Chapter 2: Neurobiologic Theories and Psychopharmacology

Neurobiologic Theories
Great strides are being made in understanding the brain and mental illness, but much is still unknown; nurses need to keep abreast of developments to provide effective teaching

Central Nervous System

Consists of: Brain Cerebrum Cerebellum Brain stem

Limbic system
Spinal cord Nerves that control voluntary acts

Cerebrum
Divided into two hemispheres with four lobes each:

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)

Cerebellum
Receives and integrates information from all body areas to coordinate movement and posture

Brain Stem
Midbrain Pons Medulla oblongata Locus ceruleus Cranial nerve nuclei 3 through 12

Limbic System
Above the brain stem and includes: Thalamus Hypothalamus Amygdala

Neurotransmitters
Chemical substances manufactured in the neuron to aid in transmission of information
Either inhibitory or excitatory

Neurotransmitters include:
Dopamine (control of complex movements, motivation, cognition, regulation of emotional responses) Norepinephrine (attention, learning, memory, sleep, wakefulness, mood regulation) Epinephrine (flight-or-fight response) Serotonin (food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions)

Neurotransmitters include:

(contd)

Histamine (alertness, control of gastric secretions, cardiac stimulation, peripheral allergic responses) Acetylcholine (sleep and wakefulness cycle, signals muscles to become alert) Glutamate (an excitatory amino acid) GABA (modulates other neurotransmitters)

Brain Imaging Techniques

Include: Computed tomography (CT)

Magnetic resonance imaging (MRI)

Positron emission tomography (PET)

Single photon emission computed tomography (SPECT)

We cannot yet diagnose mental illness with these techniques alone.

Axial PET of Male Patient With Alzheimers

Causes of Mental Illness

Genetics and heredity: play a role but alone do not account for development of mental illness Psychoimmunology: a compromised immune system could contribute, especially in at-risk populations Infections, particularly viruses, may play a role

Psychopharmacology
Psychopharmacology and medication management are important in the treatment of many mental illnesses. Principles that guide the use of medications include:

 Effect on target symptom

Adequate dosage for sufficient time

Lowest dose needed for maintenance

Lower doses for the elderly Tapering rather than abrupt cessation to avoid rebound or withdrawal Follow-up care

Simplify the regimen for increased compliance

Antipsychotic Drugs
Uses:

conventional; atypical; new generation

Schizophrenia, acute mania, psychotic depression, drug-induced psychosis, other psychotic symptoms Action:
Treat psychotic symptoms, such as delusions and hallucinations, by blocking dopamine receptors

Conventional Antipsychotic Drugs

Side Effects Extrapyramidal side effects (EPSs) Pseudoparkinsonism Dystonia Akathisia Anticholinergic side effects Tardive dyskinesia (TD) Neuroleptic malignant syndrome (NMS) Patient Teaching Adhering to medication regimen Managing side effects Thirst Constipation Sedation

phenothiazines (Thorazine, Prolixin, Mellaril, Stelazine); Navane, Haldol, Loxitane, Moban

Atypical Antipsychotic Drugs

Side Effects Fewer EPSs Weight gain Patient Teaching

Clozaril, Risperdal, Zyprexa, Seroquel, Geodon

Adhering to medication regimen Reducing sugar and caloric intake Clozaril Weekly WBC monitoring

Agranulocytosis (Clozaril)

Discontinue medication and seek care at first sign of infection

New-Generation Antipsychotic Drugs

aripiprazole (Abilify) Side Effects Headache Anxiety Patient Teaching Adhering to medication regimen

Nausea

Antidepressant Drugs
SSRIs; TCAs; MAOIs

Uses: Major depression, panic disorder and other anxiety disorders, bipolar depression, psychotic depression

Action:
Interact with the monoamine neurotransmitter systems in the brain, particularly the neurotransmitters norepinephrine and serotonin

SSRI Antidepressant Drugs

Side Effects Anxiety Agitation

fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro) Patient Teaching Take in the morning Take with food

Akathisia
Nausea Insomnia

Propanolol given for akathisia

Sexual dysfunction (anorgasmia/impotence)

TCA Antidepressant Drugs

imipramine (Tofranil), desipramine (Norpramin), amitriptyline (Elavil), doxepin (Sinequan), clomipramine (Anafranil) Side Effects Patient Teaching Anticholinergic (blurred vision, urinary retention, dry mouth, constipation) Orthostatic hypotension Sedation Weight gain Tachycardia Sexual dysfunction Taking in the evening Using caution when driving

MAOI Antidepressant Drugs

Side Effects Sedation Insomnia

phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) Patient Teaching Following tyramine-free diet (avoid aged cheeses, aged meats, beer and wine, sauerkraut, soy) Avoiding sympathomimetic drugs Using caution when driving

Weight gain
Dry mouth Orthostatic hypotension

Sexual dysfunction
Hypertensive crisis with excessive tyramine or sympathomimetic drugs

Mood Stabilizing Drugs

lithium; anticonvulsant medications (carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine (Lamictal), gabapentin (Neurontin)

Uses:
Bipolar disorder Action: Act on the neurotransmitters of the brain

Mood-Stabilizing Drugs
Side Effects (Lithium) Nausea Diarrhea Anorexia Fine hand tremor Polydipsia Polyuria Fatigue Weight gain Patient Teaching (Lithium) Taking with food Having monthly blood levels drawn 12 hours after last dose (maintain therapeutic levels between 0.51.5 mEq/L)

Acne

Antianxiety Drugs

benzodiazepines; buspirone (BuSpar)

Uses:
Anxiety disorders, insomnia, OCD, depression, PTSD, alcohol withdrawal

Action:
Moderate the actions of GABA

Antianxiety Drugs
Side Effects
Tolerance and dependence Drowsiness Sedation Poor concentration Impaired memory Clouded sensorium Patient Teaching Using caution during driving due to slower reflexes and response time

Never discontinuing abruptly as withdrawal can be fatal

Avoiding alcohol

Stimulant Drugs Uses:

methylphenidate (Ritalin), pemoline (Cylert), dextroamphetamine

ADHD, residual ADD in adults, and narcolepsy Action: Cause release of neurotransmitters

Stimulant Drugs
Side Effects Anorexia Weight loss Patient Teaching Avoiding caffeine, sugar, and chocolate Taking after meals Long-term use can cause dependency

Nausea
Irritability

Disulfiram
Antabuse

Uses:

Aversion therapy for treatment of alcoholism

Action: Causes an adverse reaction when alcohol is ingested

Disulfiram
Side Effects Fatigue Drowsiness Patient Teaching Avoiding alcohol (including products such as shaving cream, aftershave, cologne, many OTC medications) Family should never administer without the person's knowledge

Halitosis
Tremor Impotence

Cultural Considerations
Ethnic backgrounds influence responses to some

psychotropic medications:

African Americans respond more rapidly to antipsychotic and tricyclic antidepressant medications than do whites and have a greater risk of side effects Asians metabolize antipsychotic and tricyclic antidepressants more slowly, requiring lower doses to produce the same effects Hispanics require lower doses of antidepressants than whites to achieve desired effects Asians and African Americans require lower doses of lithium than whites to produce desired effects

Self-Awareness Issues

Viewing chronic mental illness as having

remissions and exacerbations, just as chronic physical illnesses do
Remaining open to new ideas that may lead to future breakthroughs Understanding that medication noncompliance is often part of the illness, not willful misbehavior