the onset of MDD
-QD tx sessions are req for several weeks

may present a barrier to some pts

Psilocybin-Based Treatment
-Preliminary data:

may be effective in tx of MDD
-5HT2a agonist with cognitive enhancement effects due to high # of receptors in the cortex
-Additional research needed to evaluate long-term effectiveness & safety

STARD -Sequenced Treatment Alternatives to Relieve Depression (STARD)
-collaborative study in 2006 funded by the National Institute of Mental Health

examine the tx of depression in pts where the initially prescribed antidepressant proved inadequate
largest and longest study ever conducted to evaluate depression treatment efficacy

STAR*D found that:
-1/3 persons will achieve remission with the 1st prescribed antidepressant
-most clients who were labeled tx resistant failed to receive an adequate medication trial
-some pts may experience med efficacy in the first 6 weeks of a tx, however, full med benefits may not be evident until 10 or 12 weeks of tx
-Prescribers should work with their clients to:

assess reasons for inadequate response & increase meds to maximum dose rather than discontinue a med prematurely
-Pts are more likely to achieve remission with an adequate trial of the 1st prescribed med than switching meds
only 25% of pts respond to a 2nd med

stepwise approach based on the STAR*D study to manage clients with TRD
Treatment Decision Process

-Initial Evaluation and Management

Not all depressions are equal
A screening tool is used to assess symptoms and severity
Rule-out medical diagnosis (hypothyroidism, anemia, etc.)
Assess for comorbidities
Substance abuse
OCD/PTSD/anxiety
SSRI based on above factors

-Wait/Reassure – minimum of 4 weeks

Adequate Response – Continue presenting tx
Inadequate Response – Next steps include:
➣adherence
➣barriers (cost, cognition)
➣repeat depression screen
➣educate
➣onset of action/dosing
➣increasing medication dose
➣consider adding psychotherapy

-Wait/Reassure – minimum of 2-4 weeks

Adequate Response – Continue presenting tx
Inadequate/Partial Response:
➣Medication adherence
➣Barriers
➣Repeat depression screen
➣Increase medication (up to max amount recommended)
➣Psychotherapy adherence

-Wait/Reassure – minimum of 4 weeks

Not Effective?:
➣Re-evaluate
➣Switch to different SSRI/serotonin and norepinephrine reuptake inhibitors (SNRI) (remission success of 25 percent)

Harry is a 48-year-old who presents to the outpatient mental health clinic for an initial evaluation of symptoms of depression. Harry has been prescribed bupropion XL 300 mg daily by his primary care provider and has been taking it for the past five years. Harry endorsed that at first, the medication “worked really well,” but states he has been feeling more down lately and is concerned that the medication is no longer working. He stated that about eight months ago, he changed to a new position at work that was “overwhelming.” He had no time to participate in his hobbies, which include reading, racquetball, and golf. He states that since his promotion, “I have no time to do anything but work, eat, and sleep, so I tend to eat and sleep a lot more than I used to.” Harry states that his wife of 18 years has become frustrated with him because he has no energy to participate in raising their children, but Harry
-switch to bupropion 150 mg twice daily
-recommend follow-up with a primary provider
-recommend initiating psychotherapy

Rationale: The most appropriate initial treatment for Harry is to switch to bupropion 150 mg twice daily, recommend follow-up with the primary provider, and recommend initiating psychotherapy. Because the client has had gastric bypass surgery, his ability to absorb extended-release medications may be impaired. Since the medication initially worked to control his symptoms, it is reasonable to begin by switching to the same medication in an immediate release format. Harry should follow up with his primary provider to obtain a complete physical, including lab work for possible deficiency of vitamin D or B12. Because of the client’s recent increase in daily stressors, psychotherapy may also be appropriate at this time.

Bettina is a 24-year-old who presents to the mental health clinic after a referral from her primary care provider. She endorses symptoms of depression that began “when I was still in college,” including excessive sleepiness, withdrawal from social activities, the guilt associated with “leaving my friends hanging,” and anhedonia. Bettina states that she saw a counselor through the college health service, which helped her symptoms somewhat, but she was unable to continue with counseling after graduation two years ago. She made an appointment with her primary care provider to discuss medications for depressive symptoms and was prescribed citalopram 20 mg daily. After six weeks on the medication, she did not experience relief of symptoms and returned to the provider at which time her dose was increased to 40 mg daily. She had a follow-up appointment with the provider six months later, at which time she was prescr
continue current medications and add aripiprazole 2 mg daily

Rationale: The most appropriate treatment for Bettina is to continue her current medications and add aripiprazole 2 mg daily. According to the STAR*D guidelines, the client may choose to remain on the current medications and add an atypical antipsychotic medication such as aripiprazole. Alternatively, the client may choose to discontinue current medications and start a tricyclic or tetracyclic antidepressant. The client may also choose to begin therapy. Inpatient admission is not indicated for this client.

Carlos is a 25-year-old who was admitted to the inpatient psychiatric unit after a nonfatal suicide attempt. He has a history of major depressive disorder which was initially diagnosed when he was 22, at which time he was started on sertraline 50 mg and then increased to sertraline 100 mg. Carlos attempted suicide approximately four months after beginning the sertraline. At that time, he was referred for psychotherapy and prescribed aripiprazole 5 mg in addition to sertraline. Carlos states that while his symptoms of depression improved after starting the aripiprazole, they never completely disappeared. He endorses frequent thoughts of dying but states “Most of the time, they are just thoughts of not being here anymore- they aren’t active thoughts of killing myself.” Carlos states that he attempted suicide by overdosing on his medications after his girlfriend broke up with him. Currently, he endorses active sui
prescribe electroconvulsive therapy

Rationale: The most appropriate management strategy for Carlos is electroconvulsive therapy. Since Carlos is experiencing active suicidal thoughts, electroconvulsive therapy may be the best treatment option at this time. Carlos’s symptoms have been resistant to multiple medications; increasing dosages is not the best option, especially since Carlos attempted to overdose on his medications. Neither a suicide contract nor one-to-one observations will provide symptom relief.

Dementia Comorbidities:
depression, anxiety, psychosis, and disordered sleep.

Dementia Comorbidities: Depression
-20-30% have significant symptoms of depression
-difficult to detect, more advanced dementia may lack insight into their depressive symptoms
-Symptoms:

fatigue & lack of energy
psychomotor agitation or retardation
increased difficulty with concentration & decision-making
-The Cornell Scale for Depression in Dementia
screening tool
provides input from both the client & caregiver
-SSRIs
may help slow functional decline in clients with dementia
improvement of depressive symptoms is typically minimal
AEs may be significant for older adults
Nonpharmacologic interventions shown to reduce depressive symptoms in clients with dementia
animal therapy
cognitive stimulation
physical activity

conducting the Cornell Scale for Depression in Dementia

Dementia Comorbidities: Anxiety

Dementia Comorbidities: Dementia-Related Psychosis

Dementia Comorbidities: Disordered Sleep

Social determinants of health
-Health Care Access and Quality
-Neighborhood and Built Environment
-Social and Community Context
-Economic Stability
-Education

importance of gender-affirming psychotherapy during gender transition
-Trans Youth with Supportive Parents

77% reported life satisfaction
33% reported life dissatisfaction
70% described mental health as very good or excellent
15% described their mental health as poor
23% report suffering depression
75% report not suffering depression

-Trans Youth with Unsupportive Parents

64% reported low self-esteem
13% reported high self-esteem
0% faced no housing problems
55% faced housing problems.
4% did not attempt suicide
57% attempted suicide

Structural stigma in U.S. drug policies: Punitive Policies
-pregnant women anonymously tested for drug use:

prevalence of use similar between Black & White women
➣Black women 10x more likely to be reported to law enforcement

-Indigenous women suffer from higher SUD rates compared to other racial & ethnic groups

disproportionately affected by criminalization laws at the federal, state, & tribal levels.

-Consistent use of medication for OUD tx during pregnancy is significantly lower for women of color.

Trauma responses: how the nervous system responds to trauma
-Flee
-Fight
-Freeze
-Collapse

Trauma-informed care
-Safety
-Trust & Transparency
-Peer Support
-Empowerment & Choice
-Cultural, Historical, & Gender Awareness

Trauma-informed care: Safety
-most fundamental principle to avoiding retraumatization
-Creating a physical setting & client-provider interactions that generate physical & psychological safety are foundational to providing trauma-informed care.

Trauma-informed care: Trust and Transparency
-Establishing a trusting relationship or therapeutic alliance is critical to the trauma-informed approach.

kind, respectful interactions
empowering intake procedures
transparency in discussions of treatment goals & modalities appropriate to the client’s developmental level.

Trauma-informed care: Peer Support
-Providing opportunities for connecting with other trauma survivors may help to establish safety, foster hope, and promote healing through shared experience.
-Collaboration: Empowering the client to play an active role in decisions about their treatment

when developmentally appropriate, fosters a sense of responsibility & helps to balance the level of power between the provider & client.

Trauma-informed care: Empowerment & Choice
-Listening to & acknowledging the client

help them find their voice & give them a sense of control over their story.
-Prioritizing choice empowers clients to be partners in their care
can promote self-efficacy, agency, & dignity.

Trauma-informed care: Cultural, Historical, and Gender Awareness
-acknowledges that some trauma may be a result of a client’s culture, historical events such as war or conflict, or being a part of a marginalized or minority group.

Sensitivity to a client’s cultural, historical, or gender identity is important to ensuring their comfort & safety during tx

Social Determinants of Mental Health (SDOMH)
-Socioeconomic Status
-Education
-Social Support
-Childhood Experiences
-Discrimination & Mental Health Stigma
-Access to Reimbursement for Mental Healthcare
-Criminalization of Mental Health Behaviors
-Physical Environment
-Social & Cultural Factors
-Social Media

SDOMH: Socioeconomic Status
can negatively affect mental health:
-Low income
-poverty
-unemployment
-job insecurity
-lack of access to resources

SDOMH: Education
-Lower educational attainment plays a role in mental health outcomes

less education influences the knowledge, skills, & opportunities for personal & professional growth

SDOMH: Social Support
-lack of supportive relationships with family, friends, communities, or other social connections

increase stress & feelings of isolation • decrease resilience & self-esteem

SDOMH: Childhood Experiences
-Adverse childhood experiences (ACEs)

can have long-lasting effects on mental health
increase risk of developing mental disorders later in life

SDOMH: Discrimination & Mental Health Stigma
-Experiencing discrimination or stigma against serious mental illness, SUDs, or other forms of mental disorders

lead to chronic stress, low self-esteem, isolation, and prevent timely diagnosis, tx, & support

SDOMH: Access to Reimbursement for Mental Healthcare
-Limited access to & reimbursement for mental healthcare services can prevent timely dx, tx, & support.

exacerbating mental health issues

SDOMH: Criminalization of Mental Health Behaviors
-Failure of the justice system to recognize the behaviors of poorly treated serious mental illness & SUDs can worsen mental health outcomes

SDOMH: Physical Environment
-Living in unsafe, violent, or unhealthy physical environments

contribute to chronic stress & negatively impact mental health

SDOMH: Social & Cultural Factors
-Cultural norms, social norms, & societal expectations can negatively shape individual experiences & mental health outcomes

SDOMH: Social Media
-Hurtful social media communication may lead to high stress & suicides

especially among youth

Structural Racism and Racial Trauma
-refers to how institutions, policies, & practices systematically disadvantage some racial or ethnic groups while privileging others
-Structural Racism in Mental Health Services

Black men 4x more likely dx’d with schizophrenia than White males.
Black, Indigenous, & People of Color (BIPOC) youth with behavioral & mental health conditions are more likely to be directed to the juvenile justice system than to specialty care institutions compared to non-Latinx white youth.
Providers are less likely to be located in low-income neighborhoods with Black and Latinx residents compared to high-income neighborhoods with less than 1% of Black or Latinx residents.
Black people make up 12% of the country’s population but 33% of the total prison population.
BIPOC are less likely than Whites to own their homes regardless of their level of education, income, location, marital status, & age.
Black people are less likely than Whites to hold jobs that offer retirement savings prioritized by the U.S. tax code.
➣creates a persistent wealth gap between White & Black communities where the median savings of blacks are 21.4% of the median savings of whites.

effects of structural racism on mental health
-Racial & ethnic minority groups consistently experience higher rates of psychological distress, mental illness, & poor mental health outcomes than their White counterparts

attributed to the chronic stressors & adverse experiences of living in a racist society
-cumulative impact of racism can lead to racial trauma or race-based traumatic stress (RBTS)

Racial symptomology may appear similar to individuals diagnosed with:
posttraumatic stress disorder (PTSD), sexual assault, domestic abuse, or war zone survivors

symptoms of racial trauma:
-Depression, social anxiety, stress, substance abuse, agoraphobia, suicidal ideology, psychosis
-Intrusion symptoms

nightmares, flashbacks, physical reactions in the presence of reminders
-Avoidance behaviors
staying away from places that are reminders of racist experiences
-Negative changes to thoughts or mood
feelings of isolation, a belief that the world is unsafe
-Decreased interest in previously enjoyable activities
-Changes in arousal and reactivity
-Cultural paranoia, avoidance of White people (dominant group members), somatic complaints, and excessive worries about loved ones

Agnieszka has experienced persistent racial discrimination since immigrating to the United States, which has led to chronic stress, anxiety, depression, and post-traumatic stress disorder (PTSD), exacerbating her chronic depression

What racism’s effect is the patient experiencing?
Limited access to resources
Intersections with other social determinants
Cultural mistrust and mental healthcare disparities
Discrimination and racial trauma
Discrimination and racial trauma

Princiana has encountered ongoing barriers to accessing housing and quality education. Her job insecurity and a lack of housing opportunities have escalated her feelings of hopelessness, powerlessness, and low self-esteem, detouring her from timely treatment for her mental health.

Mateo has experienced ongoing racism as a person of color (POC), which has caused him to mistrust the mental healthcare system, resulting in inadequate care and treatment for his chronic schizophrenia

Diona is homeless due to substance use disorder and has chronic pain. In the emergency department, she self-reports a pain rating of 10 out of 10 and does not receive the same assessment and treatment as her White counterparts

types of stigma related to structural racism and mental health inequities:
-Internalized
-Anticipated
-Experienced
-Perceived

Type of stigma that is Perceptions of social beliefs (e.g., stereotypes, prejudice, discrimination) that occur on the part of the client or provider
Perceived

Type of stigma that is Perceptions of being a victim of stereotypes, prejudice, or discrimination that occur on the part of the client
Experienced

Type of stigma that is Taking inward stereotypes, prejudice, or social discrimination that occur on the part of the client
Internalized

Type of stigma that is Expectations of discrimination that occur on the part of the client
Anticipated

Risk of Mental Health Disorders after COVID-19
154,000 COVID-19 patients in the VA system with no hx of mental illness 2 years prior to infection:
-depression: 39% increase
-anxiety: 35% increase
-sleep problems: 41% increase

Racial Trauma Assessment
-Often PTSD assessment tools are used

provide few racial-trauma-specific prompts and it is unknown if they were validated using people of color
tend to measure the impact of a specific traumatic event, not the accumulation of lifetime events

-Race-Based Traumatic Stress Symptom Scale (RBTSSS)

assesses symptoms associated with experiences of racism trauma
has a complex scoring system
measures only a single event
does not adhere to the DSM-5 framework for diagnosing trauma

-UConn Racial/Ethnic Stress and Trauma Survey (UnRESTS)

easy-to-use
culturally informed tool for assessing racial trauma within a DSM-5 framework
lengthy & requires provider administration.

-Racial Trauma Scale (RTS)

newly developed self-report measure to quantify and assess trauma symptoms specific to racial discrimination

Racial Trauma Scale (RTS)
9-Item Short-Form Research Version
-scored by adding all items
-Total scores range from 9 to 36
-three subscales:
(a) Lack of Safety: 3, 5, 9
(b) Negative Cognitions: 2, 6, 7
(c) Difficulty Coping: 1, 4, 8

Racial Trauma-Informed Interventions
-principles of trauma-informed care:

Empowerment
Trustworthiness
Collaboration
Choice
Safety

-healing ethno-racial trauma (HEART) framework (4 phases)

I. Establish sanctuary space for clients experiencing ERT
II. Acknowledge, reprocess, & cope with symptoms of ERT
III. Strengthen & connect individuals, families, & communities to survival strategies & cultural traditions that heal
IV. Liberation & resistance

Racial Trauma Community Collaboration & Advocacy
-Concurrently addressing all determinants of health through changes in practice and policies is foundational to advancing anti-racism and health outcomes and equity
-Equitable access to health care is one example of an upstream intervention to reverse historical discrimination

PMHNP Roles: Advocacy, stakeholder engagement, coalition building, & cross-sector partnerships

Dissociative disorders
-repeated discontinuity or disruption of the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior
-characterized by dissociative symptoms that occur as an adaptive defense response to trauma
-may impede various elements of psychological functioning, such as consciousness, memory, emotion, identity, & motor control
-Stigma may hinder tx

myths about the existence & validity of these disorders
-primary considerations: Safety & social problems

crucial to managing dissociative responses:
-Trauma-informed care
-Dissociation-specific psychotherapy

Somatic symptoms or psychophysiological disorders
-challenging to dx & treat
-characterized by physical symptoms or dysfunction linked to psychological factors or emotional stress
-Psychotherapies such as CBT & stress management

important to reduce symptom burden & promote health

How the nervous system responds to trauma
Flee
Fight
Freeze
Collapse

Freeze vs Shutdown
Freeze
-HYPERaroused
-muscles tense & full of energy, but can’t release it
-similar levels of sympathetic & parasympathetic activation
-Increased HR/BP
-client might say, “I feel stuck,” “I can’t move,” or “I feel like I am encased in cement.”
-Eyes widen
-body is ready to return to fight/flight as soon as the threat passes

Shutdown
-HYPOaroused
-muscles flaccid & loose
-parasympathic nervous system is dominant
-Decreased HR/BP/temp
-client may not be able to speak at all
-Blank stare
-Sensory info stops at the thalamus. It doesn’t reach the cortex (so it’s not integrated).

client less aware of their internal & external world.
-Endorphins release to numb pain.
Dynorphins release, can make the client feel detached from their body.
-Can result in fainting

How trauma impacts the 4 different types of memory: Semantic memory
-How Trauma Can Affect It

prevent info (like words, images, sounds, etc.) from different parts of the brain from combining to make a semantic memory.

-Related Brain Area

temporal lobe & inferior parietal cortex
collect infor from different brain areas to create semantic memory.

How trauma impacts the 4 different types of memory: Episodic memory
-How Trauma Can Affect It

shutdown episodic memory & fragment the sequence of events.

-Related Brain Area

hippocampus
responsible for creating & recalling episodic memory.

How trauma impacts the 4 different types of memory: Procedural Memory
-How Trauma Can Affect It

change patterns of procedural memory
example: person might tense up & unconsciously alter their posture, which could lead to pain or even numbness.

-Related Brain Area

striatum
associated with producing procedural memory & creating new habits.

How trauma impacts the 4 different types of memory: Emotional Memory
-How Trauma Can Affect It

person may get triggered & experience painful emotions, often without context.

-Related Brain Area

amygdala
plays key role in supporting memory for emotionally charged experiences.

Window of tolerance
-When you are in your Window of Tolerance, you feel like you can deal with whatever’s happening in your life.

You might feel stress or pressure, but it doesn’t bother you too much.
the ideal place to be.
-Working with a practitioner can help expand your window of tolerance
so you are more able to cope with challenges.

How trauma can affect window of tolerance
-Hyperarousal

Anxious, Angry, Out of Control, Overwhelmed
body wants to fight or run away.

-Hypoarousal

Spacy, Zoned Out, Numb, Frozen
body wants to shut down.

-When stress & trauma shrink your window of tolerance, it doesnt take much to throw you off balance

Not something you choose – reactions just take over.

Polyvagal theory
-Based on ideas from Stephen Porges, PhD & Deb Dana, LCSW
-nervous system has three pathways, each designed to protect you

ventral vagal: nervous system’s optimal state, state we can engage socially, connect and co-regulate with others, often feel more calm, curious, grounded, safe.
Sympathetic: defensive pathway, gets body to mobilize into a fight or flight response or an attach/cry-for-help response, might feel fear, panic, irritation, anger, or even rage.
Dorsal vagal: defensive pathway, gets body to immobilize into a collapse/shutdown response, may feel numb, depressed, ashamed, hopeless, lethargic, may dissociate.

Dissociation
-unconscious defense mechanism
-individuals disconnect from their thoughts, emotions, memories, or sense of identity.
-can worsen with stress and can disrupt every area of psychological functioning
-Dissociative disorders

repeated discontinuity or disruption of the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, & behavior
often develop as a response to severe or repetitive overwhelming trauma
-as many as 75% of people experience at least one episode of depersonalization or derealization in their lifetime
only 2% meet the full criteria for a dissociative disorder

Dissociative Symptoms
-sense of disconnection or detachment from one’s thoughts, feelings, actions, or sense of self
-on a continuum from mild to pathological

-Mild dissociation

normal process experienced by everyone
daydreaming, losing oneself in a book or movie, zoning out, being lost in thought, missing an exit while driving

-Adaptive Dissociation

Threat or trauma response
Sense of emotional numbness or detachment

-Pathological Dissociation: Dissociative Disorders

Significant memory loss for specific times, people, or events
Out-of-body experiences such as watching oneself from the outside
Loss of self-identity
Feeling that the world is distorted or unreal

Risk Factors for Dissociative Disorders
-trauma
-neglect & physical, sexual, or emotional abuse
-cumulative traumas early in life
-repeated or sustained trauma
-torture associated with captivity
-Women more likely to receive dx of dissociative disorder

Structural Dissociation Theory
-premised on the underlying assumption that no one is born with an integrated personality

ego integrates into a cohesive personality between 6-9 years
➣trauma, especially in childhood, can disrupt the process leaving separate ego states unable to merge leading to dissociative symptoms
-Defense and Attachment are motivational systems with opposing goals
When activated, nervous system becomes dysregulated as it is biologically incompatible to have opposing aspects activated simultaneously, structural dissociation occurs.
➣internal tug-of-war, different motivational systems working against each other (child is abused, defense system works to shield them, but their attachment system still wants to be loved by the parent)- can cause conflicting parts to separate and lead to a split in sense of self-dysregulated nervous system

Dissociation key to recovery
helping a patient have full awareness of all their parts without feeling overwhelmed.

-“Traumatized Child” Part of the Self

This part is often drawn out by reminders of the trauma, and it may not experience much of everyday life. The survival responses of this self may include Attach/Cry for Help, Collapse/Submit, Please/Appease, Freeze, along with Fight and Flight

Types of Dissociative Disorders
-Dissociative Amnesia
-Depersonalization/Derealization Disorder
-Dissociative Identity Disorder

Dissociative Amnesia
-primary symptom: difficulty remembering autobiographical info to a degree inconsistent with normal forgetting
-memory loss

most commonly r/t particular event, such as combat or abuse, may also include details about one’s identity or life hx
-usually sudden onset
may last minutes, hours, days, or, less commonly, months to years
-Many individuals initially unaware of the gaps in memory until they notice that they do not recall info about their identity or when circumstances make them aware that autobiographical info is missing

Dissociative Fugue
DSM-5-TR classifies dissociative fugue as a subtype of dissociative amnesia
-separate dx in ICD-10
-can last from minutes to months
-seen in individuals with both dissociative amnesia and dissociative identity disorder
-individual cannot recall some or all of their past, may travel from their home or daily activity, and may be confused about their identity or even assume a new one
-in children & adolescents tend to be brief & travel only involves short distances.
-formerly called psychogenic fugue

Depersonalization/Derealization Disorder
-sense of unreality or detachment from the mind, body, or self
-sense of unreality or detachment from one’s surroundings
-clinically significant persistent or recurrent depersonalization or derealization paired with intact reality testing
-ongoing detachment from their actions, feelings, thoughts, sensations, or the world around them
-may experience life as if they were watching a movie
-Things around them may feel unreal
-average age of onset is 16

<20% of individuals starting to experience episodes after age 20

Dissociative Identity Disorder (DID)
-formerly called multiple personality disorder
-individual has 2+ distinct personalities or experiences recurrent episodes of dissociative amnesia
-Alternate identities often have unique names, characteristics, voices, or mannerisms
-Women more likely to present with dissociative symptoms
-Men are more likely to present with violent behavior

can lead to false-negative dx

DID symptoms
-recurrent, unexplained intrusions into conscious functioning or a sense of self
-alterations in a sense of self
-odd perceptual changes
-intermittent functional neurological symptoms

DID triggers
-Situational: Reminders of trauma through people, places, times, & situations

times of day or year, trauma anniversary dates, lunar & seasonal cycles, night-time, & darkness
-Intrusive & arousal symptoms of traumatic memories
thoughts, flashbacks, nightmares, or being startled
-External sensory input
sounds, smells, physical touch, and other trauma-related cues

Media
DID

-Stigmatizing

forms of dissociation and DIDs: diagnosis and screening
-Dx based on ROS & pt’s hx

cultural background may influence the presenting symptoms
-Screening: NICABM suggests a simple question “Do you ever hear voices?”
70% with DIDs endorse hearing voices.
➣characteristic must be differentiated from schizophrenia or other psychosis.
-Dissociative Experiences Scale II
validated self-assessment tool
-Dissociative Disorders Interview Schedule
structured interview tool
assist in the diagnosis of DIDs, somatic disorders, some personality disorders

differentiation of DIDs from schizophrenia
-Cause:

DIDs are highly associated with trauma
schizophrenia is thought to be associated with genetic factors.

-Onset: age a client begins to experience symptoms is a helpful differentiator.

DIDs often manifest after trauma, frequently in childhood.
schizophrenia most often appear when a client is in their late 20s to early 30s.

-Number of Voices:

schizophrenia seldom hear more than three voices
hx of multiple traumas may hear many voices; more likely DID.

-Age of Voices:

Child voices common among DIDs, often linked to childhood trauma
schizophrenia seldom hear the voices of children.

Carson is a 17-year-old who presents with his mother. She is concerned because he was involved in a minor car crash last week; he states that he does not remember what happened because he “zoned out” while driving. He states that this occurs several times per week; when it happens, he is typically thinking about his upcoming college applications and admissions.Which of the following is the most likely diagnosis for Carson?

dissociative identity disorder
dissociative amnesia with dissociative fugue
does not meet diagnostic criteria
dissociative amnesia
depersonalization/derealization disorder
does not meet diagnostic criteria

Rationale: Although Carson has had episodes of derealization, he does not meet the DSM-5-TR diagnostic criteria for a dissociative disorder.

Tiffani is a 34-year-old who presents after a referral from her primary provider. She complains of severe headaches and periods of memory loss; after thorough diagnostic testing, no physiologic cause was identified. Tiffani has a history of major depressive disorder (MDD), diagnosed as a teen, and generalized anxiety disorder (GAD), diagnosed at age 28. She has a history of cutting which she states began when she was a teenager. She was prescribed escitalopram 20 mg daily by her primary provider six years ago and reports her symptoms are “better, but not gone.” Tiffani discloses that she was sexually abused by her grandfather from age seven until his death when she was 14. She did not tell anyone about the abuse. She has never sought therapy or care from a psychiatric specialist. She has no other medical or psychiatric history.
During the interview, Tiffani states that her mother recently died. She reports that t
dissociative identity disorder

Rationale: According to DSM 5-TR diagnostic criteria, Tiffani is experiencing a disruption of identity characterized by distinct personality states that are causing a discontinuity in her sense of self and self-agency, as well as alterations in her behavior and memory. She has significant gaps in memory, and her symptoms are distressing her work and primary relationship. Tiffani has a history of trauma and a recent stressor that appears to have triggered her current symptoms; however, since the symptoms are not solely related to her trauma, it is unlikely that she is experiencing post-traumatic stress disorder (PTSD). Although Tiffani uses alcohol, she does not recall buying or consuming large quantities of alcohol, suggesting that the symptoms are unrelated to blackouts or substance use. Tiffani has headaches for which no physiological cause could be established; headaches, while not a diagnostic criterion for DID, are often an associated feature, as are comorbid depression and anxiety.

Farid is a 29-year-old who was brought to the emergency department by law enforcement after workers at a local discount store called about his behavior. Farid was found wandering in the store looking confused, and when confronted, he could not recall how or why he was in the store. Upon arrival in the emergency department, a toxicology screen was obtained, which was negative for common drugs of abuse. Farid denies psychiatric or medical history but states that he has not had regular health care for years as he is a survivor of the Syrian conflict and a recent refugee to the United States along with his brother. He states that his parents and sister were killed in the conflict. He has very little recall of the conflict or his escape from Syria and subsequent travel to the U.S. Farid’s brother endorses that Farid occasionally leaves the apartment they share and will “get lost for a few hours”; he comes back unhar
dissociative amnesia with dissociative fugue

Rationale: According to the DSM 5-TR (APA, 2022) diagnostic criteria, the most likely diagnosis for Farid is dissociative amnesia with dissociative fugue. Farid cannot recall autobiographical information associated with a traumatic time in his life. He frequently experiences purposeful travel or wandering associated with periods of amnesia.

Roman is a 16-year-old who has been admitted to the inpatient adolescent psychiatric unit after a non-fatal suicide attempt. Roman states he feels like he is “going crazy.” He endorses that his life seems to be happening in slow motion, like he is watching everything through a curtain of fog. He also reports that he feels like a robot and does not have control of his body most of the time. Roman understands that his symptoms are not actually occurring, and his experiences are occurring “all in my head.” Which of the following is the most likely diagnosis for Roman?

dissociative identity disorder
dissociative amnesia
depersonalization/derealization disorder
major depressive disorder
unable to determine
unable to determine

Rationale: Although Roman has symptoms consistent with depersonalization/derealization disorder, including time distortion, experiences of detachment from his surroundings, lack of body agency, and intact reality testing, more information is needed before selecting a diagnosis. Hallucinogens, 3,4-methylenedioxymethamphetamine (MDMA), and cannabis may all cause symptoms of depersonalization and derealization. A toxicology screen and interview questions will help rule out substance use as the cause of Roman’s symptoms.

Paola is a 22-year-old who presents with complaints of insomnia. She states that she experienced a sexual assault during an off-campus party about three months ago, and since then, she has not been able to sleep through the night. She can recall what she did the day of the assault and remembers, specifically, what she was wearing to the party, how she got there, and with whom she arrived. She stated that she had two beers and flirted with a man she knew casually through a shared acquaintance; the next thing she remembers was being in a bedroom, alone, with her shirt off and undergarments torn. She is concerned that she cannot remember everything that happened, especially since she has been having vivid nightmares about the event. She states that when she walks past the house where the party occurred, she feels like she is floating outside her body and does not feel like anything is real, so she has started walking a
post-traumatic stress disorder

Rationale: According to the DSM 5-TR diagnostic criteria, the most likely diagnosis for Paola is post-traumatic stress disorder. Paola has selective amnesia surrounding her assault but remembers what happened before and following the attack. She is experiencing nightmares, insomnia, guilt, and depersonalization related specifically to the assault. Although Paola has some symptoms that are consistent with dissociative amnesia or depersonalization/derealization disorder, post-traumatic stress disorder is a better diagnostic fit.

Treatment of dissociative disorders
-psychotherapy

techniques to process the trauma that triggers dissociative symptoms
CBT
sensorimotor psychotherapy
Eye movement desensitization and reprocessing (EMDR) (controversial)
-trauma-informed care
-meds may be used to tx other related symptoms

DID Integration
-psychotherapy with a tx goal of integrated functioning of the dissociated aspects of the personality
-integration process may include the following stages:

uncovering & mapping the dissociated aspects
treating the traumatic memories & fusing the dissociated aspects
fortifying the newly integrated personality

Somatic Symptom and Related Disorder
-characterized by the prominence of somatic symptoms and/or illness anxiety

associated with significant distress or impairment
-Symptoms may or may not be explained by pathophysiological processes
-often have medical comorbidities, more likely to encounter PCPs rather than psychiatric/MH providers
-Anxiety, depression, PTSD, OCD also common comorbidities
-Somatic symptoms can increase their severity, complexity, related functional impairment, & refractoriness to tx

Types of somatic symptom disorder & related disorders
-Somatic Symptom Disorder
-Illness Anxiety Disorder
-Conversion Disorder
-Factitious Disorder

Somatic Symptom Disorder
characterized by individual’s significant focus on 1+ physical symptoms to the extent that it causes major distress and/or disruption of daily life

pain, fatigue, weakness, SOB
may or may not be associated with another medical condition
-worry about symptoms or their overall health disproportionate to their condition
may experience persistent thoughts about the symptoms, expend excessive time & energy devoted to the symptoms
-often use a high level of medical care & may seem unresponsive to interventions.

Illness Anxiety Disorder
-formerly hypochondriasis
-preoccupation with having/getting a serious illness

high anxiety about one’s health & performance of excessive health-related behaviors or maladaptive avoidance of medical care
-differs from somatic symptom disorder in that individuals experience extensive worries about health with few or no somatic symptoms
-Reassurance by medical professionals does not alleviate the anxiety and may even increase it

Conversion Disorder
-AKA functional neurological symptom disorder
-presentation of a loss of a voluntary motor or sensory function that is incompatible with physiological findings
-Specifiers include symptom types
-Symptoms:

paralysis, blindness, deafness, or seizures
acute or persistent
-onset may be associated with trauma or stress
-Functional neurological symptom disorder is also associated with dissociative symptoms during attacks.

Factitious Disorder
-falsify presenting physical signs and symptoms in the absence of illness or impairment to deceive others even in the absence of external rewards
-related dx is factitious disorder imposed on another (formerly factitious disorder by proxy or Munchausen by proxy)
-differentiated from malingering in intent

malingering report signs & symptoms for personal gain such as money or time off work.

Treatment of somatic symptom and related disorders
-psychotherapy

CBT shown the highest efficacy
brief psychodynamic psychotherapy, exercise, & biofeedback may be beneficial for some symptoms
-medication
Antidepressants, particularly tricyclics, may be helpful for pain-related syndromes
-combination of both psychotherapy & medication.

Leanne is a 56-year-old who presents for therapy with the PMHNP for symptoms of depression. Per medical records, she has a history of hyperlipidemia, coronary artery disease, and major depressive disorder, and her current medications include atorvastatin 20 mg daily and sertraline 75 mg daily. Leanne is seeking therapy due to the recent death of her aunt, with whom she was very close.
During the interview, Leanne discloses that she has been having chest pain “more frequently” since her aunt died three months ago. Upon further inquiry, Leanne endorses that she has had chest pain “at least twice a week” for the past 14 months. The pain typically presents with an acute onset without identifiable triggers and is accompanied by sweating, dyspnea, palpitations, and dizziness. The pain is not relieved by rest, but typically “starts to fade” after a few hours. Leanne presents to the emergency department several t
somatic symptom disorder

Rationale: The most likely diagnosis for Leanne is somatic symptom disorder. Leanne is preoccupied with her symptoms of chest pain, dyspnea, dizziness, and palpitations even with repeated negative diagnostic testing. She spends large amounts of time and energy worrying about and researching her symptoms and the symptoms have been present for more than a year. Because she experiences significant symptoms, the diagnosis of illness anxiety disorder is not appropriate. There is no evidence that Leanne is feigning symptoms, so the diagnosis of factitious disorder is not appropriate.

Based on the information collected at the initial visit, which of the following are the most appropriate management strategies for Leanne at this time? Select all that apply.

-provide a consultation letter to Leanne’s primary provider
-cognitive behavioral therapy
-biofeedback
-increase sertraline to 100 mg daily
-provide a consultation letter to Leanne’s primary provider
-cognitive behavioral therapy
-biofeedback

Rationale: The appropriate management strategies for Leanne include a consultation letter to her primary provider, cognitive behavioral therapy, and biofeedback. A consultation letter to the primary provider may be effective to assist Leanne in reducing her use of health services (Boland & Verduin, 2022). Both cognitive behavioral therapy and biofeedback are valid therapy approaches for a client with somatic symptom disorder. Increasing the client’s antidepressant dosage is not indicated at this time.

Arisa is a 47-year-old inmate who began a 3-year incarceration sentence two weeks ago. She presents to the prison dispensary with complaints of dizziness. She states that she has been experiencing dizziness when she bends over, and she is always tired regardless of how long she sleeps or rests. She states that these symptoms have been occurring since her incarceration; she has been evaluated by both a primary provider and a neurologist. Her medical records indicate that she has had a CT scan, magnetic resonance imaging (MRI) of the head and neck, and vestibular testing, all of which were negative. Arisa states “I hope someone here will take me seriously since nobody on the outside would. I know I must have multiple sclerosis; a friend of mine was diagnosed two years ago, and I have the same symptoms.” She endorses spending her free time using the library computers to look up symptoms and worries about the symptom
illness anxiety disorder

Rationale: The most likely diagnosis for Arisa is illness anxiety disorder. her primary symptom is dizziness when bending over, which is not pathologic. Her fatigue may have multiple origins. She spends large amounts of time and energy worrying about and researching her symptoms and the symptoms have been present for several months. Because she experiences vague somatic symptoms, the diagnosis of somatic symptom disorder is not appropriate. Although there may be a concern that Arisa is feigning symptoms due to her recent incarceration, there is evidence that her symptoms were present before entering the prison environment; a diagnosis of malingering or factitious disorder is not appropriate.

Saoirse is a 36-year-old who presents with a new onset of paralysis in her right arm. She denies recent illness or injury. When the strength in her arm is tested, there is evidence of give-away weakness. She reports that her relationship with her significant other is contentious and stressful. She states that she sometimes gets so angry with him that she wants to hit him, which upsets her as she does not believe in using violence against others. She has a history of depersonalization/derealization disorder. Despite the apparent seriousness of the situation, she does not seem particularly concerned by the paralysis. Which of the following is the most likely diagnosis for Saoirse?

-somatic symptom disorder
-factitious disorder
-functional neurological symptom disorder
-malingering
functional neurological symptom disorder

Rationale: The most likely diagnosis for Saoirse is functional neurological symptom disorder. Saoirse presents with acute onset of a neurological symptom in the absence of neurological disease or injury. She reports a stressful relationship with a recent conflict with her significant other and has a history of other psychological issues. Paralysis is a common presentation of functional neurological symptom disorder (conversion disorder). She also evidences la belle indifference as she seems unconcerned about the impairment, which is common with functional neurological symptom disorder.

What happens in the brain during a potentially traumatic event
-brain stem is critical in fast, defensive responses. It’s directly connected with the retina

retina sends visual info to the brain stem immediately, before higher levels of brain are even aware of threat.
-If predator moves closer, periaqueductal gray initiates a fight or flight response.
periaqueductal gray activates the sympathetic nervous system
➣HR goes up, Blood flow to muscles increases, BP increases, Pupils dilate.
-Not always safe or possible to fight or escape.
may enter the freeze response, or feigned death.
periaqueductal gray activates the parasympathetic nervous system as well.
➣Muscles get tight & freeze, Both gaze & breath may freeze, not cognitive choice
-“decisions” made at the level of the brain stem & nervous system
-Predator doesn’t move away, the person may shutdown completely
Hr drops. RR drops. Some people stop breathing. Muscles become limp. Metabolism shuts down. Endorphins released.
person enters state of “no pain”, no longer aware of their surroundings.
During inescapable trauma, this is a very adaptive way for the brain and body to respond.

Four Key Ways Collapse/Submit Can Present in a Client

Compliance / Obedience
Treatment-Resistant Depression
Interpersonal Conflict
Social Avoidance / Desire to Isolate

Brain-based approaches to trauma
-Top-down approaches

Encourage different ways of thinking
Cognitive-Behavioral Therapy (CBT)
Dialectical-Behavior Therapy (DBT)
Mindfulness-based Cognitive Therapy (MBCT)

-Bottom-up approaches

Ways to cope with emotions & defenses
Eye Movement Desensitization and Reprocessing (EMDR)
Yoga
Trauma Resiliency Model (TRM)

CDC has declared violence in the United States:
an urgent public health concern affecting people in all stages of life

Violence
-extreme form of aggression

can lead to trauma & lifetime of psychological, physical, & economic burdens for individuals, families, & communities

What Happens When People Experience Violence or Trauma
polyvagal theory
-nervous system attempts to regulate a traumatic event by activating the social engagement system using relational cues

facial expressions, vocalizations, & language
-social engagement system can only be activated when ind is within their window of tolerance & views the threat as manageable given their skills and resources.
when client perceives trauma or threat as unmanageable, they leave their window of tolerance & nervous system moves into a state of defense
➣triggering a sympathetic or dorsal vagal response
➣sympathetic state can lead to fear, panic, and irritation, while the dorsal vagal response can lead to a collapse/shutdown response

Nervous System’s Response to Trauma
-polyvagal theory

nervous system has three pathways, each designed to protect you:
➣ventral vagal
➣sympathetic pathway
➣dorsal vagal pathway
-ventral vagal
nervous system’s optimal state
state from which we can engage socially, and connect and co-regulate with others
we often feel more calm, curious, grounded, and safe

-sympathetic pathway

defensive pathway that gets the body to mobilize into a fight or flight response, or an attach/cry-for-help response
we might feel fear, panic, irritation, anger, or even rage

-dorsal vagal pathway

defensive pathway that gets the body to immobilize into a collapse/shutdown response
we may feel numb, depressed, ashamed, hopeless, or lethargic
We may dissociate

polyvagal theory: ventral vagal
-ventral vagal

nervous system’s optimal state
state from which we can engage socially, and connect and co-regulate with others
we often feel more calm, curious, grounded, and safe

polyvagal theory: sympathetic pathway
-sympathetic pathway

defensive pathway that gets the body to mobilize into a fight or flight response, or an attach/cry-for-help response
we might feel fear, panic, irritation, anger, or even rage

polyvagal theory: dorsal vagal pathway
-dorsal vagal pathway

defensive pathway that gets the body to immobilize into a collapse/shutdown response
we may feel numb, depressed, ashamed, hopeless, or lethargic
We may dissociate

Risk Factors Related to Violence: Individual
-History of victimization
-ADHD or learning disorders
-Substance use
-Low intelligence
-Emotional distress
-Exposure to family violence
-Social or cognitive deficits

Risk Factors Related to Violence: Family
-Authoritarian parenting style
-Inconsistent or harsh discipline
-Low parental involvement
-Low parental income & education level
-Dysfunctional family functioning

Risk Factors Related to Violence: Community
-Gang involvement
-Social rejection
-Lack of economic opportunities
-Neighborhood poverty
-High level of transient people
-Low community participation
-Low school support
-High density of alcohol outlets

Protective Factors Related to Violence: Individual
-Positive social behaviors
-High IQ & academic achievement
-Religious beliefs
-High-level planning skills

Protective Factors Related to Violence: Family
-Family connections
-Open communication style
-Shared family activities
-Consistent parental presence
-Constructive coping mechanisms

Protective Factors Related to Violence: Community
-Close peers
-Community activities
-Stable housing
-Community support of schools

Sexual Violence
-sexual activity without freely given consen
-considered a public health emergency

impacts people of all ages, races, genders, & sexual orientations
->1/3 women experienced sexual violence involving physical contact during lifetime
-Nearly 1/4 men experienced sexual violence involving physical contact during lifetime
-estimated lifetime cost of rape is $122,461 per victim

Child sexual abuse
-victim is under 18 years old and does not consent or is unable to give consent to sexual activity

touching, penetration, exposure, voyeurism, or child pornography
-Approx 1/10 have experienced sexual abuse before age 18
60% of abuse victims do not tell anyone
-Approx 93% of victims under age 18 know their abuser

Consequences of Child Sexual Abuse
-Physical

genital injury
bruising
sexually transmitted infections
pregnancy
reproductive problems

-Psychological

anxiety
depression
PTSD
suicidal thoughts
increased substance use
risky sexual behaviors

-Sexual trauma

may impact ability to maintain relationships & employment
-Victims of sexual violence
more likely to experience future sexual violence

Perpetrators of Child Sexual Abuse
-vary in gender, marital status, ethnicity, sexual orientation, & economic status

majority male
-exhibit poor information processing & social skills, loneliness, & feelings of inadequacy
-many experienced exposure to sexually explicit material or behavior at an early age
-may have experienced child sexual abuse themselves
-Female perpetrators more likely to co-perpetrate with men in organized child sexual abuse rather than act as single perpetrators
-Pedophiles have a sexual preference for children, not all offend
-Nonpedophilic perpetrators typically prefer sexual interaction with adults and may have concurrent sexual relationships with adults but sexually abuse children as a result of situational factors or stressors

Child Sexual Abuse Stigma
-Social stigmas related to pedophilia are strong

not all pedophiles offend; Providers need to be aware of their preconceptions and feelings about working with this population

Classifying abusers
-relationship to the child

intrafamilial, or incest offenders
-Extrafamilial perpetrators, or those who are unrelated to their victims

Sexual Violence Prevention
-Promote social norms that protect against violence

Bystander approaches
Mobilizing men and boys as allies
-Teach skills to prevent SV
Social-emotional learning
Teaching healthy, safe dating & intimate relationship skills to teens
Promoting healthy sexuality
Empowerment-based training
-Provide opportunities to empower & support girls & women
Strengthening economic supports for women & families
Strengthening leadership and opportunities for girls
-Create protective environments
Improving safety and monitoring in schools
Establishing and consistently applying workplace policies
Addressing community-level risks through environmental approaches
-Support victims/survivors to lessen harm
Victim-centered services
Treatment for victims of SV
Treatment for at-risk children & families to prevent problem behavior including sex offending

intimate partner violence (IPV)
-occurs within a current or past romantic relationship
-may involve physical, psychological, economic, or sexual violence or stalking behaviors
-many encounter before age 18
-Increase risk for victimization:

hx of anxiety disorder, depression, PTSD
pregnancy

IPV Statistics
-About 1/5 women & 1/7 men report having experienced severe physical violence from an intimate partner in their lifetime
-About 1/4 women & 1/10 men have experienced contact sexual violence by an intimate partner
-10% of women & 2% of men report having been stalked by an intimate partner
-26% of women and 15% of men experienced intimate partner violence for the first time before age 18

Consequences of IPV
-can lead to serious physical injury & even death

35% of female IPV survivors & 11% of male IPV survivors experience physical injury r/t IPV
over half of female homicide victims are killed by a current or former male intimate partner
-Poor health outcomes
mental: depression, anxiety, PTSD, high-risk behaviors such as substance misuse
physical: cardiac, neurological, digestive, & reproductive system disorders
development of chronic diseases and pain

Perpetrators of IPV
-may be a maladaptive defense against rejection from an intimate partner, a form of retaliation, or a result of poor conflict resolution
-Many IPV perpetrators suffer from mental health disorders and have experienced childhood trauma
-hx of borderline personality disorder or antisocial personality disorder is correlated with an increased risk for IPV perpetration
-close relationship exists between alcohol use and violence

IPV Prevention
-Teach safe and healthy relationship skills

Social-emotional learning programs for youth
Healthy relationship programs for couples
-Engage Influential adults and peers
Men & boys as allies in prevention
Bystander empowerment & education
Family-based programs
-Disrupt the developmental pathways toward partner violence
Early childhood home visitation
Preschool enrichment with family engagement
Parenting skill & family relationship programs
Treatment for at-risk children, youth, & families
-Create protective environments
Improve school climate & safety
Improve organizational policies & workplace climate
Modify the physical & social environments of neighborhoods
-Strengthen economic supports for families
Strengthen household financial security
Strengthen work-family supports
-Support survivors to increase safety & lessen harms
Victim-centered services
Housing programs
First responder & civil legal protections
Patient-centered approaches
Treatment & support for survivors of IPV, including teen dating violence

Providing Care to Survivors of Violence
-must be individualized
-Addressing safety needs is critical
-Trauma-informed approaches

help providers avoid retraumatizing clients
-understand the role stigma & shame play in clients’ willingness to ask for help/support
-Social support (especially emotional & financial) is an important factor in improving mental health outcomes for survivors

Mandated Reporting
-Many federal & state laws include mandated reporting requirements r/t abuse & IPV
-requirements for children differ from requirements for adults

Providing Care to Perpetrators of Violence
-CBT & relapse prevention care to sex offenders & intimate partner violence offenders

can help reduce recidivism rates
-tailor interventions to the perpetrators’ unique characteristics, taking into account risk factors
anger or hostility, trauma hx, offending patterns, personality styles, readiness to change, substance abuse
-Cultural training may be beneficial for providers working with IPV in LGBTQ relationships
-Often, perpetrators mandated to attend therapy instead of a prison sentence or as a condition of parole
When tx not voluntary, may lack self-motivation to change behaviors
Including motivational strategies such as MI can increase the success of court-mandated therapy

Duty to Warn
-Most states have laws that either require or allow mental health professionals to disclose confidential information to protect others from clients who they believe may become violent
-1976 case Tarasoff v. Regents of the University of California, courts in California imposed a legal duty to warn third parties if clients posed a risk to the parties’ safety leading to the passage of duty to warn laws in most other states

Complex Post-Traumatic Stress Disorder (CPTSD)
-prolonged & repeated trauma may be more severe than symptoms caused by time-limited trauma

-have a poorer prognosis and may benefit from different treatments than individuals with PTSD

Complex symptoms of PTSD
-Symptoms

emotional dysregulation
dissociation
impaired perception of self or perpetrator
difficulty in relationships
sense of hopelessness or despair
loss of faith

-common in clients who have experienced:

childhood trauma, including sexual abuse
persons who have been unable to leave a violent situation, such as prisoners of war
prolonged intimate partner violence
victims of human trafficking

Treatment of CPTSD
-cognitive processing therapy (CPT)
-prolonged exposure (PE)
-Skills Training in Affective and Interpersonal Regulation (STAIR)

allows clients the choice in identifying target problems & interventions

Prolonged exposure
a treatment approach in which clients confront not only trauma-related objects and situations, but also their painful memories of traumatic experiences
-work to approach things you have steered clear of since the event
-challenge the “I can’t” rules to prove to self that “you can”

Cognitive processing therapy (CPT)
psychotherapy to build skills to deal with effects of trauma in other areas of life
-discuss how “stuck points” (negative thoughts about the trauma) have changed you
-practice strategies to change/challenge “stuck points”
-usually takes about 3 months of weekly visits

STAIR
Skills Training in Affective & Interpersonal Regulation
-Evidence-Based Psychotherapy for people struggling with the after effects of trauma
-Can help with emotions and relationships
-STAIR Coach app

training plan: suggested activities to help learn & practice skills
self-care, set goals, tools
readings
mood journal, understand & track mood over time
progress section, assessment

Complementary and Alternative Medicine (CAM) Treatments for CPTSD
-mindfulness
-acupuncture
-yoga
-relaxation techniques
-transcendental meditation treatment
-equine-assisted therapy

CPTSD in Veterans
-Understanding military culture is critical to addressing
-CPTSD may be more common than PTSD in veterans who seek tx
-Veterans with CPTSD often:

delay seeking help
report higher rates of childhood adversity
experience increased emotional or physical bullying during their military careers
># of psychiatric comorbidities, including depressive, panic, generalized anxiety disorders, alcohol & SUDs
report > functioning impairment, including social isolation & sleep difficulties.

PTSD & SUD in Veterans
-> 2 of 10 Veterans with PTSD also have SUD.
-Almost 1/3 Veterans seeking tx for SUD also has PTSD.
-The # of Veterans who smoke is double for those with PTSD (about 6/10) vs those without a PTSD ds (3/10).
-War Veterans with PTSD & alcohol problems tend to binge drink, drinking 4-5 drinks or more in a short period (1-2 hrs).

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE)
-structured 12-week integrated tx cognitive-behavioral psychotherapy program
-features two evidence-based treatments:

Prolonged Exposure (PE) therapy for PTSD
Relapse Prevention for substance use disorders
-address the PTSD & SUD concurrently
-Psychoeducation provided:
how PTSD symptoms & substance use impact each other
common reactions to trauma
strategies to manage impulse urges for alcohol or drugs
-Coping skills emphasized
help veterans prevent substance relapse

benefits of PTSD treatment for veterans
-Find Resolve (learning a new sense of purpose)
-Improve Self-Esteem
-Learn Coping Skills
-Reduce Anger
-Improve Sleep
-Improve Relationships
-Reduce Substance Use
-Achieve Education and Career Goals

Traumatic Brain Injury (TBI)
-alteration in normal brain function following some type of trauma to the head
-90-95% of clients improve within days to weeks

some TBIs can result in mild, moderate, or severe symptoms for months to years and may cause lasting disability
-Repeated TBIs lead to poorer outcomes
including chronic traumatic encephalopathy

factors that influence the long-term outcome of TBI and CTE
-Biological factors
-Age when disease occurs
-Severity of the injury
-Social & family support
-Availability of services
-School support
-Access to rehabilitation
-Psychiatric & social services

TBI symptoms
-physical or psychiatric

trouble sleeping
headaches
difficulty with concentration and memory
irritability aggression
PTSD
depression
anxiety disorders

Concussion
-mild traumatic brain injury
-alteration in mental state that results from injury to the head
-typically arise from MVAs, falls, or hits to the head while playing sports
-Symptoms arise minutes to hours after injury

vacant stares
disorientation
inability to focus
memory impairment
slurred speech
stumbling
may or may not involve a LOC
-Symptoms typically resolve on their own within a few months

The brain is encased by three coverings, called __, and a protective layer of _____. These structures keep the brain supported and floating within the skull.
meninges, cerebrospinal fluid

coup injury
Brain injury at the initial point of impact

contrecoup injury
brain injury that occurs when brain bounces back and hits the opposite side of the skull

What leads to characteristic concussion symptoms
Damaged neurons
-When the brain hits the skull, neurons (brain cells) are stretched, sheared, or transected (cut into pieces)

cannot effectively transmit brain signals

TBI may be classified as:
-blunt, penetrating, or blast injury

based on the causative factor

-clinical severity using the Glasgow Coma Scale (GCS):

mild injury: GCS 13-15
moderate injury: GCS 9-12
severe injury: GCS 3-8

leading causes of TBI in the U.S.
-Falls
-Assaults
-Sports injuries
-Motor vehicle crashes

Chronic-Post Traumatic Headaches
-18-58% of clients with TBI will have chronic post-traumatic headaches
-Risk factors:

female gender
older age
PMH of headaches
-presentation may be similar to migraine, tension, or cluster

Chronic-Post Traumatic Headaches Preventative pharmacologic treatment:
-tricyclic antidepressants

amitriptyline
nortriptyline

-anti-epileptics

topiramate
valproic acid
gabapentin
zonisamide

-beta-blockers

propranolol
timolol
metoprolol

-calcium channel blockers

flunarizine

-angiotensin-converting enzyme inhibitors

Candesartan

-anti-CGRP monoclonal antibodies

erenumab
fremanezumab

-onabotulinumtoxinA injections
-nerve blocks
-trigger point injections
-epidural steroid injections
-radiofrequency ablation

Chronic Traumatic Encephalopathy (CTE)
-degenerative brain disease caused by repeated head trauma
-seen in athletes, such as boxers & football players, & veterans
-course of disease progression is highly variable with a broad range of non-specific behavioral, emotional, & cognitive changes

Depression
Confusion
Irritability
Impulsivity
Aggression
Memory problems
Attention problems
Poor decision-making

CTE can only be diagnosed definitively ___
upon autopsy
-client hx & presenting signs/symptoms may lead to a working dx

Long-Term Management of TBI and CTE
-Symptoms of anxiety & depression can be treated with antidepressants

clients taking bupropion or tricyclic medications should be monitored for seizures
-Amantadine, stimulants, or wakefulness-promoting agents such as modafinil or armodafinil
may help with irritability, fatigue, & attention
-may benefit from social, support, and caregiver support services similar to those offered to clients with dementia
-Acetylcholinesterase inhibitors such as rivastigmine or donepezil
may help treat memory symptoms

-Stigmatizing

-have a poorer prognosis and may benefit from different treatments than individuals with PTSD

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