MENTAL HEALTH: CHAPTER 2: NEUROBIOLOGIC THEORIES & PSYCHOPHARMACOLOGY

Drugs Available Via IM Injection:

- 6 drugs are available via IM injection - Due to possibility of post-injection delirium/sedation, patients must be observed to be symptom free for at least 3 hours after injection

Metabolic Syndrome:

- Increases risk for heart disease, stroke, diabetes If you have 3 or more of these: high bp, high cholesterol, diabetes, obese

Serotonin:

- Inhibitory - Controls emotion, pain, sexual drive, temperature regulation, food regulation

GABA:

- Inhibitory - Modulates other neurotransmitters medications like benzodiazepines (which alleviate anxiety and induce sleep) increase GABA function

Akathisia:

- Intense need to move about - Client will appear restless/agitated - Treated with anticholinergics, beta blockers, benzodiazepines

Central Nervous System: Brain: Cerebrum: Parietal Lobe:

- Interpret sensations of taste and touch and assist in spatial orientation.

Central Nervous System: Limbic System: Hippocampus & Amygdala:

- Involved in emotional arousal and memory

Central Nervous System: Limbic System: Hypothalamus:

- Involved in temperature regulation, appetite control, endocrine function, sexual drive, and impulsive behavior associated with feelings of anger, rage, or excitement.

PET/SPECT:

- Involves injection of radioactive substance into bloodstream

Histamine:

- Neuromodulator - Controls gastic secretions, cardiac stimulation, allergic response

Mood Stabilizing Drugs: Lithium:

- Normal dose is 900-3600mg, more than 1.5 mEq is toxic - Side effects: weight gain, acne, polydipsia, polyuria, metallic taste in mouth, nausea, anorexia

Antabuse:

- Treatment for alcoholism - If person ingests alcohol while taking this medication, 5-10 minutes later they'll experience sweating, nausea, vomiting, weakness - Symptoms can last 30 minutes to 2 hours - Be careful about common products containing alcohol (shaving cream, aftershave, cologne, deodorant, OTC medications (like cough syrup) - Side effects: Halitosis and impotence

Antipsychotics: Side Effects: Neuroleptic malignant syndrome (NMS):

- A potentially fatal idiosyncratic reaction to an antipsychotic (or neuroleptic) drug. - The major symptoms of NMS are rigidity; high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine phosphokinase. - Clients with NMS are usually confused and often mute; they may fluctuate from agitation to stupor. - All antipsychotics seem to have the potential to cause NMS, but high dosages of high-potency drugs increase the risk. NMS most often occurs in the first 2 weeks of therapy or after an increase in dosage, but it can occur at any time. - Dehydration, poor nutrition, and concurrent medical illness all increase the risk for NMS. - Treatment includes immediate discontinuance of all antipsychotic medications and the institution of supportive medical care to treat dehydration and hyperthermia until the client's physical condition stabilizes. - After NMS, the decision to treat the client with other antipsychotic drugs requires full discussion between the client and the physician to weigh the relative risks against the potential benefits of therapy.

Brain Imaging Techniques: Computed Tomography (CT) Scan:

- A procedure in which a precise x-ray beam takes cross-sectional images (slices) layer by layer. - A computer reconstructs the images on a monitor and also stores the images on magnetic tape or film. - Visualize the brain's soft tissues, so it is used to diagnose primary tumors, metastases, and effusions and to determine the size of the ventricles of the brain. - Some people with schizophrenia have been shown to have enlarged ventricles; this finding is associated with a poorer prognosis and marked negative symptoms

Central Nervous System: Brain Stem: Locus Coeruleus:

- A small group of norepinephrine-producing neurons in the brain stem, is associated with stress, anxiety, and impulsive behavior.

Antipsychotics: Side Effects: Tardive dyskinesia (permanent involuntary movements):

- A syndrome of permanent involuntary movements, is most commonly caused by the long-term use of conventional antipsychotic drugs. - About 20% to 30% of patients on long-term treatment develop symptoms of TD, and the pathophysiology is still unclear. - Symptoms of TD include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. - Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. - After it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression. - Unfortunately, antipsychotic medications can mask the beginning symptoms of TD; that is, increased dosages of the antipsychotic medication cause the initial symptoms to disappear temporarily. As the symptoms of TD worsen, however, they "break through" the effect of the antipsychotic drug. - In 2017, the FDA approved valbenazine (Ingrezza) and deutetrabenazine (Austedo, Teva) as the first drugs to treat TD. These drugs are vesicular monoamine transporter 2 (VMAT2) inhibitors. - It is believed that these drugs decrease activity of monoamines, such as dopamine, serotonin, and norepinephrine, thereby decreasing the abnormal movements associated with Huntington chorea and TD. - Valbenazine has a dosage range of 40 to 80 mg daily, and deutetrabenazine ranges from 12 to 48 mg daily. - Both drugs cause somnolence, QT prolongation, akathisia, and restlessness. - In addition, valbenazine can cause nausea, vomiting, headache, and balance disturbances. - Deutetrabenazine can also cause NMS and increased depression and suicidality in patients with Huntington chorea (Kim, Baker, & Levien, 2018). - Preventing TD is the primary goal when administering antipsychotics. - This can be done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for initial signs of TD using a standardized assessment tool such as the Abnormal Involuntary Movement Scale. - Clients who have already developed signs of TD but still need to take an antipsychotic medication are often given one of the atypical antipsychotic drugs that have not yet been found to cause or therefore worsen TD.

Central Nervous System: Limbic System:

- Above brain stem oThalamus (activity, sensation, emotion) oHypothalamus (temperature regulation, appetite control, endocrine function, sexual drive, impulsive behavior) oHippocampus and amygdala (emotional arousal, memory) - Disturbances in the limbic system have been implicated in a variety of mental illnesses, such as the memory loss that accompanies dementia and the poorly controlled emotions and impulses seen with psychotic or manic behavior.

Central Nervous System: Brain Stem: Pons:

- Above the medulla and in front of the cerebrum, the pons bridges the gap both structurally and functionally, serving as a primary motor pathway. - The midbrain connects the pons and cerebellum with the cerebrum. - It includes most of the reticular activating system and the extrapyramidal system. - The reticular activating system influences motor activity, sleep, consciousness, and awareness. - The extrapyramidal system relays information about movement and coordination from the brain to the spinal nerves

Neurotransmitters (Excitatory): Epinephrine:

- Also known as noradrenaline and adrenaline - Has limited distribution in the brain but controls the fight or flight response in the peripheral nervous system.

Mood-Stabilizing Drugs: Mechanism Of Action:

- Although lithium has many neurobiologic effects, its mechanism of action in bipolar illness is poorly understood. - Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. - It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder - The mechanism of action for anticonvulsants is not clear because it relates to their off-label use as mood stabilizers. - Valproic acid and topiramate are known to increase the levels of the inhibitory neurotransmitter GABA. - Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process. - This can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. - It is suspected that this same kindling process may also occur in the development of full-blown mania with stimulation by more frequent minor episodes. - This may explain why anticonvulsants are effective in the treatment and prevention of mania as well.

What Happens When Abruptly Stopping Psych. Medications?

- DO NOT abruptly stop psych medications - Can result in rebound (temporary return of symptoms) - Can result in recurrence (complete return of symptoms) - Can result in withdrawal effects

PSYCHOPHARMACOLOGY: Potency:

- Describes the amount of the drug needed to achieve that maximum effect - Low-potency drugs require higher dosages to achieve efficacy, while high-potency drugs achieve efficacy at lower dosages

Antianxiety Drug: Side Effects:

- Although not a side effect in the true sense, one chief problem encountered with the use of benzodiazepines is their tendency to cause physical dependence. - Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. - This is especially a problem for clients with long-term benzodiazepine use, such as those with panic disorder or generalized anxiety disorder. - Psychological dependence on benzodiazepines is common; clients fear the return of anxiety symptoms or believe they are incapable of handling anxiety without the drugs. - This can lead to overuse or abuse of these drugs. - Buspirone does not cause this type of physical dependence. - The side effects most commonly reported with benzodiazepines are those associated with CNS depression, such as drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium. - When used for sleep, clients may complain of next-day sedation or a hangover effect. - Clients often develop a tolerance to these symptoms, and they generally decrease in intensity. - Common side effects from buspirone include dizziness, sedation, nausea, and headache - Elderly clients may have more difficulty managing the effects of CNS depression. - They may be more prone to falls from the effects on coordination and sedation. - They may also have more pronounced memory deficits and may have problems with urinary incontinence, particularly at night.

Stimulants: Mechanism Of Action:

- Amphetamines and methylphenidate are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. - They also block the reuptake of these neurotransmitters. Methylphenidate produces milder CNS stimulation than amphetamines; pemoline primarily affects dopamine and therefore has less effect on the sympathetic nervous system. - It was originally thought that the use of methylphenidate and pemoline to treat ADHD in children produced the reverse effect of most stimulants—a calming or slowing of activity in the brain. - However, this is not the case; the inhibitory centers in the brain are stimulated, so the child has greater abilities to filter out distractions and manage his or her own behavior. - Atomoxetine helps block the reuptake of norepinephrine into neurons, thereby leaving more of the neurotransmitter in the synapse to help convey electrical impulses in the brain.

Neurotransmitters (Excitatory): Glutamate:

- An excitatory amino acid that can have major neurotoxic effects at high levels. - It has been implicated in the brain damage caused by stroke, hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases such as Huntington or Alzheimer.

Antidepressants: Drug Interactions:

- An uncommon but potentially serious drug interaction called serotonin syndrome (or serotonergic syndrome) can result from taking an MAOI and an SSRI at the same time. - It can also occur if the client takes one of these drugs too close to the end of therapy with the other. - In other words, one drug must clear the person's system before initiation of therapy with the other. Symptoms include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death - These symptoms are similar to those seen with an SSRI overdose.

Neurotransmitters:

- Approximately 100 billion brain cells form groups of neurons, or nerve cells, that are arranged in networks. - These neurons communicate information with one another by sending electrochemical messages from neuron to neuron, a process called neurotransmission. - These electrochemical messages pass from the dendrites (projections from the cell body), through the soma or cell body, down the axon (long extended structures), and across the synapses (gaps between cells) to the dendrites of the next neuron. In the nervous system, the electrochemical messages cross the synapses between neural cells by way of special chemical messengers called neurotransmitters. - Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. - They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory). - These neurotransmitters fit into specific receptor cells embedded in the membrane of the dendrite, just like a certain key shape fits into a lock. - After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO) - Important in right proportions to relay messages; studies showing differences in brains of people with some mental disorders - Play role in psychiatric illness and psychotropic medications, including their actions and side effects - Major neurotransmitters have been found to play a role in psychiatric illnesses as well as in the actions and side effects of psychotropic drugs. - Dopamine and serotonin have received the most attention in terms of the study and treatment of psychiatric disorders.

Central Nervous System: Brain: Cerebrum: Occipital Lobe:

- Assist in coordinating language generation and visual interpretation, such as depth perception.

PSYCHOPHARMACOLOGY: Off-Label Use:

- At times, a drug will prove effective for a disease that differs from the one involved in original testing and FDA approval.

Neurotransmitters (Excitatory): Norepinephrine:

- Attention, learning, memory, sleep, wakefulness, mood regulation - The most prevalent neurotransmitter in the nervous system, is located primarily in the brain stem - Excess norepinephrine has been implicated in several anxiety disorders; deficits may contribute to memory loss, social withdrawal, and depression. - Some antidepressants block the reuptake of norepinephrine, while others inhibit MAO from metabolizing it

Second Generation:

- Atypical - Weak blocker of d2 so less extrapyramidal effects. - Here, elderly patients are at increased risk for death due to cardiovascular/infectious problems

Central Nervous System: Brain: Cerebellum:

- Below cerebrum - Center for coordination of movements and postural adjustments - Reception, integration of information from all body areas to coordinate movement and posture - Research has shown that inhibited transmission of dopamine, a neurotransmitter, in this area is associated with the lack of smooth coordinated movements in diseases such as Parkinson disease and dementia.

Anti-depressants Associated W/ Norepinephrine & Serotonin: MAOIs:

- Do NOT ingest foods with tyramine (aged meats/cheeses and beer) b/c it can result in hypertensive crisis - Do NOT take other MAOIs, many anti-hypertensive general anesthesia, and Demerol - Side effects: orthostatic hypotension, sexual dysfunction, daytime sedation, insomnia

Third Generation:

- Dopamine stabilizer, so works to enhance dopamine when too little and decrease when too much - Only medication here is Abilify

Third-generation antipsychotics:

- Dopamine system stabilizers - Aripiprazole

Antianxiety Drug: Mechanism Of Action:

- Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. - Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory. - Benzodiazepines produce their effects by binding to a specific site on the GABA receptor. - Buspirone is believed to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors, which decreases serotonin turnover - The benzodiazepines vary in terms of their half-lives, the means by which they are metabolized, and their effectiveness in treating anxiety and insomnia. - Drugs with a longer half-life require less frequent dosing and produce fewer rebound effects between doses; however, they can accumulate in the body and produce "next-day sedation" effects. - Conversely, drugs with shorter half-lives do not accumulate in the body or cause next-day sedation, but they do have rebound effects and require more frequent dosing. - Temazepam (Restoril), triazolam (Halcion), and flurazepam (Dalmane) are most often prescribed for sleep rather than for relief of anxiety. - Diazepam (Valium), chlordiazepoxide (Librium), and clonazepam are often used to manage alcohol withdrawal as well as to relieve anxiety.

Antipsychotics: Mechanism Of Action:

- Block dopamine receptors

Central Nervous System:

- Brain: oCerebrum oCerebellum oBrain stem oLimbic system - Nerves that control voluntary acts (neurotransmitters)

Serotonin Syndrome:

- Can occur when taking a MAOI and SSRI at same time. - Extreme cases can result in coma/death

Central Nervous System: Brain: Cerebrum: Temporal Lobe:

- Centers for the senses of smell and hearing and for memory and emotional expression

Brain:

- Cerebrum - Cerebellum - Brain stem (midbrain, pons, medulla & contains cranial nerves 3-12)

Conventional or First-Generation Antipsychotics:

- Chlorpromazine - Fluphenazine - Thioridazine - Haloperidol - Loxapine

Antianxiety Drugs: Client Teaching:

- Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. - Benzodiazepines strongly potentiate the effects of alcohol; one drink while on a benzodiazepine may have the effect of three drinks. - Therefore, clients should not drink alcohol while taking benzodiazepines. - Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work. - Benzodiazepine withdrawal can be fatal. After the client has started a course of therapy, he or she should never discontinue benzodiazepines abruptly or without the supervision of the physician

Antidepressants: Client Teaching:

- Clients should take SSRIs first thing in the morning unless sedation is a problem; generally, paroxetine most often causes sedation. - If the client forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose. - To minimize side effects, clients generally should take cyclic compounds at night in a single daily dose when possible. - If the client forgets a dose of a cyclic compound, he or she should take it within 3 hours of the missed dose or omit the dose for that day. - Clients should exercise caution when driving or performing activities requiring sharp, alert reflexes until sedative effects can be determined. - Clients taking MAOIs need to be aware that a life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary restrictions. - They should receive a written list of foods to avoid while taking MAOIs. - The nurse should make clients aware of the risk for serious or even fatal drug interactions when taking MAOIs and instruct them not to take any additional medication, including OTC preparations, without checking with the physician or pharmacist

Atypical or Second-Generation Antipsychotics:

- Clozapine - Risperidone - Olanzapine

Neurotransmitters (Excitatory): Dopamine:

- Complex movements, motivation, cognition, regulation of emotional response - It is generally excitatory and is synthesized from tyrosine, a dietary amino acid. - Implicated in schizophrenia and other psychoses as well as in movement disorders such as Parkinson disease. - Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity.

Central Nervous System: Brain: Cerebrum: Frontal Lobe:

- Control the organization of thought, body movement, memories, emotions, and moral behavior. - The integration of all this information regulates arousal, focuses attention, and enables problem-solving and decision-making. - Abnormalities in the frontal lobes are associated with schizophrenia, attention-deficit/hyperactivity disorder (ADHD), and dementia.

Neurotransmitters (Neuromodulator): Histamine:

- Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses - The role of histamine in mental illness is under investigation. - It is involved in peripheral allergic responses, control of gastric secretions, cardiac stimulation, and alertness. - Some psychotropic drugs block histamine, resulting in weight gain, sedation, and hypotension.

First Generation:

- Conventional - Blocks d2, d3, d4 - Blocking d2 can result in extrapyramidal effects

Cerebellum:

- Coordinates movement/posture adjustment

Side Effects of Cyclic Antidepressants:

- Cyclic compounds have more side effects than do SSRIs and the newer miscellaneous compounds. - The individual medications in this category vary in terms of the intensity of side effects, but generally side effects fall into the same categories. - The cyclic antidepressants block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision. - More severe anticholinergic effects such as agitation, delirium, and ileus may occur, particularly in older adults. - Other common side effects include orthostatic hypotension, sedation, weight gain, and tachycardia. - Clients may develop tolerance to anticholinergic effects, but these side effects are common reasons that clients discontinue drug therapy. - Clients taking cyclic compounds frequently report sexual dysfunction similar to problems experienced with SSRIs. - Both weight gain and sexual dysfunction are cited as common reasons for noncompliance

Antipsychotics: Side Effects: Extrapyramidal Side Effects: Extrapyramidal symptoms (EPSs): Acute Dystonia:

- Includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. - Dystonia is most likely to occur in the first week of treatment, in clients younger than 40 years, in males, and in those receiving high-potency drugs such as haloperidol and thiothixene. - Spasms or stiffness in muscle groups can produce torticollis (twisted head and neck), opisthotonus (tightness in the entire body with the head back and an arched neck), or oculogyric crisis (eyes rolled back in a locked position). - Acute dystonic reactions can be painful and frightening for the client. Immediate treatment with anticholinergic drugs, such as intramuscular benztropine mesylate (Cogentin) or intramuscular or intravenous diphenhydramine (Benadryl), usually brings rapid relief. - Treatment: anticholinergic drugs or diphenhydramine

Antipsychotics: Side Effects: Pseudoparkinsonism:

- Drug-induced parkinsonism, or pseudoparkinsonism, is often referred to by the generic label of EPS. - Symptoms resemble those of Parkinson disease and include a stiff, stooped posture; masklike facies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and coarse pill-rolling movements of the thumb and fingers while at rest. - Parkinsonism is treated by changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine, which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug.

Anti-Cholinergic Side Effects:

- Dry mouth - Dry eyes - Constipation - Urinary retention - Orthostatic hypotension

Atypical Antipsychotics:

- Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death. - Causes of death are varied, but most appear to be either cardiovascular or infectious in nature.

Antipsychotic Side Effects:

- Elevated prolactin levels - Weight gain - Increased risk for hyperglycemia and diabetes

Limbic System: Amygdala:

- Emotional arousal/memory

Limbic System: Hippocampus:

- Emotional arousal/memory

THE NURSE'S ROLE IN RESEARCH AND EDUCATION:

- Ensure all clients and families are well informed - Help distinguish between facts and hypotheses - Explain if or how new research may affect client's treatment or prognosis - Provide information and answer questions

Glutamate:

- Excitatory - Can cause nephrotoxicity if levels are too high

Dopamine:

- Excitatory - Controls complex movement, cognition, motivation

Epinephrine:

- Excitatory - Fight or flight

Norepinephrine:

- Excitatory - Controls mood, sleep/wakefulness, learning/memory - Excess norepinephrine associated with many anxiety disorders

Acetylcholine:

- Excitatory/inhibitory - Controls sleep/wakefulness and signals muscles to become alert

Neurotransmitters (Inhibitory): Serotonin:

- Food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions - Is derived from tryptophan, a dietary amino acid. - Serotonin plays an important role in anxiety, mood disorders, and schizophrenia. - It has been found to contribute to the delusions, hallucinations, and withdrawn behavior seen in schizophrenia. - Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood.

Mood-Stabilizing Drugs: Client Teaching:

- For clients taking lithium and the anticonvulsants, monitoring blood levels periodically is important. - The time of the last dose must be accurate so that plasma levels can be checked 12 hours after the last dose has been taken. - Taking these medications with meals minimizes nausea. - The client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided.

Stimulants: Dosage:

- For the treatment of narcolepsy in adults, both dextroamphetamine and methylphenidate are given in divided doses totaling 20 to 200 mg/day. - The higher dosages may be needed because adults with narcolepsy develop tolerance to the stimulants and so require more medication to sustain improvement. - Stimulant medications are also available in sustained-release preparations so that once-a-day dosing is possible. - Tolerance is not seen in persons with ADHD. - The dosages used to treat ADHD in children vary widely depending on the physician; the age, weight, and behavior of the child; and the tolerance of the family for the child's behavior. - Arrangements must be made for the school nurse or another authorized adult to administer the stimulants to the child at school. - Sustained-release preparations eliminate the need for additional dosing at school.

Antipsychotic Drugs:

- Formerly known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. - Off-label uses of antipsychotics include treatment of anxiety and insomnia; aggressive behavior; and delusions, hallucinations, and other disruptive behaviors that sometimes accompany Alzheimer disease. - Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine. - They have been in clinical use since the 1950s. - They are the primary medical treatment for schizophrenia and are also used in psychotic episodes of acute mania, psychotic depression, and drug-induced psychosis. - Clients with dementia who have psychotic symptoms sometimes respond to low dosages of conventional antipsychotics. - Second-generation antipsychotics can increase mortality rates in elderly clients with dementia-related psychosis. - Short-term therapy with antipsychotics may be useful for transient psychotic symptoms such as those seen in some clients with borderline personality disorder.

Limbic System: Hypothalamus:

- Homeostasis - Temperature regulation - Appetite control - Sexual drive - Impulsive behavior

Efficacy:

- How well drug works to have a therapeutic effect

Neuroleptic Malignant Syndrome (NMS):

- Idiosyncratic reaction to antipsychotic - Results in high fever, sweating, muscle rigidity, uncontrollable bp, and elevated levels of phosphokinase - Treatment: immediate dc of antipsychotic and management of dehydration and fever

Antipsychotic Drugs: Side Effects: Other Side Effects:

- Increased prolactin levels - Weight gain (most likely with second-generation agents, except ziprasidone) - Metabolic syndrome - Cardiovascular adverse effects - Lengthening of QT interval (thioridazine, droperidol, mesoridazine) - Agranulocytosis (clozapine)

Antipsychotics: Side Effects: Akathisia:

- Is reported by the client as an intense need to move about. - The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures. - This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication. - Can be treated by a change in antipsychotic medication or by the addition of an oral agent such as a beta-blocker, anticholinergic, or benzodiazepine.

PSYCHOPHARMACOLOGY: Half-Life:

- Is the time it takes for half of the drug to be removed from the bloodstream. - Drugs with a shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day. - The time that a drug needs to leave the body completely after it has been discontinued is about five times its half-life.

What Is SORL-1 Gene Associated With?

- Late onset Alzheimers

Mood-Stabilizing Drugs: Side Effects:

- Lithium o Nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste in the mouth, fatigue, lethargy; weight gain, acne (later in therapy) o Toxicity: severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination - Carbamazepine and valproic acid: drowsiness, sedation, dry mouth, blurred vision - Common side effects of lithium therapy include mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, a metallic taste in the mouth, and fatigue or lethargy. - Weight gain and acne are side effects that occur later in lithium therapy; both are distressing for clients. - Taking the medication with food may help with nausea, and the use of propranolol often improves the fine tremor. - Lethargy and weight gain are difficult to manage or minimize and frequently lead to noncompliance. - Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. - Untreated, these symptoms worsen and can lead to renal failure, coma, and death. When toxic signs occur, the drug should be discontinued immediately. If lithium levels exceed 3 mEq/L, dialysis may be indicated. Side effects of carbamazepine and valproic acid include drowsiness, sedation, dry mouth, and blurred vision. In addition, carbamazepine may cause rashes and orthostatic hypotension, and valproic acid may cause weight gain, alopecia, and hand tremor. Topiramate causes dizziness, sedation, weight loss (rather than gain), and increased incidence of renal calculi

Central Nervous System: Brain Stem: Medulla Oblongata:

- Located at the top of the spinal cord, contains vital centers for respiration and cardiovascular functions

Antidepressant Use:

- Major depressive illness, - Anxiety disorders - Depressed phase of bipolar disorder - Psychotic depression

Neurotransmitters (Inhibitory): GABA:

- Major inhibitory neurotransmitter; modulation of other neurotransmitters - An amino acid, is the major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. - Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and to induce sleep.

Foods (Containing Tyramine) to Avoid When Taking Monoamine Oxidase Inhibitors:

- Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. - Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, meat extracts, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated. - Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado. - All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 oz of wine per day. - Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast). - Yogurt, sour cream, peanuts, brewer's yeast, and monosodium glutamate (MSG).

➔ WARNING - Clozapin:

- May cause agranulocytosis, a potentially life-threatening event. - Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine.

➔ WARNING - Droperidol, Thioridazine, and Mesoridazine:

- May lengthen the QT interval, leading to potentially life-threatening cardiac dysrhythmias or cardiac arrest.

PSYCHOPHARMACOLOGY:

- Medication management is a crucial issue that greatly influences the outcomes of treatment for many clients with mental disorders.

Central Nervous System: 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 coeruleus: norepinephrine-producing neurons (stress, anxiety, impulsive behavior)

Cultural Considerations:

- More rapid response to antipsychotic medications and tricyclic antidepressants for African Americans than white people o Higher risk of side effects - Slower metabolism of antipsychotics and tricyclic antidepressants for Asians than white people o Lower doses to produce the same effects - Studies from a few years ago have shown that people from different ethnic backgrounds respond differently to certain drugs used to treat mental disorders. - For example, African Americans responded more rapidly to antipsychotic medications and tricyclic antidepressants than did white people and had a greater risk for developing side effects from both these classes of drugs. - Asians metabolized antipsychotics and tricyclic antidepressants more slowly than did white people and therefore required lower dosages to achieve the same effects. - Although these findings may be true for some of the various racial or ethnic groups, race or ethnicity may not be primarily responsible for differing responses. - Genetic differences are more likely to provide the explanation for slower drug metabolism rather than race. - As the science progresses, it may be that a person's genes can be linked with the most efficacious treatment, much like advances in cancer treatment. - As the population becomes more blended, perhaps it is not wise to rely on past data or experiences. - Asking the client about past responses and experiences and being open to the possibility of differing responses may be the best approach so that nurses avoid stereotyping their expectations of clients. - Herbal medicines have been used for hundreds of years in many countries and are now being used with increasing frequency in the United States. St. John's Wort is used to treat depression and is a commonly purchased herbal product in the United States. - Kava is used to treat anxiety and can potentiate the effects of alcohol, benzodiazepines, and other sedative-hypnotic agents. - Valerian helps produce sleep and is sometimes used to relieve stress and anxiety. - Ginkgo biloba is primarily used to improve memory but is also taken for fatigue, anxiety, and depression. - It is essential for the nurse to ask clients specifically if they use any herbal preparations. - Clients may not consider these products "medicine" or may be reluctant to admit their use for fear of censure by health professionals. - Herbal medicines are often chemically complex and are not standardized or regulated for use in treating illnesses. - Combining herbal preparations with other medicines can lead to unwanted interactions, so it is essential to assess all clients' use of these products.

Pons:

- Motor pathway

Dystonia:

- Muscle rigidity - Can be treated with anticholinergics like Congentin and Benadryl

Self-Awareness Issues:

- Nurses must examine their own beliefs and feelings about mental disorders as illnesses and the role of drugs in treating mental disorders. - Some nurses may be skeptical about some mental disorders and may believe that clients could gain control of their lives if they would just put forth enough effort. - Nurses who work with clients with mental disorders come to understand that many disorders are similar to chronic physical illnesses such as asthma or diabetes, which require lifelong medication to maintain health. - Without proper medication management, clients with certain mental disorders, such as schizophrenia or bipolar affective disorder, cannot survive in and cope with the world around them. - The nurse must explain to the client and family that this is an illness that requires continuous medication management and follow-up, just like a chronic physical illness. - It is also important for the nurse to know about current biologic theories and treatments. - Many clients and their families will have questions about reports in the news about research or discoveries. - The nurse can help them distinguish between what is factual and what is experimental. - Also, it is important to keep discoveries and theories in perspective. - Clients and families need more than factual information to deal with mental illness and its effects on their lives. - Many clients do not understand the nature of their illness and ask, "Why is this happening to me?" They need simple but thorough explanations about the nature of the illness and how they can manage it. - The nurse must learn to give out enough information about the illness while providing the care and support needed by all those confronting mental illness.

Side Effects of Other Antidepressants:

- Of the other or novel antidepressant medications, nefazodone, trazodone, and mirtazapine commonly cause sedation. - Both nefazodone and trazodone commonly cause headaches. - Nefazodone can also cause dry mouth and nausea. Bupropion, venlafaxine, and desvenlafaxine may cause loss of appetite, nausea, agitation, and insomnia. - Venlafaxine may also cause dizziness, sweating, or sedation. - Sexual dysfunction is much less common with the novel antidepressants, with one notable exception: Trazodone can cause priapism (a sustained and painful erection that necessitates immediate treatment and discontinuation of the drug). - Priapism may also result in impotence.

Antipsychotics: Side Effects: Anticholinergic side effects:

- Often occur with the use of antipsychotics and include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory. - These side effects usually decrease within 3 to 4 weeks but do not entirely remit. The client taking anticholinergic agents for EPSs may have increased problems with anticholinergic side effects. Using calorie-free beverages or hard candy may alleviate dry mouth, and stool softeners, adequate fluid intake, and the inclusion of grains and fruit in the diet may prevent constipation.

Arched Back:

- Opisthotonus

Cerebrum Is Broken Into 4 Main Lobes: Frontal:

- Organization of thought, emotion, moral behavior, body movement. - Dysfunction here is associated with schizophrenia, ADHD, dementia

Antidepressants:

- Precise mechanism is not known. - Major interaction is with monoamine neurotransmitter systems, especially norepinephrine and serotonin.

CT Scan:

- Precise x-rays of cross sections

Midbrain:

- RAS/EPS

PSYCHOPHARMACOLOGY: Efficacy:

- Refers to the maximal therapeutic effect that a drug can achieve

Psychotropic Medications:

- Regulate mood, behavior, thinking

Central Nervous System: Limbic System: Thalamus:

- Regulates activity, sensation, and emotion

Limbic System: Thalamus:

- Regulates activity, sensation, emotion

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Stress and the Immune System (Psychoimmunology):

- Researchers are following many avenues to discover possible causes of mental illness. - Psychoimmunology, a relatively new field of study, examines the effect of psychosocial stressors on the body's immune system. - A compromised immune system could contribute to the development of a variety of illnesses, particularly in populations already genetically at risk. - So far, efforts to link a specific stressor with a specific disease have been unsuccessful. - However, the immune system and the brain can influence neurotransmitters. - When the inflammatory response is critically involved in illnesses such as multiple sclerosis or lupus erythematosus, mood dysregulation and even depression are common

Medulla:

- Respiration/cardiovascular centers

Tardive Dyskinesia:

- Results from long-term use of antipsychotics - Uncontrolled movements like protruding tongue, upper/lower extremities, face/neck movement - It's irreversible - Once patient develops it but still needs to be on antipsychotic, they're switched to atypical second generation class of medication

Anti-depressants Associated W/ Norepinephrine & Serotonin: SSRIs: Prozac:

- SSRI - Effective for mild to moderate depression - Side effects: anxiety, agitation, akathisia, insomnia, sedation, sexual dysfunction

Side Effects of Selective Serotonin Reuptake Inhibitors:

- SSRIs have fewer side effects compared to the cyclic compounds. - Enhanced serotonin transmission can lead to several common side effects such as anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction, specifically diminished sexual drive or difficulty achieving an erection or orgasm. - In addition, weight gain is both an initial and ongoing problem during antidepressant therapy, although SSRIs cause less weight gain than other antidepressants. - Taking medications with food usually can minimize nausea. - Akathisia is usually treated with a beta-blocker, such as propranolol (Inderal) or a benzodiazepine. - Insomnia may continue to be a problem even if the client takes the medication in the morning; a sedative-hypnotic or low-dosage trazodone may be needed. - Less common side effects include sedation (particularly with paroxetine [Paxil]), sweating, diarrhea, hand tremor, and headaches. - Diarrhea and headaches can usually be managed with symptomatic treatment. - Sweating and continued sedation most likely indicate the need for a change to another antidepressant.

Clozapine:

- Second generation antipsychotic that has less EPS side effects, but has the potentially fatal side effect of agranulocytosis, indicated by: - Fever - Sore throat - Leukopenia - Need WBC baseline 1 week before start of treatment, weekly during treatment, weekly up to 4 weeks after dc

Antidepressant Divided In 4 Groups:

- Selective serotonin reuptake inhibitors (SSRIs) - Cyclic compounds - Other antidepressants - Monoamine oxidase inhibitors

Antipsychotics: Side Effects: Extrapyramidal Side Effects: Extrapyramidal symptoms (EPSs):

- Serious neurologic symptoms, are the major side effects of antipsychotic drugs. - They include acute dystonia, pseudoparkinsonism, and akathisia. - Although often collectively referred to as EPSs, each of these reactions has distinct features. - One client can experience all the reactions in the same course of therapy, which makes distinguishing among them difficult. - Blockade of D2 receptors in the midbrain region of the brain stem is responsible for the development of EPSs. - First-generation antipsychotic drugs cause a greater incidence of EPSs than do second-generation antipsychotic drugs, with ziprasidone (Geodon) rarely causing EPSs

Pseudo-Parkinsonism:

- Shuffling gait - Mask-like face - Pill-rolling movement of fingers when at rest

Extrapyramidal Effects:

- Side effects of antipsychotics resulting from d2 receptors

Anti-depressants Associated W/ Norepinephrine & Serotonin: Tricyclic/Cyclic:

- Side effects: anticholinergic effects, orthostatic hypotension, sexual dysfunction

Anti-depressants Associated W/ Norepinephrine & Serotonin: Others: Wellbutrin, Effexor, Cymbalta:

- Side effects: priaprism, seizures (especially with Wellbutrin)

Neurotransmitters: (Excitatory or Inhibitory): Acetylcholine

- Sleep-and-wakefulness cycle; signals muscles to become alert - Found in the brain, spinal cord, and peripheral nervous system, particularly at the neuromuscular junction of skeletal muscle. - It can be excitatory or inhibitory. - It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. - Studies have shown that people with Alzheimer disease have decreased acetylcholine-secreting neurons, and people with myasthenia gravis (a muscular disorder in which impulses fail to pass the myoneural junction, which causes muscle weakness) have reduced acetylcholine receptors.

Cerebrum Is Broken Into 4 Main Lobes: Temporal:

- Smell/hearing

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Infection As Possible Cause:

- Some researchers are focusing on infection as a cause of mental illness. - Most studies involving viral theories have focused on schizophrenia, but so far, none has provided specific or conclusive evidence. - Theories that are being developed and tested include the existence of a virus that has an affinity for tissues of the CNS, the possibility that a virus may actually alter human genes, and maternal exposure to a virus during critical fetal development of the nervous system. - Prenatal infections may impact the developing brain of the fetus, giving rise to a proposed theory that inflammation may causally contribute to the pathology of schizophrenia

Stimulants:

- Specifically amphetamines, were first used to treat psychiatric disorders in the 1930s for their pronounced effects on CNS stimulation. - In the past, they were used to treat depression and obesity, but those uses are uncommon in current practice. - Dextroamphetamine (Dexedrine) has been widely abused to produce a high or to remain awake for long periods. - Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention-deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt the person's life). - The primary stimulant drugs used to treat ADHD are methylphenidate (Ritalin), amphetamine (Adderall), and dextroamphetamine (Dexedrine). - Pemoline (Cylert) is infrequently used for ADHD because of the potential for liver problems. - Of these drugs, methylphenidate accounts for 90% of the stimulant medication given to children for ADHD - About 10% to 30% of clients with ADHD who do not respond adequately to the stimulant medications have been treated with antidepressants. - In 2003, atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor, was approved for the treatment of ADHD, becoming the first nonstimulant medication specifically designed and tested for ADHD.

PSYCHOPHARMACOLOGY: Role of FDA:

- The U.S. Food and Drug Administration (FDA) is responsible for supervising the testing and marketing of medications for public safety. - These activities include clinical drug trials for new drugs and monitoring the effectiveness and side effects of medications. - The FDA approves each drug for use in a particular population and for specific diseases. - At times, a drug will prove effective for a disease that differs from the one involved in original testing and FDA approval. This is called off-label use. - An example is some anticonvulsant drugs (approved to prevent seizures) that are prescribed for their effects in stabilizing the moods of clients with bipolar disorder (off-label use). - The FDA also monitors the occurrence and severity of drug side effects. - When a drug is found to have serious or life-threatening side effects, even if such side effects are rare, the FDA may issue a black box warning. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious or life-threatening side effects.

Side Effects of Monoamine Oxidase Inhibitors:

- The most common side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction. - The sedation and insomnia are difficult to treat and may necessitate a change in medication. - Of particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. - Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias. - Drugs that may cause potentially fatal interactions with MAOIs include SSRIs, certain cyclic compounds, buspirone (BuSpar), dextromethorphan, and opiate derivatives such as meperidine. - The client must be able to follow a tyramine-free diet; - Studies are currently underway to determine whether a selegiline transdermal patch would be effective in treating depression without the risks of dietary tyramine and orally ingested MAOIs.

Stimulants: Side Effects:

- The most common side effects of stimulants are anorexia, weight loss, nausea, and irritability. - The client should avoid caffeine, sugar, and chocolate, which may worsen these symptoms. - Less common side effects include dizziness, dry mouth, blurred vision, and palpitations. - The most common long-term problem with stimulants is the growth and weight suppression that occurs in some children. - This can usually be prevented by taking "drug holidays" on weekends and holidays or during summer vacation, which helps restore normal eating and growth patterns. - Atomoxetine can cause decreased appetite, nausea, vomiting, fatigue, or upset stomach.

Antipsychotics: Client Teaching:

- The nurse informs clients taking antipsychotic medication about the types of side effects that may occur and encourages clients to report such problems to the physician instead of discontinuing the medication. - The nurse teaches the client methods of managing or avoiding unpleasant side effects and maintaining the medication regimen. - Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth. - The client should avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. - Methods to prevent or relieve constipation include exercising and increasing water and bulk-forming foods in the diet. - Stool softeners are permissible, but the client should avoid laxatives. - The use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily. - Clients should monitor the amount of sleepiness or drowsiness they feel. - They should avoid driving and performing other potentially dangerous activities until their response times and reflexes seem normal. - If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4 hours late. If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten dose. - The nurse encourages clients who have difficulty remembering to take their medication to use a chart and to record doses when taken or to use a pillbox that can be pre-filled with accurate doses for the day or week. Management Of Side Effects: - Thirst/dry mouth (sugar-free candy, liquids) - Constipation (dietary fiber, exercise) - Sleepiness/drowsiness (safety measures) - Actions for missed dose (dose if within 4 hours of usual time)

Stimulants: Client Teaching:

- The potential for abuse exists with stimulants, but this is seldom a problem in children. - Taking doses of stimulants after meals may minimize anorexia and nausea. - Caffeine-free beverages are suggested; clients should avoid chocolate and excessive sugar. - Most important is to keep the medication out of the child's reach because as little as a 10-day supply can be fatal.

Limitations of Brain Imaging Techniques:

- The use of radioactive substances in PET and SPECT limits the number of times a person can undergo these tests. - There is the risk that the client will have an allergic reaction to the substances. - Some clients may find receiving intravenous doses of radioactive material frightening or unacceptable. - Imaging equipment is expensive to purchase and maintain, so availability can be limited. A PET camera costs about $2.5 million; a PET scanning facility may take up to $6 million to establish. - Some persons cannot tolerate these procedures because of fear or claustrophobia. - Researchers are finding that many of the changes in disorders such as schizophrenia are at the molecular and chemical levels and cannot be detected with current imaging techniques

Stimulants:

- Today, stimulants are most commonly used to treat ADHD in children/adults and narcolepsy - Most common ones: Ritalin, Adderall, Dexedrine - Side effects: anorexia, weight loss, nausea, irritability - Important for patients to avoid caffeine, sugar, chocolate

Cerebrum Is Broken Into 4 Main Lobes: Parietal:

- Touch/taste

Anxiolytic Drugs:

- Treat anxiety/depression, OCD, PTSD, alcohol withdrawal - Benzodiazepines found to be the most effective in treating anxiety - They bind to GABA receptors - Side effects: dependence, CNS depression like cloudiness, drowsiness, sedation - Do NOT drink alcohol with benzodiazepines - Do NOT abruptly dc, can be fatal

Mood Stabilizing Drugs:

- Treat bipolar disorder - Topomax: Can inhibit kindling process - Lamictal: side effects: stevens-johnson syndrome - Klonopin

Antipsychotic Drugs:

- Treat psychotic symptoms such as hallucinations/delusions associated with schizophrenia, schizoaffective disorder, manic phase in bipolar - These drugs work to block dopamine receptors (dopamine classified into d1-d5)

Central Nervous System: Brain: Cerebrum:

- Two hemispheres: all lobes and structures are found in both halves except for the pineal body, or gland, which is located between the hemispheres (The pineal body is an endocrine gland that influences the activities of the pituitary gland, islets of Langerhans, parathyroids, adrenals, and gonads) - The corpus callosum is a pathway connecting the two hemispheres and coordinating their functions. - The left hemisphere controls the right side of the body and is the center for logical reasoning and analytic functions such as reading, writing, and mathematical tasks. - The right hemisphere controls the left side of the body and is the center for creative thinking, intuition, and artistic abilities. - Four lobes: oFrontal lobe (thought, body movement, memories, emotions, moral behavior) oParietal lobe (taste, touch, spatial orientation) oTemporal lobe (smell, hearing, memory, emotional expression) oOccipital lobe (language, visual interpretation such as depth perception)

Brain Imaging Techniques: Magnetic Resonance Imaging (MRI):

- Type of body scan, an energy field is created with a huge magnet and radio waves. - The energy field is converted to a visual image or scan. - MRI produces more tissue detail and contrast than CT and can show blood flow patterns and tissue changes such as edema. - It can also be used to measure the size and thickness of brain structures; persons with schizophrenia can have as much as 7% reduction in cortical thickness. - The person undergoing an MRI must lie in a small, closed chamber and remain motionless during the procedure, which takes about 45 minutes. - Those who feel claustrophobic or have increased anxiety may require sedation before the procedure. - Clients with pacemakers or metal implants, such as heart valves or orthopedic devices, cannot undergo MRI.

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Genetics and Heredity:

- Unlike many physical illnesses that have been found to be hereditary, such as cystic fibrosis, Huntington disease, and Duchenne muscular dystrophy, the origins of mental disorders do not seem to be simple. - Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes but that the source is not solely genetic; nongenetic factors also play important roles. - Research is continuing in an attempt to find genetic links to other diseases such as schizophrenia and mood disorders. - It has identified all human DNA and continues with research to discover the human characteristics and diseases to which each gene is related (encoding). - In addition, the project also addresses the ethical, legal, and social implications of human genetics research. - Three types of studies are commonly conducted to investigate the genetic basis of mental illness: Twin studies, adoption studies, family studies - Although some genetic links have been found in certain mental disorders, studies have not shown that these illnesses are solely genetically linked. - Investigation continues about the influence of inherited traits versus the influence of the environment—the "nature versus nurture" debate.

Disulfiram (Antabuse):

- 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 - Drug interactions: with phenytoin, isoniazid, warfarin, barbiturates, long-acting benzodiazepines - Client teaching: avoidance of alcohol, including common products that may contain it o Shaving cream, deodorant, OTC cough preparations

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Genetics and Heredity: Twin Studies:

- Used to compare the rates of certain mental illnesses or traits in monozygotic (identical) twins, who have an identical genetic makeup, and dizygotic (fraternal) twins, who have a different genetic makeup. - Fraternal twins have the same genetic similarities and differences as non-twin siblings.

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Genetics and Heredity: Family Studies:

- Used to compare whether a trait is more common among first-degree relatives (parents, siblings, and children) than among more distant relatives or the general population.

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS: Genetics and Heredity: Adoption Studies:

- Used to determine a trait among biologic versus adoptive family members.

Brain Imaging Techniques: Positron Emission Tomography (PET):

- Used to examine the function of the brain - Radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the client performs cognitive activities as instructed by the operator. - Uses two photons simultaneously - Provides better resolution with sharper and clearer pictures and takes about 2 to 3 hours - Used primarily for research, not for the diagnosis and treatment of clients with mental disorders - A recent breakthrough is the use of the chemical marker FDDNP with PET to identify the amyloid plaques and tangles of Alzheimer disease in living clients; these conditions previously could be diagnosed only through autopsy. - These scans have shown that clients with Alzheimer disease have decreased glucose metabolism in the brain and decreased cerebral blood flow. - Some persons with schizophrenia also demonstrate decreased cerebral blood flow.

Brain Imaging Techniques: Single-Photon Emission Computed Tomography (SPECT):

- Used to examine the function of the brain. - Radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the client performs cognitive activities as instructed by the operator. - Uses a single photon - Takes 1 to 2 hours - Used primarily for research, not for the diagnosis and treatment of clients with mental disorders

Cerebrum Is Broken Into 4 Main Lobes: Occipital:

- Vision/coordinating language generation

PSYCHOPHARMACOLOGY: Black-Box Warning:

- When a drug is found to have serious or life-threatening side effects, even if such side effects are rare, the FDA may issue a black box warning. - This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious or life-threatening side effects.

Mood-Stabilizing Drugs:

- are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. - Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers. - Other anticonvulsants, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used for mood stabilization. - Occasionally, clonazepam (Klonopin) is also used to treat acute mania. Clonazepam is included in the discussion of antianxiety agents.

Antianxiety Drugs:

- or anxiolytic drugs, are used to treat anxiety and anxiety disorders, insomnia, obsessive-compulsive disorder (OCD), depression, posttraumatic stress disorder, and alcohol withdrawal. - Antianxiety drugs are among the most widely prescribed medications today. - A wide variety of drugs from different classifications have been used in the treatment of anxiety and insomnia. - Benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. - Benzodiazepines may also be prescribed for their anticonvulsant and muscle relaxant effects. - Buspirone is a nonbenzodiazepine often used for the relief of anxiety - Other drugs such as propranolol, clonidine (Catapres), and hydroxyzine (Vistaril) that may be used to relieve anxiety are much less effective and are not included in this discussion.

3 Studies Associated With Genetic Impact On Mental Illness:

1. Twin studies 2. Family studies 3. Adoption studies

Which of the following drugs would the nurse expect to administer to a client with ADHD? A. Disulfiram B. Methylphenidate C. Buspirone D. Lithium

B. Methylphenidate - Rationale: Methylphenidate is a stimulant used to treat ADHD. o Disulfiram is used to treat alcoholism. Buspirone is used to treat depression. Lithium is used to treat bipolar illness.

Which of the following drugs would be classified as a conventional antipsychotic? A. Clozapine B. Risperidone C. Fluphenazine D. Aripiprazole

C. Fluphenazine - Rationale: Fluphenazine is classified as a conventional antipsychotic. o Clozapine and risperidone are considered second-generation antipsychotics. Aripiprazole is considered a third-generation antipsychotic.

Is the following statement true or false? A client who takes an SSRI with an MAOI is at risk for a hypertensive crisis.

False - Rationale: A client who takes an SSRI with an MAOI is at risk for serotonin syndrome. o Hypertensive crisis can occur if the client is taking an MAOI and ingests foods containing tyramine.

Is the following statement true or false? Single-photon emission computed tomography (SPECT) is considered the best type of brain imaging technique to diagnose disease:

False - Rationale: Single-photon emission computed tomography (SPECT) is not considered the best 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.

Is the following statement true or false? The cerebellum consists of four lobes.

False - Rationale: The cerebrum consists of four lobes. The cerebellum is located below the cerebrum.

Locked Upward Eye Movement:

Oculogyric crisis

Principles that Guide Pharmacologic Treatment:

The following are several principles that guide the use of medications to treat psychiatric disorders: •A medication is selected based on its effect on the client's target symptoms such as delusional thinking, panic attacks, or hallucinations. The medication's effectiveness is evaluated largely by its ability to diminish or eliminate the target symptoms. •Many psychotropic drugs must be given in adequate dosages for some time before their full effects are realized. For example, tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal therapeutic benefit. •The dosage of medication is often adjusted to the lowest effective dosage for the client. Sometimes a client may need higher dosages to stabilize his or her target symptoms, while lower dosages can be used to sustain those effects over time. •As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects. It may also take longer for a drug to achieve its full therapeutic effect in older adults. •Psychotropic medications are often decreased gradually (tapering) rather than abruptly. This is because of potential problems with rebound (temporary return of symptoms), recurrence (of the original symptoms), or withdrawal (new symptoms resulting from discontinuation of the drug). •Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dosage, and to manage side effects. •Compliance with the medication regimen is often enhanced when the regimen is as simple as possible in terms of both the number of medications prescribed and the number of daily doses.

Twisted Neck:

Torticollis

1. The nurse is teaching a client taking an MAOI about foods with tyramine that he or she should avoid. Which statement indicates that the client needs further teaching? a."I'm so glad I can have pizza as long as I don't order pepperoni." b."I will be able to eat cottage cheese without worrying." c."I will have to avoid drinking nonalcoholic beer." d."I can eat green beans on this diet."

a."I'm so glad I can have pizza as long as I don't order pepperoni."

8. Clients taking which type of psychotropic medications need close monitoring of their cardiac status? a.Antidepressants b.Antipsychotics c.Mood stabilizers d.Stimulants

b.Antipsychotics

5. The nurse is caring for a client with schizophrenia who is taking haloperidol (Haldol). The client complains of restlessness, cannot sit still, and has muscle stiffness. Of the following prn medications, which would the nurse administer? a.Haloperidol (Haldol), 5 mg PO b.Benztropine (Cogentin), 2 mg PO c.Propranolol (Inderal), 20 mg PO d.Trazodone, 50 mg PO

b.Benztropine (Cogentin), 2 mg PO

6. Client teaching for lamotrigine (Lamictal) should include which instructions? a.Eat a well-balanced diet to avoid weight gain. b.Report any rashes to your doctor immediately. c.Take each dose with food to avoid nausea. d.This drug may cause psychological dependence.

b.Report any rashes to your doctor immediately.

2. A client who has been depressed and suicidal started taking a tricyclic antidepressant 2 weeks ago and is now ready to leave the hospital to go home. Which is a concern for the nurse as discharge plans are finalized? a.The client may need a prescription for diphenhydramine (Benadryl) to use for side effects. b.The nurse will evaluate the risk for suicide by overdose of the tricyclic antidepressant. c.The nurse will need to include teaching regarding the signs of neuroleptic malignant syndrome. d.The client will need regular laboratory work to monitor therapeutic drug levels.

b.The nurse will evaluate the risk for suicide by overdose of the tricyclic antidepressant.

4. Which is a concern for children taking stimulants for ADHD for several years? a.Dependence on the drug b.Insomnia c.Growth suppression d.Weight gain

c.Growth suppression

7. Which physician order would the nurse question for a client who has stated, "I'm allergic to phenothiazines?" a.Haldol, 5 mg PO bid b.Navane, 10 mg PO bid c.Prolixin, 5 mg PO tid d.Risperdal, 2 mg bid

c.Prolixin, 5 mg PO tid

3. The signs of lithium toxicity include which? a.Sedation, fever, and restlessness b.Psychomotor agitation, insomnia, and increased thirst c.Elevated WBC count, sweating, and confusion d.Severe vomiting, diarrhea, and weakness

d.Severe vomiting, diarrhea, and weakness

Points To Consider When Working On Self-Awareness:

• Chronic mental illness has periods of remission and exacerbation just like chronic physical illness. A recurrence of symptoms is not the client's fault, nor is it a failure of treatment or nursing care. • Research regarding the neurobiologic causes of mental disorders is still in its infancy. Do not dismiss new ideas just because they may not yet help in the treatment of these illnesses. • Often, when clients stop taking medication or take medication improperly, it is not because they intend to; rather, it is the result of faulty thinking and reasoning, which is part of the illness.