Chapter 3

and Ch 19 20 21 22 Karch
Psychiatric Disorders and
Pharmacological
Treatments

Role of the Nervous System

Controlling the functions of the human body
Analyzing incoming stimuli
Integrating internal and external responses

Make Up of the Nervous System

Central Nervous System (CNS)
Composed of the brain and spinal cord
Peripheral Nervous System (PNS)
Sensory receptors bring information into the CNS
Motor nerves carry information away from the CNS
Autonomic Nervous System (ANS)
Uses components of the CNS and PNS to regulate
automatic or unconscious responses to stimuli

Function of the Cells that Make Up the Nervous

System
Allow movement
Allow realization of various sensations
Provide response to internal and external stimuli
Stimulate learning, thinking, and emotions

Function and Activities of the Brain

Maintenance of homeostasis
Regulation of autonomic nervous
system (ANS) and hormones
Control of biological drives and
behavior
Cycle of sleep and wakefulness
Circadian rhythms
Conscious mental activity
Memory
Social skills

Cellular Composition of the Brain

Neurons
Respond to stimuli
Conduct electrical impulses
Release chemicals
Neurotransmitters
Presynaptic neuron

synapse

Transmitter destruction
Enzymes
Reuptake

postsynaptic neuron

Organization of the Brain

Brainstem
Core Regulates internal organs and vital functions
Hypothalamus Basic drives and link between thought and emotion and function of internal organs
Processing center for sensory information
Cerebellum Regulates skeletal muscle
Coordination and contraction
Maintains equilibrium
Cerebrum
Conscious sense of being
Emotional status
Memory
Control of skeletal muscles movement
Language and communication

Visualizing the Brain

Structured imaging techniques
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Functional imaging techniques
Positron emission tomography (PET)
Single photon emission computed tomography
(SPECT)

Types of Neuron Axons

Afferent Fibers
Nerve axons that run from
peripheral receptors into the
CNS
Efferent Fibers
Nerve axons that carry nerve
impulses from the CNS to the
periphery to stimulate
muscles or glands
Electrolytes :
Sodium: goes into the cell
Potassium: leaves the cell
Calcium

Formation of Myelin Sheath

Question
What nerve axons carry nerve impulses from the central
nervous system to the peripheral nervous system?
A. Somatic axons
B. Efferent fibers
C. Afferent fibers
D. Sensory axons

Neurotransmitters
Acetylcholine
Communicates between nerves and muscles
Norepinephrine and Epinephrine
Catecholamines released by nerves in the sympathetic
branch of the ANS
Dopamine
Involved in the coordination of impulses and responses
Gamma-aminobutyric Acid (GABA)
Inhibits nerve activity and is important in preventing
over-excitability or stimulation such as seizure activity
Serotonin
Important in arousal and sleep and in preventing
depression and promoting motivation
ALL IMPORTANT FOR PHARMACOLOGICAL CONTROL OF CNS

Mechanisms of Action of Psychotropic

Drugs
Anxiolytic and Hypnotic Agents
Ch 20 Karch

Antianxiety and Hypnotic Drugs

Benzodiazepines

Diazepam (Valium)
Clonazepam (Klonopin)
Alprazolam (Xanax)
Lorazepam (Ativan)
Flurazepam (Dalmane)
Temazepam (Restoril)
Triazolam (Halcion)
Estazolam (ProSom)
Quazepam (Doral)

Short-acting sedative-hypnotic sleep agents (Z-hypnotics)

Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta)

Melatonin receptor agonists

Ramelteon (Rozerem)
Doxepin (Silenor)
Buspirone (BuSpar)

Types of Anxiolytic and Hypnotic Agents

Anxiolytics: Prevent feelings of tension or fear
Sedatives: Calm and make patients unaware of the
environment
Hypnotics: Cause sleep
Minor Tranquilizers: Produce a state of tranquility in
anxious patients
Hypnosis: Extreme sedation resulting in further CNS
depression and sleep

Benzodiazepines

Act in the limbic system and the RAS

Make GABA more effective
Causes interference with neurons firing
Lower doses cause anxiolytic effects
Higher doses cause sedation and
hypnosis

Used in anxiety, alcohol withdrawal,

hyperexcitability and agitation, preop anxiety

Well absorbed from GI tract

Peak levels achieved in 30 minutes to 2
hours
Lipid soluble and distributes well
throughout the body
Cross placenta/Enter breast milk
Metabolized in the liver
Excretion is primarily in the urine

Benzodiazepine: Adverse Effects

Sedation
Drowsiness
Depression
Lethargy
Blurred Vision
Confusion

Dry Mouth
Constipation
Nausea
Vomiting
Hypotension
Urinary Retention

Benzodiazepine: Drug-to-Drug Interactions

Increase CNS depression when taken with alcohol
Increase in effect when taken with cimetidine, oral
contraceptives, or disulfiram
Decrease in effect if given with theophylline or ranitidine

Question
A client presents at the clinic with symptoms of
hyperexcitability and agitation. Which medication would
the nurse expect the physician to prescribe?
A. Hypnotic
B. Benzodiazepine
C. Barbiturate
D. Other Anxiolytic and Hypnotic Drugs

Barbiturates
CNS depressants
Inhibit neuroral impulse conduction in the
ascending RAS
Depress cerebral cortex, motor output
Cause: sedation, hypnosis, anesthesia, and
coma
Used: Relief of anxiety, Sedation,
Insomnia, Preanesthesia, Seizures
Well absorbed
Reaching peak in 20 60 minutes
Metabolized in the liver
Excreted in the urine
Contraindications: Allergy, history of
addiction, porphyria, marked hepatic
impairment or nephritis, respiratory
distress or severe respiratory dysfunction,
pregnancy

Barbiturates: Drug-to-Drug Interactions

Increase CNS depression when given with alcohol,
antihistamines, and other tranquilizers
Altered response to phenytoin
MAO cause increase serum levels and effect
Decrease effectiveness of the following drugs: anticoagulants,
digoxin, tricyclic antidepressants, corticosteroids, oral
contraceptive

Barbiturates: Adverse Reactions

CNS Depression
Physical Dependency
Drowsiness
Somnolence
Lethargy
Ataxia

Vertigo
Nausea
Vomiting
Constipation

Question
Please answer the following statement as true or false.

Peak levels of barbiturates occur in 60 to 90 minutes.

Other Anxiolytic and Hypnotic Drugs

Paraldehyde (Paral): Sedates patients with delirium
tremens or psychiatric conditions characterized by
extreme excitement
Meprobamate (Miltown): Manages acute anxiety for up to
4 months
Chloral Hydrate (Aquachloral): Produces nocturnal
sedation or preoperative sedation
Glutethimide (generic), zaleplon (Sonata), and zolpidem
(Ambien): Short-term treatment of insomnia
Antihistamines: promethazine [Phenergan],
diphenhydramine [Benadryl]: Preoperative medications
and postoperative to decrease the need for narcotics
Buspirone (BuSpar): Reduces the signs and symptoms of
anxiety without severe CNS and adverse effects

Use of Anxiolytic and Hypnotic Agents Across the Life Span

Prototype Benzodiazepines Agent

Prototype Barbiturates Agent

Question
You are admitting a new patient to the clinic. A review of home
medications indicates the patient is taking a barbiturate to help
him sleep. The patient tells you that he is having problems
with both his visual and auditory senses. The patient wants to
know what is wrong. What would be the best response?
A. We will have to wait and see what the doctor says.
B. What you are describing could be adverse effects from the
sleep medicine you are taking.
C. There is nothing wrong. You are just getting older.
D. Sometimes these things happen with our patients. We need
to do a complete assessment before we know for sure.

Antidepressant Agents
KARCH Chapter 21

Antidepressant Drugs
Tricyclic antidepressants (TCAs)
Nortriptyline (Pamelor)
Amitriptyline (Elavil)
Imipramine (Tofranil)

Selective serotonin reuptake inhibitors (SSRIs)

Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluvoxamine (Luvox)

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)

Serotonin-norepinephrine disinhibitors (SNDIs)

Mirtazapine (Remeron)

Antidepressant Drugs
Monoamine oxidase inhibitors (MAOIs) (Note these!)
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (EMSAM)
Tranylcypromine (Parnate)
Other Antidepressants
Bupropion (Wellbutrin, Zyban)
Vilazodone (Viibryd)
Trazodone (Oleptro)

Affective Disorder vs. Depression

Affective Disorder
A persons mood goes far beyond the usual, normal ups
and downs
Depression
Severe and long-lasting feelings of sadness lasting beyond
period identified with precipitating event

Signs and Symptoms of Depression

Low energy level

Sleep disturbances
Lack of appetite
Limited libido
Inability to perform activities of daily living
Overwhelming feelings of sadness, despair, hopelessness,
and disorganization

Biogenic Amine Theory of Depression

Depression results from a deficiency of norepinephrine

(NE), dopamine, or serotonin (5HT)
Monoamine oxidase (MAO) may break them down to be
recycled or restored in the neuron
Rapid fire of the neurons may lead to their depletion
The number or sensitivity of postsynaptic receptors may
increase, depleting neurotransmitter levels

Actions of Antidepressant Therapy

Inhibit the effects of MAO, leading to increased NE or 5HT in

the synaptic cleft
Block reuptake by the releasing nerve, leading to increased
neurotransmitter levels in the synaptic cleft
Regulate receptor sites and breakdown of neurotransmitters,
leading to an accumulation of neurotransmitters in the
synaptic cleft

Tricyclic Antidepressants
Actions: Reduce the reuptake of
5HT and NE into nerves
Use: Choice depends on
individual response to the drug
and tolerance of adverse effects
Indications: Relief of symptoms
of depression, Used in patients
with sleep disorders, Treatment
of enuresis, Chronic pain
Pharm: Absorbed from GI track,
Peak 2-4 hours, Metabolized in
the liver, Excreted in the urine, T
8-46 hours
Contraindications: Known
allergy, recent MI, myelography,
pregnancy, and lactation
Cautions: CV disease, angle closure glaucoma, urinary retention, manic-depression
Adverse Reactions:Sedation, sleep disturbances, fatigue, hallucinations, ataxia, dry
mouth, constipation, nausea, vomiting
Drug-to-Drug Interactions: MAOIs, cimetidine, fluoxetine, ranitidine, oral
anticoagulants

Tricyclic Agent

Monoamine Oxidase Inhibitors (MAOIs)

Actions: Irreversibly inhibits MAO,

allowing norepinephrine, serotonin, and

dopamine to accumulate in the synaptic
cleft
Use: Treatment of patients with
depression who are unresponsive to, or
unable to take other antidepression
agents
Pharm: Absorbed from GI track, Peak
2-4 hours, Metabolized in the liver,
Excreted in the urine, T 8-46 hours

Adverse Reactions: Dizziness, excitement, nervousness,

mania, hyperreflexia, tremors, confusion, insomnia, agitation,
liver toxicity, nausea, vomiting, diarrhea or constipation, anorexia, weight
gain, dry mouth, and abdominal pain
Drug-to-Drug Interactions: Other antidepressants: Hypertensive crisis,
coma
Methyldopa Sympathomimetic effects increase
Insulin or oral antidiabetic agents Additive hypoglycemia
Food Interactions: Tyramine or pressor amines Increase blood
pressure

MOAIs (Recognize these)

Isocarboxazid (Marplan)
Used for clients who did not respond to or could
not take newer, safer antidepressants
Phenelzine (Nardil)
Used for some clients who did not respond to
newer, safer antidepressants
Tranylcypromine (Parnate)
Used for adult outpatients with reactive
depression

Question
Please answer the following statement as true or false.

MAOIs are generally prescribed for people with depression

who respond to safer drugs.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Actions: Specifically block the

reuptake of 5HT, with little to no known

effect on NE
Do not have many adverse effects
associated with TCAs and MAOIs,
Use: Depression, OCDs, panic attacks,
bulimia, PMDD, posttraumatic stress
disorders, social phobias, social anxiety
disorders
Pharm: Absorbed from the GI tract,
Metabolized in the liver, Associated with
congenital abnormalities
Contradindications: Known allergy,
pregnancy, lactation, impaired renal
function or hepatic function

Adverse Reactions: Headache, drowsiness, dizziness, insomnia,

anxiety, tremor, agitation
Drug-to-Drug Interactions: MAOIs, TCAs increase of therapeutic
and toxic effect

Prototype SSRI Agent

Use of Antidepressant Agents Across

the Lifespan

Mood Stabilizers: Bipolar Disease

Lithium salts (Lithane, Lithotabs)
Anticonvulsant drugs
Valproate (Depakote, Depakene)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Gabapentin (Neurontin)
Topiramate (Topamax)
Oxcarbazepine (Trileptal)
Quetiapine (Seroquel)
Lamotrigine Olanzapine (Zyprexa)

Action of Lithium
Alters sodium transport in nerve and muscle cells
Inhibits the release of norepinephrine and dopamine, but
not serotonin, from stimulated neurons
Increases the intraneuronal stores of norepinephrine and
dopamine slightly
Decreases intraneuronal content of second messengers
Pharmacokinetics
Absorbed from GI tract
Peak in 30 minutes
Distribution pattern in the body as water
Slowly crosses the blood-brain barrier.
Excreted from the kidney, 80% is reabsorbed
Crosses the placenta associated with congenital abnormalities
Enters the breast milk
Contraindications
Known allergy, renal, cardiac disease, leukemia, metabolic
disorders, pregnancy, lactation

Lithium
Adverse Reactions
Effects directly related to the lithium serum level
Less than 1.5 lethargy, slurred speech, muscle
weakness, nausea, vomiting
Levels 1.5-2 above reactions plus ECG changes
Levels 2-2.5 ataxia, clonic movements, hyperreflexia,
seizures
>2.5 Complex multiorgan toxicity, significant risk of death
Drug-to-Drug Interactions
Haloperidol
Carbamazepine
Thiazide Diuretic

Question
Lithium is a drug that has been used for a long time to
treat the manic phase of bipolar disorder. What is the
primary action of lithium?
A. Inhibits the release of serotonin and norepinephrine
B. Inhibits the release of serotonin and dopamine
C. Inhibits the release of norepinephrine and dopamine
D. Inhibits the release of serotonin and second
messengers

Psychotherapeutic Agents

KARCH Chapter 22

Antipsychotic Drugs
First-generation, conventional, typical of standard
antipsychotic drugs
Antagonists of receptors for
Acetylcholine
Norepinephrine
Histamine
Significant side effects
Weight gain
Sedation
Strong antagonists (blocking agents)
Bind to D2 receptors
Block attachment of dopamine
Reduce dopaminergic transmission

Second-Generation (Atypical) Antipsychotics

Produce fewer extrapyramidal side effects (EPS)

Target both the negative and positive symptoms
Often chosen as first-line treatment
Dopamine and serotonin blockers
Will raise blood sugar

Clozapine (Clozaril)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Olanzapine (Zyprexa, Zyprexa Relprevv)
Ziprasidone (Geodon)
Paliperidone (Invega)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Asenapine (Saphris)

Third -Generation (Atypical) Antipsychotics

Aripiprazole (Abilify): Dopamine stabilizer

Psychotherapeutic Agents
Used to treat psychoses perceptual and behavioral
disorders
Schizophrenia
Mania/Bipolar Disease
Narcolepsy
Attention-Deficit Disorder
Drugs do not cure the disorder help clients function
in a more acceptable manner and carry on activities of
daily living
Used in both children and adults

Psychotic Disorders
Condition

Characteristics

Causes

Schizophrenia

Hallucinations, paranoia,
delusions, speech
abnormalities, and affective
problems

Strong genetic association

May reflect a fundamental
biochemical abnormality

Mania/Bipolar
Illness

Mania: Periods of extreme

overactivity and excitement
Bipolar illness: Extremes of
depression followed by
hyperactivity and excitement

May reflect a biochemical

imbalance followed by
overcompensation on the part
of neurons and their inability
to re-establish stability

Narcolepsy

Daytime sleepiness and

sudden periods of loss of
wakefulness

Problems with stimulation of

the brain by the reticular
activating system (RAS)
Problems with response to that
stimulation

AttentionDeficit
Disorders

Inability to concentrate on
one activity for longer than a
few minutes
State of hyperkinesis

Debated: Usually diagnosed in

school-aged children, but can
occur in adults

Antipsychotics
Typical: Primarily dopamine receptor
blockers
Cause several adverse effects including
hypotension, anticholinergic effects, and
extrapyramidal side effects (EPS)
Atypical
Block both dopamine receptors and
serotonin receptors
May alleviate some of the unpleasant
neurological effects and depression of
typical antipsychotics

Types of Extrapyramidal Effects

Pseudoparkinsonism
Dystonia
Akathisia
Tardive Dyskinesia
Potentially irreversible neuroleptic malignant syndrome

Antipsychotics
Indications:: Schizophrenia,

hyperactivity, combative behavior,

agitation in the elderly, severe
behavioral problems in children

Pharmacokinetics: Absorbed from GI IM

dose provides 4 to 5 times the active dose as
oral doses
Widely distributed in the tissues
Metabolized in the liver
Excreted through bile and urine
Cross placenta and enter breast milk
Contraindications: Underlying diseases
that could be exacerbated by dopamineblocking effects of these drugs
circulatory collapse, Parkinsons disease, coronary disease
severe hypotension Prolonged QT interval
Adverse Reactions: Sedation, Weakness Tremors, Drowsiness, EPS,
Dry mouth, Nasal congestion, Constipation
Drug-to-Drug Interactions: Beta blockers, alcohol, mesoridazine,
thioridazine

CNS STIMULANTS

CNS Stimulants
For attention deficit hyperactivity disorder (ADHD)

Methylphenidate (Ritalin, also Daytrana: transdermal system)

Dextroamphetamine (Adderall, Vyvanse)
Atomoxetine (Strattera)
Intuniv (guanfacine)
Kapvay (clonidine)

For Alzheimer's disease

Tacrine (Cognex)
Donepezil (Aricept)
Galantamaine (Razadyne)
Revastigmine (Exelon)
Memantine (Namenda, Namenda XR)

CNS Stimulants
Actions: CNS stimulants act as cortical and
RAS, possible by increasing the release of
catecholamines from presynaptic neurons
leading to an increase in stimulation of the
postsynaptic neurons
Indications:: attention deficit syndromes

Narcolepsy
Pharmacokinetics: Rapidly absorbed from the
GI tract, Peak 2-4 hours,
Metabolized in the liver, Excreted in the urine
T 2-15 hours
Contraindications: Known allergy, marked
anxiety, agitation, or tension and severe fatigue
or glaucoma

Adverse Effects: Nervousness, insomnia, dizziness, headache,

blurred vision, anorexia, nausea, weight loss
Drug-to-Drug Interactions :MAOIs, Guanethidine, TCAs,
Phenytonin

Use of Psychotherapeutic Agents Across

the Lifespan

Prototype Typical Antipsychotic Drug

Prototype Central Nervous System Stimulants

Herbal Medicine
Major concerns
Potential long-term effects
Nerve damage
Kidney damage
Liver damage
Possibility of adverse chemical reactions
With other substances
With conventional medications
St. Johns Wart = Prozac

Questions
1. If a person has decreased circulating levels of GABA,
which health problem would be expected?
A.

Alzheimers disease

B.

Parkinsons disease

C.

Anxiety disorders

D.

Insomnia

Questions
2. Which neuroimaging technique would reveal
problems in the anatomical structure of the brain but
not problems in function?
A.

CT

B.

PET

C.

SPECT