NR606 Week 4 Questions and Answers

NR606 Week 4 Questions and Answers develop schizophrenia -Many genes play a role • as do epigenetic factors • Heritability as high as 79% -gene-environment interaction -Environmental Triggers: • Regular Cannabis Use • Exposure to Early Life Trauma Sexual Abuse Emotional Abuse Emotional Neglect Bullying schizophrenia Neuroanatomy -Mesocortical & ventromedial prefrontal cortex: negative and affective symptoms -Dorsolateral: cognitive symptoms -Orbitofrontal & connections to the amygdala: aggressive, impulsive symptoms Brain Circuits Affected in Schizophrenia: -Dopamine Pathways • explain the (+) & (-) symptoms seen in schizophrenia & psychosis Dopamine Role in Psychosis -leading hypothesis • psychosis & schizophrenia associated with dysfunction of neurotransmitter dopamine (DA) Traditionally surplus of dopamine Glutamate Role in Psychosis -primary excitatory neurotransmitter -implicated in the overactivity of mesolimbic DA pathway in schizophrenia -Glutamate hypoactivity may result in lost activation of the mesocortical dopamine pathway leading to negative symptoms of schizophrenia GABA is the primary _________ neurotransmitter inhibitory Clinical domains of psychosis symptoms: Positive Symptoms -Hallucinations -Delusions -Thought disorder -Hostility -Excitability Clinical domains of psychosis symptoms: Motor Symptoms -Motor delay -Dyscoordination -EPS, e.g. • Parkinsonism • Dyskinesia Clinical domains of psychosis symptoms: Affective Symptoms -Depression -Anxiety -Suicidality Clinical domains of psychosis symptoms: Cognition -Attention -Working memory -Verbal memory -Visual memory -Executive functioning -Processing speed -Social conditioning Clinical domains of psychosis symptoms: Negative Symptoms -Affective flattening -Alogia -Anhedonia -Amotivation -Asociality Hallucinations: -perceptual experiences in the absence of external stimuli • Auditory • Visual • Tactile (feeling) • Olfactory • Gustatory (tasting) Delusions: -fixed false, irrational beliefs • Persecution: delusions related to being threatened, victimized, or spied on • Reference: delusions related to receiving personal messages from television (tv), radio, or actions of others • Somatic: delusions related to the body, including illness or the presence of foreign objects (e.g. Sometimes people believe there are objects in their bodies; for example they might think they are infested with insects.) • Grandeur: delusions related to beliefs of special abilities or powers • Control: delusions that actions and thoughts are controlled by others Thought Disorder: -impairment in the process of thinking & difficulty organizing thoughts in a logical pattern • incoherent speech • loose associations • meaningless words • perseveration Disorganized behavior: -disordered or impaired behavior or communication • childlike silliness • unpredictable agitation • inappropriate clothing for the weather • poor hygiene Erica is a 24-year-old with a newly diagnosed schizophreniform disorder. She is a current smoker. She does not use alcohol or other drugs. She has no medical history. Which of the following would be the least appropriate initial medication for Erica? aripiprazole lurasidone olanzapine quetiapine olanzapine Rationale: Olanzapine requires up to 30% increased dosage for clients who smoke concurrently. Initiating a medication that does not interact with smoking is preferable. Tony is a 56-year-old who has recently been diagnosed with schizophrenia. He takes amiodarone for a history of cardiac dysrhythmias. He does not use alcohol or other drugs. He is a nonsmoker. Which of the following is the most appropriate medication for Tony? aripiprazole lurasidone quetiapine risperidone risperidone Rationale: Amiodarone is a moderate CYP3A4 inhibitor. Risperidone does not interact with CYP3A4 inhibitors or inducers. Jenny is a 22-year-old who has been prescribed aripiprazole 15 mg/day for the past 8 months. She has gained approximately 30 lbs. during treatment. Jenny's psychiatric symptoms have been managed well on aripiprazole and she has no other adverse effects. What is the most appropriate initial intervention for Jenny? switch to a different antipsychotic medication prescribe metformin refer to a bariatric specialist prescribe metformin Rationale: Prescribing metformin as an adjunct treatment to assist with weight loss associated with antipsychotics is appropriate. Jenny is well-managed on the current dose of aripiprazole; switching to a different medication is not indicated at this time. Referral to a bariatric specialist may be indicated if the client continues to gain weight but is not indicated as the most appropriate initial intervention. Scott is a 33-year-old who is currently without housing. He has been unable to adhere to his prescribed oral medication regimen. The PMHNP recommends a long-acting intramuscular form of medication. Scott is willing to try but would like to receive the medication at the community clinic near the shelter where he is staying. Which medication option is the least appropriate for Scott at this time? aripiprazole monohydrate olanzapine paliperidone palmitate risperidone olanzapine Rationale: Olanzapine must be given in a registered health care facility with available emergency medical services. The client receiving olanzapine must be monitored for 3 hours post-injection. Autism Spectrum Disorder (ASD) -neurological and developmental disorder -impacts communication, relationships with others, learning, behavior -1-2% of population -all racial, ethnic, and socioeconomic groups -Males 4x more likely than females -Factors with increased risk: • having a sibling with ASD • having older parents • having certain genetic conditions: Fragile X syndrome Down syndrome • very low birth weight -spectrum disorder • wide variation in the types and severity of symptoms symptoms typically appear in first 2 years of life DSM-5-TR criteria for ASD -persistent deficits in communication and social interaction across multiple contexts and restrictive, repetitive patterns of behavior, interests, or activities -Symptoms must appear early in development and can cause clinically significant impairment in functioning -severity is classified based on the level of support needed by the individual ASD Diagnosis and Screening -The American Academy of Pediatrics (AAP) recommends that all children be screened for ASD • Providers perform basic developmental screenings at children's 18-month and 24-month well-child visits • demonstrate developmental differences in behavior or functioning require additional evaluation, typically performed by a team of ASD specialists child psychologist, speech-language pathologist, occupational therapist, developmental pediatrician, or neurologist -Dx based on clinical observations, observations in a natural setting, caregiver history, or self-reports ASD different developmental screening tools available -Screening tools: • Ages and Stages Questionnaires (ASQ) • Communication and Symbolic Behavior Scales (CSBS) • Parents' Evaluation of Developmental Status (PEDS) • Modified Checklist for Autism in Toddlers (MCHAT) • Screening Tool for Autism in Toddlers and Young Children (STAT) -Diagnostic tools • Autism Diagnosis Interview - Revised (ADI-R) • Autism Diagnostic Observation Schedule - Generic • Childhood Autism Rating Scale (CARS) • Gilliam Autism Rating Scale - Second Edition (GARS-2) Early signs of ASD include: -avoiding eye contact -showing little interest in peers or caretakers -limited language abilities -frustration with minor changes in routine -repetitive behaviors Quentin is a 4-year-old who presents with his parents for evaluation. Before the appointment, the psychiatric mental health nurse practitioner (PMHNP) read a report submitted to the office by Quentin's preschool teacher, who notes that he is easily distracted, often "fidgety", and has difficulty waiting his turn. He gets frustrated when the school schedule changes and has difficulty interacting with his peers. He does not seem bothered by his lack of friends; rather, he chooses most times to play alone, and he resists playing group games with the class. When pressed to engage, Quentin becomes agitated. The teacher reports that he responds appropriately when asked a question directly, but rarely makes eye contact and avoids physical contact with others. Based on the information provided by the teacher, which of the following diagnoses should be considered potential diagnoses for Quentin? attention-deficit/hyper attention-deficit/hyperactivity disorder (ADHD) autism spectrum disorder (ASD) social anxiety disorder social communication disorder Rationale: Based on the information provided by the teacher, Quentin's current list of differential diagnoses includes ADHD, ASD, social anxiety disorder, and social communication disorder. Additional information is required to narrow the list. Quentin's parents express that preschool has been Quentin's first interaction with other children. He is an only child, and his parents were able to work opposite shifts to avoid sending him to daycare during the pandemic. His mother notes that he has never been an overly affectionate child but tolerates being hugged and kissed by his parents. She reports that he has limited eye contact with both parents, and they find his emotions "hard to read." He has always preferred playing alone to engaging with his parents in play, and his father describes his play as "methodical in that he doesn't seem to play pretend with his toys, but instead lines them up or takes them apart. He only has interest in cars and doesn't play with other toys." His parents both endorse that Quentin seems to have difficulty interacting with adults who visit the home; he seems to struggle with engaging in conversation typical for a yes Rationale: Quentin meets the DSM-5-TR (APA, 2022) criteria for autism spectrum disorder, including persistent deficits in social communication and interaction across multiple contexts manifested as deficits in social-emotional reciprocity, nonverbal communication, and the ability to develop relationships. He also displays repetitive behavior patterns with his toys and difficulties with changes to routines and transitions. Based on the information provided, which of the following specifiers are appropriate for Quentin at this time? Select all that apply. requiring very substantial support requiring substantial support requiring support with accompanying intellectual impairment with accompanying language impairment associated with a known genetic or other medical condition or environmental factor associated with a neurodevelopmental, mental, or behavioral problem with catatonia requiring support Rationale: Specifiers describe current symptoms and may change over time. Only one specifier is pertinent at this time. Quentin's current presentation is consistent with ASD requiring support; his social communication deficits and inflexibility cause interference with functioning, but deficits do not cause marked distress. Quentin's language abilities appear to be age-appropriate. Further testing should be conducted to determine whether an intellectual impairment exists. Quentin does not have known genetic or medical factors that may relate to ASD, and he does not display symptoms of catatonia. Further assessment may determine whether Quentin has an associated neurodevelopmental, mental, or behavioral problem, such as ADHD or anxiety. ASD treatment tx should begin at dx -pharmacologic interventions • no med specific to ASD • meds may be used to treat symptoms of irritability, aggression, repetitive behavior, hyperactivity, problems with attention, anxiety, depression • serotonergic agents, antipsychotics, beta-blockers, alpha-2 agonists, mood stabilizers, stimulants -nonpharmacologic • therapies focused on different areas of functioning behavioral developmental educational psychological social-relational • Applied behavior analysis (ABA) therapy • Speech and language therapy • Occupational therapy • Physical therapy • Parent training • Dietary therapy • Social skills trainingLinks to an external site. Joaquin, a 12-year-old with ASD, has difficulty sleeping and displays impulsive behaviors at school. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate guanfacine Rationale: Alpha-agonist medications, such as guanfacine or clonidine, may be used for clients with ASD who have hyperactivity, impulsive behaviors, and sleep problems. Ariana, a 9-year-old with ASD, has a history of aggressive behaviors, tantrums, and motor tics. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate aripiprazole Rationale: Second-generation antipsychotic medications may be used for clients with ASD who have aggressive behaviors, tantrums, sleep disorders, or motor tics. Seth, a 15-year-old with ASD, has a history of stereotypies including toe-walking and arm flapping. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate clomipramine Rationale: Tricyclic antidepressant medications may be used for clients with ASD who have repetitive behaviors and aggression. Tyrek, an 11-year-old with ASD, has a history of hyperactivity and impulsive behaviors at school. match the scenario with the appropriate med: guanfacine clomipramine aripiprazole methylphenidate methylphenidate Rationale: Stimulant medications may be used for clients with ASD who have hyperactivity, short attention spans, and impulsive behaviors. Rett Syndrome -rare neurodevelopmental disorder • typically caused by mutation in methyl CpG binding protein 2 (MECP2) -affecting one in every 10,000-15,000 live female births worldwide • Boys born with the defect typically have severe problems when they are born & die shortly after birth -spontaneously and is not inherited -Characterized by: • normal growth and development early in life followed by impaired growth and development later in life • children may exhibit behaviors similar to ASD • mental & physical symptoms, loss of the purposeful use of the hands & ability to speak • Apraxia why boys are affected worse by rett syndrome -MECP2 gene is carried on the X chromosome. -In girls, only one X chromosome is active in any given cell, so some cells express the mutation while others do not. -severity of the symptoms r/t the % of cells that express an abnormal copy of the MECP2 gene. -Because boys only have one X chromosome, there is no compensation for the gene defect Rett Syndrome Diagnosis and Screening -Children with symptoms of Rett syndrome • refer to neurologist or neurodevelopmental pediatrician further evaluation of physical & neurological status -clinical geneticist can help confirm the diagnosis Rett Syndrome treatment -No cure -treatment can help: • slow the loss of abilities • preserve function • improve communication & socialization -Therapy • Physical, occupational, & speech assist with function, safety, communication -Orthotics, prosthetics, braces, specialized seating, mobility equipment • encourage independence, manage bone & joint deformities -Meds • control seizures, assist with breathing problems & motor difficulties. Treating Rett Syndrome continued: -Anti-seizure medications -Spinal fusion surgery (if scoliosis develops) -Custom seating equipment -Augmentative communication -Occupational therapy -Physical therapy -Leg braces Tourette syndrome (TS) -chronic neurodevelopmental disorder -often referred to as a tic disorder -characterized by: • abrupt, quick, recurrent, nonrhythmic motor movements or phonic vocalizations -onset typically between 5-7 years • often increases in frequency & severity between 8-12 years -0.52% of children 4-18 have TS -Males more common than females -often comorbid with other psychiatric conditions: • ADHD, OCD, learning difficulties, depression predominant symptoms of TS Tics -often begin as motor tics in the neck & head area -Tics often intensify with stress or excitement -improve with focused or calming activities -often decrease during late adolescence & early adulthood & may disappear in some individuals Tourette syndrome (TS) Diagnosis DSM-5-TR four diagnostic criteria are required for TS including: -presence of multiple motor tics & one or more vocal tics, which may not occur concurrently -tics may wax & wane in frequency but have persisted for more than 1 year since the first tic onset -tic onset is before 18 years of age -not caused by the use of a substance or other medical conditions Tourette syndrome (TS) Screening The Yale Global Tic Severity Scale (YGTSS) -valid instrument used to assess tic severity and overall impairment of TS on the client's quality of life. John is a 7-year-old who often clears his throat while playing. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Simple vocal tics Rationale: Simple vocal tics are caused by contraction of the diaphragm or oropharynx muscles and include frequent throat clearing, sniffs, chirps, barks, or grunting. Clarence is an 8-year-old who blinks his eyes or makes facial grimaces when doing his homework. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Simple motor tics Rationale: Simple motor tics are of short duration and can include eye blinks, facial grimaces, shoulder shrugs, or extension of the extremities. Samuel is a 12-year-old who presents with repetitive head-turning and shoulder shrugging. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Complex motor tics Rationale: Complex motor tics include a combination of simple tics that last for a longer duration. Neil is a 10-year-old who presents with his mother after repeated episodes of barking ethnic, racial, and religious slurs at school. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Complex vocal tics: Coprolalia Rationale: Coprolalia is a complex vocal tic characterized by abrupt, sharp bark or grunt vocalization of socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs. This type of tic is less common. Brett is a 12-year-old who often makes sexual or taboo gestures when he gets excited. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Complex motor tics: Copropraxia Rationale: Copropraxia is a less common complex motor tic that involves making obscene gestures. Amy is a 14-year-old who frequently echoes what she just heard, saying that word or phrase over and over. match the clinical scenario with the appropriate tic: Simple motor tics Complex vocal tics: Coprolalia Complex motor tics Simple vocal tics Complex vocal tics: Echolalia Complex motor tics: Copropraxia Complex vocal tics: Echolalia Rationale: Echolalia is a complex vocal tic characterized by repeating the last heard word or phrase. Tourette syndrome (TS) Treatment Tx necessary when tics affect child's physical, mental, or social wellbeing -nonpharmacological • psychoeducation (first-line) • behavioral therapies comprehensive behavioral intervention for tics (CBIT) • exercise therapies -pharmacological interventions • antipsychotics such as pimozide & aripiprazole to control tics comprehensive behavioral intervention for tics (CBIT) non-drug treatment consisting of three important components: -Training patient to be more aware of tics -Training patients to do competing behavior when they feel the urge to tic -Making changes to day to day activities in ways that can be helpful in reducing tics.