Transcript Psych Mental Health Power Point CH

Chapter 2
Neurobiologic Theories and
Psychopharmacology
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Central Nervous System
• Brain
– Cerebrum
– Cerebellum
– Brain stem
– Limbic system (see Figure 2.2)
• Spinal cord
• Nerves that control voluntary acts
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Cerebrum
• Two hemispheres
• Four lobes:
– Frontal lobe (thought, body movement, memories,
emotions, moral behavior)
– Parietal lobe (taste, touch, spatial orientation)
– Temporal lobe (smell, hearing, memory, emotional
expression)
– Occipital lobe (language, visual interpretation)
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Cerebellum
• Below cerebrum
• Center for coordination of movements, postural
adjustments
• Reception, integration of information from all body areas
to coordinate movement, posture
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Brain Stem
• Midbrain: reticular activating system (motor activity,
sleep, consciousness, awareness) and extrapyramidal
system
• Pons: primary motor pathway
• Medulla oblongata: vital centers for cardiac, respiratory
function
• Nuclei for cranial nerves III through XII
• Locus ceruleus: norepinephrine-producing neurons
(stress, anxiety, impulsive behavior)
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Limbic System
• Above brain stem
– Thalamus (activity, sensation, emotion)
– Hypothalamus (temperature regulation, appetite
control, endocrine function, sexual drive, impulsive
behavior)
– Hippocampus (emotional arousal, memory)
– Amygdala (emotional arousal, memory)
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Question
• Is the following statement true or false?
• The cerebellum consists of four lobes.
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Answer
• False
• Rationale: The cerebrum consists of four lobes. The
cerebellum is located below the cerebrum.
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Neurotransmitters
• Chemical substances to facilitate neurotransmission (see
Figure 2.3)
• Important in right proportions to relay messages
• Play role in psychiatric illness, and psychotropic
medications, including their actions and side effects.
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Neurotransmitters (cont.)
• Excitatory or inhibitory (see Table 2.1)
– Excitatory
• Dopamine: complex movements, motivation,
cognition, regulation of emotional response
• Norepinephrine: attention, learning, memory,
sleep, wakefulness, mood regulation
• Epinephrine: flight-or-fight response
• Glutamate: major neurotoxic effects at high levels
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Neurotransmitters (cont.)
• Excitatory or inhibitory (see Table 2.1) (cont.)
– Inhibitory
• Serotonin: food intake, sleep, wakefulness,
temperature regulation, pain control, sexual
behaviors, regulation of emotions
• GABA: modulation of other neurotransmitters
– Excitatory or inhibitory
• Acetylcholine: sleep-and-wakefulness cycle;
signals muscles to become alert
• Histamine: neuromodulator
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Neurobiologic Causes
• Genetics and heredity: play role but not solely genetic
– Twin, adoption, family studies used
• Psychoimmunology: compromised immune system
possibly contributing, especially in at-risk populations
• Infections: particularly viruses during fetal development,
possibly play role
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Nurse’s Role in Research and Education
• Ensure all clients, families are well informed.
• Help distinguish between facts and hypotheses.
• Explain if or how new research may affect client’s
treatment or prognosis.
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Brain Imaging Techniques
•
•
•
•
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
• Limitations
– Use of radioactive substances; expense of
equipment; client’s inability to tolerate technique
– Changes nondetectable with current techniques
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Question
• Is the following statement true or false?
• Single photon emission computed tomography is
considered the best type of brain imaging technique to
diagnose disease.
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Answer
• False
• Rationale: Single photon emission computed tomography
(SPECT) is not considered the major type of brain
imaging used to diagnose disease. In fact, many of the
changes in the brain are not currently detectable with
any of the current techniques.
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Psychopharmacology
• Psychotropic drugs
• Efficacy (maximum therapeutic effect)
• Potency (amount of drug needed for maximum effect)
• Half-life
• Approved use
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Psychopharmacology (cont.)
• Off-label use (effective for disease different from one
involved in original testing)
• Black box warning (serious or life-threatening side
effects)
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Principles of Psychopharmacology
•
•
•
•
•
Effect on target symptom
Adequate dosage for sufficient time
Lowest effective dose
Lower doses for older adults
Tapering rather than abrupt cessation to avoid rebound
or withdrawal
• Follow-up care
• Simple regimen to increase compliance
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Antipsychotic Drugs
• Antipsychotic agents (see Table 2.3)
– Conventional (e.g., chlorpromazine, fluphenazine,
thioridazine, haloperidol, loxapine)
– Second generation (e.g., clozapine, risperidone,
olanzapine)
– Third generation (dopamine system stabilizers; e.g.,
aripiprazole)
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Antipsychotic Drugs (cont.)
• Use: treatment of psychotic symptoms
• Mechanism of action: block dopamine receptors
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Antipsychotics: Side Effects
• Extrapyramidal syndrome (EPS):
– Acute dystonia
• Torticollis, opisthotonus, oculogyric crisis
• Treatment: anticholinergic drugs or
diphenhydramine (see Table 2.4)
– Pseudoparkinsonism (stooped posture, mask-like
faces, shuffling gait)
– Akathisia (restlessness, anxiety, agitation)
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Antipsychotics: Side Effects (cont.)
• Neuroleptic malignant syndrome (NMS)
• Tardive dyskinesia (irreversible involuntary movements)
• Anticholinergic effects (dry mouth, constipation, urinary
hesitancy or retention)
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Antipsychotics: Side Effects (cont.)
• Other side effects:
– Increased prolactin levels
– Weight gain (second-generation agents, except
ziprasidone)
– Prolonged QT interval (thioridazine, droperidol,
mesoridazine)
– Agranulocytosis (clozapine)
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Antipsychotics: Client Teaching
• Adherence to regimen
• Side effects, management
– Thirst/dry mouth (sugar-free candy, liquids)
– Constipation (dietary fiber, stool softeners)
– Sedation (safety measures)
• Actions for missed dose (dose if within 4 hours of usual
time)
• CBC, ANC with clozapine
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Question
• Which of the following drugs would be classified as a
conventional antipsychotic?
– A. Clozapine
–
B. Risperidone
–
C. Fluphenazine
–
D. Aripiprazole
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Answer
•
C. Fluphenazine
• Rationale: Fluphenazine is classified as a conventional
antipsychotic.
– Clozapine and risperidone are considered secondgeneration antipsychotics. Aripiprazole is considered
a third-generation antipsychotic.
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Antidepressants
• Use: major depressive illness, anxiety disorders,
depressed phase of bipolar disorder, psychotic
depression
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Antidepressants (cont.)
• Four groups (see Table 2.5):
– Tricyclic and related cycle antidepressants (TCAs)
– Selective serotonin reuptake inhibitors (SSRIs)
– MAO inhibitors (MAOIs)
– Others (venlafaxine, bupropion, duloxetine,
trazodone, nefazodone)
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Antidepressants (cont.)
• Mechanism of action: interact with monoamine
neurotransmitter systems, especially norepinephrine and
serotonin
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Antidepressants: Side Effects
• SSRIs
– Anxiety, agitation, akathisia, nausea, insomnia,
sexual dysfunction
– Weight gain
• TCAs
– Anticholinergic effects
– Orthostatic hypotension, sedation, weight gain,
tachycardia
– Sexual dysfunction
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Antidepressants: Side Effects (cont.)
• MAOIs
– Daytime sedation, insomnia, weight gain, dry mouth,
orthostatic hypotension, sexual dysfunction
– Hypertensive crisis (with foods containing tyramine)
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Antidepressants: Side Effects (cont.)
• Other agents
– Sedation; headache (nefazodone, trazodone)
– Loss of appetite, nausea, agitation, insomnia
(bupropion, venlafaxine)
– Priapism (trazodone)
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Antidepressants: Drug Interactions
• Serotonin syndrome
– MAOI + SSRI
– Agitation, sweating, fever, tachycardia, hypotension,
rigidity, hyperreflexia
– Coma, death (extreme reactions)
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Antidepressants: Client Teaching
• Time of dosage
– SSRI first thing in morning
– TCAs at night
• Actions for missed dose
– SSRI up to 8 hours after missed dose
– TCAs within 3 hours of missed dose
• Safety measures
• Dietary restrictions if taking MAOI (see Box 2.1)
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Mood-Stabilizing Drugs
• Lithium, some anticonvulsants (carbamazepine, valproic
acid; gabapentin, topiramate, oxcarbazepine, and
lamotrigine)
• Use: treatment of bipolar disorders
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Mood-Stabilizing Drugs (cont.)
• Mechanism of action
– Normalize reuptake of certain neurotransmitters
(lithium)
– Increase levels of GABA (valproic acid, topiramate)
– Kindling process (valproic acid, carbamazepine)
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Mood-Stabilizing Drugs: Side Effects
• Lithium
– Nausea, diarrhea, anorexia, fine hand tremor,
polydipsia, polyuria, metallic taste, fatigue, lethargy;
weight gain, acne (later in therapy)
– Toxicity: severe diarrhea, vomiting, drowsiness,
muscle weakness, lack of coordination
• Carbamazepine and valproic acid: drowsiness, sedation,
dry mouth, blurred vision
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Mood-Stabilizing Drugs: Side Effects
(cont.)
• Carbamazepine: rash, orthostatic hypotension
• Valproic acid: weight gain, alopecia, hand tremor
• Topiramate: dizziness, sedation, weight loss
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Mood-Stabilizing Drugs: Client Teaching
• Periodic monitoring of blood levels
– 12 hours after last dose taken
• Drug with meals
• Safety measures
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Question
• Is the following statement true or false?
• A client who takes an SSRI with an MAOI is at risk for a
hypertensive crisis.
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Answer
• False
• Rationale: A client who takes an SSRI with an MAOI is at
risk for serotonin syndrome.
– Hypertensive crisis occurs if the client is taking MAOI
and ingests foods containing tyramine.
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Antianxiety Drugs
• Use: treatment of anxiety and anxiety disorders,
insomnia, OCD, depression, posttraumatic stress
disorder, alcohol withdrawal
• Benzodiazepines, buspirone (see Table 2.6)
• Mechanism of action
– Mediation of GABA (benzodiazepines)
– Partial agonist activity at serotonin receptors
(buspirone)
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Antianxiety Drugs: Side Effects
• Benzodiazepines
– Physical, psychological dependence
– CNS depression
– Hangover effect
– Tolerance
• Buspirone
– Dizziness, sedation, nausea, headache
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Antianxiety Drugs: Client Teaching
• Safety measures
• Avoidance of alcohol
• Avoidance of abrupt discontinuation
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Stimulants
• Amphetamines (methylphenidate amphetamine,
dextroamphetamine)
• Use: treatment of ADHD in children and adolescents,
residual attention deficit disorder in adults, narcolepsy
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Stimulants (cont.)
• Mechanism of action
– Cause release of norepinephrine, dopamine,
serotonin presynaptically
– Direct agonist effects postsynaptically
– Block reuptake of neurotransmitters
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Stimulants: Side Effects and Client
Teaching
• Side effects
– Anorexia, weight loss, nausea, irritability
– Growth and weight suppression
• Client teaching
– Dose after meals
– Avoidance of caffeine, sugar, chocolate
– Proper storage out of reach of children
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Disulfiram
• Use: aversion therapy for alcoholism
• Mechanism of action: inhibition of enzyme involved with
alcohol metabolism
– Adverse reaction with alcohol ingestion
• Side effects: fatigue, drowsiness, halitosis, tremor,
impotence
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Disulfiram (cont.)
• Drug interactions with phenytoin, isoniazid, warfarin,
barbiturates, long-acting benzodiazepines
• Client teaching: avoidance of alcohol, including common
products that may contain it
– Shaving cream, deodorant, OTC cough preparations
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Question
• Which of the following drugs would the nurse expect to
administer to a client with ADHD?
–
A. Disulfiram
–
B. Methylphenidate
–
C. Buspirone
–
D. Lithium
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Answer
•
B. Methylphenidate
• Rationale: Methylphenidate is a stimulant used to treat
ADHD.
– Disulfiram is used to treat alcoholism. Buspirone is
used to treat depression. Lithium is used to treat
bipolar disorder.
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Cultural Considerations
• More rapid response to antipsychotics, TCAs for African
Americans than whites
– Greater risk of side effects
• Slower metabolism of antipsychotics, TCAs for Asians
– Lower doses to produce the same effects
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Cultural Considerations (cont.)
• Lower doses of antidepressants for Hispanics than whites
to achieve desired effects
• Lower doses of lithium for Asians and African Americans
than whites to produce desired effects
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Cultural Considerations (cont.)
• Increased frequency of herbal medicine use
– St. John’s wort
– Kava
– Valerian
– Ginkgo biloba
• Increased risk for interactions
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Common Barriers to Maintaining
Medication Management
• Long-term, chronic illness requires ongoing treatment.
• Symptoms of poor insight and confusion
• “Faulty” thinking
• Major side effects/interactions of meds
• Stereotyping and discrimination against mental illness
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Self-Awareness Issues
• View chronic mental illness as having remissions and
exacerbations, just as chronic physical illnesses do.
• Remain open to new ideas that may lead to future
breakthroughs.
• Understand that medication noncompliance is often part
of the illness, not willful misbehavior.
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