ANCC PMHNP-BC Prep Online

Safety is the priority in acute mania, especially when hyperactivity and impulsivity increase the risk of harm. The first step is to complete an immediate safety and risk assessment (including suicidality, homicidality, inability to care for self, severe agitation, substance use, and access to means) to determine whether the patient can be managed outpatient or needs urgent escalation (e.g., ED evaluation or hospitalization). Adjusting medications without further assessment can lead to inappropriate changes and misses urgent safety concerns. A detailed exploratory psychotherapy session is typically not effective as an initial intervention in acute mania due to impaired attention, insight, and impulse control. Brief de-escalation and limit-setting can be helpful, but it should not replace completing a safety assessment when immediate risk is possible.

Serotonin syndrome is most often triggered by combining serotonergic agents or increasing serotonergic dose, leading to neuromuscular hyperactivity, autonomic instability (including hyperthermia), and altered mental status. St. John’s wort has serotonergic activity and can interact with SSRIs such as fluoxetine, increasing serotonergic tone and making serotonin syndrome more likely. Vaccination, dental cleaning, a family history of schizophrenia, and nonspecific influenza exposure do not increase serotonin levels and do not explain this abrupt toxidrome in the setting of an SSRI.

Splitting is a defense mechanism in which a person views others in extreme, all-or-nothing terms (all good or all bad), with rapid shifts between idealization and devaluation. In this scenario, the statement “You’re the only one who understands me” reflects idealization of the therapist, followed quickly by devaluation (“You never listen to me”) when boundaries are introduced. Projection involves attributing one’s own unacceptable feelings or impulses to someone else. Intellectualization is focusing on facts and logic to avoid emotional distress. Sublimation is channeling unacceptable impulses into socially acceptable activities.