Fluent Essays

Hello, this is a psychiatry assignment. Please read Chapter 11 of the PowerPoint attached below and answer the questions separately.  = Which disorder/ condition piqued your interest the most and why?   = List at least two defense mechanisms that are relevant to your selected disorder.  = What medications are typically used in its management? (List at least 2)  =List two important medication teaching a nurse could be engaged in related to side effects and/or food and dietary restrictions.  To help with psychopharmacology, use other resources associated with psychopharmacology in (Chapter 4). Chapter 11 Anxiety, Anxiety Disorders, Obsessive-Compulsive, and Related Disorders Copyright © 2017, Elsevier Inc. All Rights Reserved. Anxiety: Universal Human Experience Is the most basic emotion. Dysfunctional behavior is often a defense against anxiety. When behavior is recognized as dysfunctional, interventions can be initiated by the nurse to reduce anxiety. As anxiety decreases, dysfunctional behavior will frequently decrease. Copyright © 2017, Elsevier Inc. All Rights Reserved. 2 Anxiety Versus Fear Anxiety and fear are indistinguishable except for the cause. FEAR = a reaction to a specific danger. ANXIETY = a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized. Copyright © 2017, Elsevier Inc. All Rights Reserved. 3 Objective 1: Differentiate among normal anxiety, acute anxiety, and chronic anxiety. Normal anxiety: Healthy life force necessary for survival. Acute anxiety: Precipitated by imminent loss or threat. “Pathological anxiety differs from normal anxiety in terms of duration, intensity, and disturbance in a person’s ability to function (e.g., dysfunctional behaviors or extreme withdrawal).” Chronic anxiety: Long-term; thought to be associated with increased risk for cardiovascular morbidity; usually begins at young age. Copyright © 2017, Elsevier Inc. All Rights Reserved. 4 Objective 2: Contrast and compare the four levels of anxiety in relation to perceptual field, ability to learn, and physical and other defining behavioral characteristics. Levels of Anxiety Mild Moderate Severe Panic Behaviors and Characteristics Perceptual field Ability to learn Physical or other characteristics Copyright © 2017, Elsevier Inc. All Rights Reserved. 5 Case Studies—Anxiety Choose Normal, Acute, or Chronic for the following: Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name. Alex has a chemistry test this morning. She “crammed” for the test the previous night but did not study before that. She has an upset stomach and headache. Mr. Jones has not left his house for 3 months. He tells his family, “I know this is not normal, but I just can’t go outside.” His wife died 3 years earlier. Copyright © 2017, Elsevier Inc. All Rights Reserved. 6 Case Studies—Anxiety (Answers) Choose Normal, Acute, or Chronic for the following: Acute—Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name. Normal—Alex has a chemistry test this morning. She “crammed” for the test the previous night but did not study before. She has an upset stomach and headache. Chronic—Mr. Jones has not left his house for 3 months. He tells his family, “I know this is not normal, but I just can’t go outside.” His wife died 3 years earlier. Copyright © 2017, Elsevier Inc. All Rights Reserved. 7 Objective 3: Summarize five properties of the defense mechanisms. Defense mechanisms are: Major means of managing conflict Relatively unconscious Discrete from one another Hallmarks of major psychiatric syndromes, which are reversible Adaptive as well as pathologic Copyright © 2017, Elsevier Inc. All Rights Reserved. 8 Group Challenge: Suggest the best classification (on the left) for each defense mechanism listed here. Classification Healthy Intermediate Immature Defense Mechanisms Altruism Sublimation Humor Suppression Repression Displacement Reaction formation Somatization  Undoing Rationalization Passive aggression Acting out Dissociation Devaluation Idealization Splitting Projection Denial  Copyright © 2017, Elsevier Inc. All Rights Reserved. 9 Objective 4: Give a definition for at least six defense mechanisms. Immature Passive aggression Acting out Dissociation Devaluation Idealization Splitting Projection Denial  Healthy Altruism Sublimation Suppression Humor Intermediate Repression Displacement Reaction formation Somatization  Undoing Rationalization Copyright © 2017, Elsevier Inc. All Rights Reserved. 10 Objective 5: Rank the defense mechanisms from healthy to highly detrimental. Immature Passive aggression Acting out Dissociation Devaluation Idealization Splitting Projection Denial  Healthy Altruism Sublimation Suppression Humor Intermediate Displacement Reaction formation Somatization Rationalization  Undoing Copyright © 2017, Elsevier Inc. All Rights Reserved. 11 Anxiety Disorders: Prevalence and Co-Morbidity Highly co-occurring Substance abuse Major depressive disorder (MDD) Frequently co-occurring Eating disorder, bipolar disorder, dysthymia Co-occurring medical conditions Cancer, heart disease, hypertension, irritable bowel syndrome, renal or liver dysfunction, reduced immunity Chronic anxiety Associated with increased risk for cardiovascular morbidity and mortality Copyright © 2017, Elsevier Inc. All Rights Reserved. 12 Theory Neurobiology Limbic system Main mediators of anxiety Serotonin, norepinephrine, gamma-aminobutyric acid (GABA) Genetics (twin studies) Cognitive-behavioral Cultural considerations Copyright © 2017, Elsevier Inc. All Rights Reserved. 13 Clinical Picture Panic Disorders (PD) Panic attack Sudden onset of extreme apprehension or fear, usually with a feeling of doom Terror is so severe that normal function is suspended Signs similar to a heart attack Phobias Persistent, intense irrational fear of something Social anxiety disorders (SADs) or social phobias (e.g., agoraphobia) General Anxiety Disorders Severe distress with pervasive cognitive dysfunction and impaired functioning; no specific triggers or targets Copyright © 2017, Elsevier Inc. All Rights Reserved. 14 Clinical Picture (Cont.) Anxiety Due to Medical Conditions Respiratory: asthma, hypoxia, pulmonary edema, chronic obstructive pulmonary disease (COPD), pulmonary embolism Cardiovascular: cardiac dysrhythmias such as torsades de pointes, angina, congestive heart failure, mitral valve prolapse, hypertension Endocrine: hyperthyroidism, hypoglycemia, hypercortisolism, pheochromocytoma Neurologic: Parkinson disease, akathisia, postconcussion syndrome, complex partial seizures Metabolic: hypercalcemia, hyperkalemia, hyponatremia, porphyria Copyright © 2017, Elsevier Inc. All Rights Reserved. 15 Objective 6: Describe the clinical manifestations of each anxiety disorder. (Let’s take a closer look now at each disorder in the following slides.) Panic disorder (PD) PD with agoraphobia Phobia Social anxiety disorder (SAD) or social phobia Generalized anxiety disorder (GAD) Anxiety caused by a medical condition Obsessive-compulsive disorder (OCD) and related disorders Body dysmorphic disorder and hoarding Copyright © 2017, Elsevier Inc. All Rights Reserved. 16 Panic Disorders Panic attack: Feelings of terror Suspension of normal function Severely limited perceptual field Misinterpretation of reality Sudden occurrence of panic attacks (not necessarily in response to stress) Increased rates of suicide and suicide attempts Symptoms include: Palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal symptoms Copyright © 2017, Elsevier Inc. All Rights Reserved. 17 Panic Disorders (Cont.) Copyright © 2017, Elsevier Inc. All Rights Reserved. 18 Someone is rushed to the emergency department with signs and symptoms of a heart attack. An extensive workup is negative for cardiac problems. The patient needs a referral for the potential diagnosis and treatment of an anxiety disorder (e.g., PD). Panic Disorders with Agoraphobia Agoraphobia Is an intense and excessive level of anxiety and a fear of being in places and situations from which escape is impossible. Feared places are avoided to control anxiety. Avoidance behaviors can be debilitating and life constricting. (Discuss.) Copyright © 2017, Elsevier Inc. All Rights Reserved. 19 Phobias Specific phobias Specific objects or situations include dogs, spiders, heights, storms, water, blood, and closed spaces, among others. Are common, but do not usually cause much difficulty. Copyright © 2017, Elsevier Inc. All Rights Reserved. 20 20 Social Anxiety Disorders Social Phobias SAD Is severe anxiety provoked by exposure to a social or performance situation. Fear of saying something foolish, not being able to answer questions in a classroom, eating in the presence of others, and performing on a stage, among others Fear of public speaking is the most common. Copyright © 2017, Elsevier Inc. All Rights Reserved. 21 Anxiety Caused by Medical Conditions Symptoms of anxiety are a direct physiologic result of a medical condition. Respiratory Cardiovascular Endocrine Neurologic Metabolic   Evidence must be present in the history, physical examination, and/or laboratory findings to diagnose the medical condition. Copyright © 2017, Elsevier Inc. All Rights Reserved. 22 Obsessive-Compulsive Disorder Obsessions: Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress Compulsions: Unwanted, ritualistic behavior the individual feels driven to perform to reduce anxiety Copyright © 2017, Elsevier Inc. All Rights Reserved. 23 I have to wash my hands! I don’t want to! 23 Obsessive-Compulsive Disorder (Cont.) OCD behavior exists along a continuum. “Normal” individuals may experience mild obsessive-compulsive behaviors. Mild compulsions are valued traits in U.S. society. More severe symptoms: Center on dirtiness, contamination, and germs and occur with corresponding compulsions such as cleaning and hand washing Most severe symptoms: Include persistent thoughts of sexuality, violence, illness, and death Copyright © 2017, Elsevier Inc. All Rights Reserved. 24 Other Diagnoses Related to OCD Body Dysmorphic Disorder Preoccupation with an imagined “defective body part” Obsessional thinking about the body Impairment of normal social activities related to academic or occupational functioning Compulsive Hoarding Excessive collection of items considered worthless Individual is ashamed of failure to discard items Extreme life disruption and distress Social isolation Unsafe living conditions Copyright © 2017, Elsevier Inc. All Rights Reserved. 25 Objective 7: Compare and contrast the difference between hoarding behaviors with OCD and hoarding behaviors without OCD. Hoarding Behaviors with OCD Excessively collects items, and exhibits a failure to discard items. Approximately 50\% of patients who exhibit hoarding have co-occurring OCD. OCD and excessive hoarding are associated with: Increase in co-morbidity Impairment in performing activities of daily living (ADLs) Reduced insight Poor response to treatment Genetic and neurobiologic profile Hoarding Behaviors Without OCD Exhibits compulsive and disabling hoarding. Results in social isolation. No extreme disruption occurs in the performance of ADLs. Has difficulty discarding possessions. Has strong urges to save items. Exhibits distress when discarding items. Accumulation results in clutter. Interventions of third parties (family members, cleaners, authorities) are staged. Copyright © 2017, Elsevier Inc. All Rights Reserved. 26 Nursing Process Guidelines Assessment Guidelines Physical/neurologic exam to determine whether anxiety is primary or secondary Assess for potential self-harm Psychosocial assessment Cultural and background assessment Nursing Diagnoses Anxiety (rated) Fear Ineffective coping Deficient diversional actions Social isolation Ineffective role performance Impaired social interaction Posttrauma syndrome Fatigue; sleep deprivation Low self-esteem, spiritual distress Self-care deficit Copyright © 2017, Elsevier Inc. All Rights Reserved. 27 Remind students that nursing diagnoses for patients with anxiety are too numerous to list here. Refer the class to Table 11-7 for more details. 27 Objective 8: Formulate four NANDA International nursing diagnoses that might be appropriate in the care of an individual with an anxiety disorder. Patient X: Symptoms History of severe domestic abuse, including social isolation in a locked basement Patient is now hypervigilant, has intrusive memories of being held hostage by spouse Impulse to keep child safe by isolating her as well Inability to go to sleep related to her intrusive thoughts, worrying, replaying of a traumatic event, hypervigilance Nursing Diagnoses Anxiety (rated) Ineffective coping Social isolation Ineffective role performance Impaired social interaction Posttrauma syndrome Fatigue; sleep deprivation Copyright © 2017, Elsevier Inc. All Rights Reserved. 28 Remind students that nursing diagnoses for patients with anxiety are too numerous to list here. Refer the class to Table 11-7 for more details. 28 Objective 9: Propose realistic outcome criteria for patients with the following anxiety disorders. Anxiety disorders: GAD PD OCD Outcomes should: Reflect patient values and ethical and environmental situations. Be culturally appropriate. Be documented as measurable goals. Include a time estimate. Copyright © 2017, Elsevier Inc. All Rights Reserved. 29 PLANNING: Whenever possible, include the patient in planning to increase likelihood of possible outcomes. Self-Care for Nurses Burnout: Exhaustion caused by long-term involvement in emotionally demanding situations Compassion Fatigue: Cumulative physical, emotional, and psychologic effect of working closely with those suffering from the consequences of heart-wrenching/traumatic events (see Chapter 10) “Common responses when working with anxiety-disordered clients include increased anxiety, frustration, anger and other negative emotions.” Copyright © 2017, Elsevier Inc. All Rights Reserved. 30 Point out that supervision, stress management courses, mindfulness, yoga, exercise, creative activities, and humor are all examples of stress reduction techniques (refer to Box 11-1 for selected stress reduction techniques). 30 Implementation Identify community resources offering specialized treatment. Identify community support groups for people with specific anxiety disorders and their families. Use therapeutic communication, milieu therapy, promotion of self-care activities, psychotherapy, and health teaching and health promotion as appropriate. Copyright © 2017, Elsevier Inc. All Rights Reserved. 31 (See Table 11-7 with this case study.) 31 Behavior Modification Therapy Modeling—mimicking appropriate behaviors in situations Systematic desensitization—gradually exposing a person to the feared object or situation until the person is free of incapacitating anxiety Response prevention—starts with the therapist preventing the compulsion, such as hand washing, and gradually helping the patient limit the time between rituals until the urge dissipates Thought stopping—examples include snapping a rubber band on one’s wrist to stop an obsession or negative thought Copyright © 2017, Elsevier Inc. All Rights Reserved. 32 (See Table 11-7 with this case study.) 32 Case Study Remember Charlie? He is the 19-year-old with an ileostomy and rectal surgery for cancer that has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name. Five days have now passed. His anxiety has subsided as a result of medication management and milieu therapy. You are emptying his ileostomy bag. He is tearful. (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 33 (See Table 11-7 with this case study.) 33 Audience Response Question Charlie asks you, “How will I ever be able to go to the beach or be with a girl with this gross bag hanging on my stomach? What is your best therapeutic response? A. “This has to be extremely difficult for you to face.” B. “Don’t worry about that now. Just get well!” C. “I will ask your doctor to increase your medicine.” D. “If a girl really likes you, the bag won’t matter.” Copyright © 2017, Elsevier Inc. All Rights Reserved. 34 Answer *A. Stating that Charlie’s condition is extremely difficult to face lets him know that you are actually listening to and thinking about what he is saying. This helps establish trust so that the conversation can possibly continue. Telling a patient not to worry implies that you do not really want to engage in meaningful and therapeutic communication. It also devalues the patient’s concerns. Attributing the patient’s concern strictly to medication management sidesteps the problem. Offering a cliché does not communicate to the patient that you are interested in helping solve the problem. Copyright © 2017, Elsevier Inc. All Rights Reserved. 35 Objective 10: Discuss three classes of medications that have demonstrated evidence-based effectiveness in treating anxiety disorders. Medications Benzodiazepines (anxiolytics): Prescribed for short-term treatment only; not for patients with substance use problems Buspirone: Management of anxiety disorders. Non-addictive; excellent for long-term relief of anxiety symptoms, e.g. GAD SSRIs: First-line treatment for anxiety disorders, OCD, and BDD SNRIs: Panic disorder (PD), generalized anxiety disorder (GAD), and social affective disorder (SAD) Tricyclic antidepressants: Second- or third-line use for PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD) MAOIs: Reserved for treatment-resistant conditions due to risk of life-threatening hypertensive crisis. Recently being used in people with social anxiety disorder (SAD) and rejection sensitivity       Copyright © 2017, Elsevier Inc. All Rights Reserved. 36 Audience Response Question Rene, a restaurant manager, is hospitalized after working 15-hour days for several weeks. Her anxiety level is severe upon admission. She has not slept well during the past 2 weeks. Her psychiatrist has ordered amitriptyline (Elavil) 25 mg, to be administered orally, three times daily. Rene asks you, her nurse, why she is so drowsy. What is your best response? A. “Drowsiness is a side effect of this medication.” B. “Don’t worry about being drowsy at this time.” C. “Aren’t you glad you will finally get to sleep?” D. “I will tell the doctor. I don’t want you to fall.” Copyright © 2017, Elsevier Inc. All Rights Reserved. 37 Answer *A. Giving an anxious patient a simple and accurate answer helps the patient understand that she is experiencing something that is expected. Telling the patient not to worry diminishes her concern and does not convey interest on your part. Cliché responses are not therapeutic. Although it may be true that the patient will sleep better with this medication, this answer does not give the patient requested information. The patient is at risk for falling as a result of the sedative effects of the medication and the level of anxiety she is experiencing. Placing the patient on the unit’s Falls Precautions Protocol is a critical nursing intervention. You would not notify the physician. Copyright © 2017, Elsevier Inc. All Rights Reserved. 38 Objective 11: Identify the patient’s experience and needs when planning patient-centered care for a person with OCD. Case Study A patient is admitted to your psychiatric unit after being found by a friend in his apartment. The patient has not left his apartment for 2 weeks. You are completing the admission assessment and search his small brown suitcase. You observe that the patient, using black ink and precise lettering, has etched his first name, Klim, on the side. (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 39 Case Study (Cont.) The suitcase contains three T-shirts, three pajama bottoms, and a toothbrush wrapped in several layers of plastic wrap. You return the suitcase to him. Klim begins to unfold and refold his clothing slowly and repetitively. (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 40 Klim Audience Response Question What is your best nursing action in response to Klim? Immediately stop Klim, and tell him his behavior is inappropriate. Continue the interview and allow Klim to continue as long as he is not harming himself or others. Explain that his behavior is a part of his illness and that you can help him work toward change. Leave the room and come back later when Klim has stopped the behavior. Copyright © 2017, Elsevier Inc. All Rights Reserved. 41 Answer Klim’s compulsive behavior is likely triggered or worsened by anxiety as a result of his admission to the psychiatric unit. Telling him that his behavior is inappropriate (he already knows that) will only serve to increase his anxiety. During the initial hours of Klim’s hospitalization, he needs to be allowed to continue his ritual as long as it does not pose harm to himself or others. You will need to begin to set appropriate behavior limits later. An explanation during the admission process will probably result in increased anxiety. When Klim is feeling more comfortable and trusting, he may be able to invest in behavior changes. It would not be safe at this time to leave Klim alone. Although his current behavior is benign, his compulsive behavior indicates that his anxiety is increasing. Copyright © 2017, Elsevier Inc. All Rights Reserved. 42 Closing Discussion: Nursing Interventions As time on the unit passes for Klim, how would you, his nurse, intervene? Use the following topics to conduct the discussion: Counseling Milieu therapy Promotion of self-care activities Pharmacologic interventions Health teaching Copyright © 2017, Elsevier Inc. All Rights Reserved. 43 Klim 43 Chapter 4 Biological Basis for Understanding Psychopharmacology Copyright © 2017, Elsevier Inc. All Rights Reserved. Psychotropic Drugs Psychiatric illness is related to a number of factors (e.g., genetics, neurodevelopmental factors, drugs, infection, psychosocial experience). Psychiatric illness results in an alteration in neurotransmitters. These alterations are the targets of psychotropic drugs. Copyright © 2017, Elsevier Inc. All Rights Reserved. 2 Psychotropic Drugs (Cont.) All mental activity has its locus in the brain. The primary goals of psychiatric mental health nursing is to: Understand the biological basis of both normal and abnormal brain functions. Apply this understanding to the care of individuals treated with psychotropic drugs. Copyright © 2017, Elsevier Inc. All Rights Reserved. 3 Objective 1: Identify at least three major brain structures and eight major brain functions that can be altered by mental illness and psychotropic medications. Copyright © 2017, Elsevier Inc. All Rights Reserved. 4 Copyright © 2017, Elsevier Inc. All Rights Reserved. 5 Figure 4-1 in text. 5 Functions 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 Copyright © 2017, Elsevier Inc. All Rights Reserved. 6 Objective 2: Describe how evidence-based neuroimaging is helpful in understanding abnormalities of brain function, structure and receptor pharmacology. Positron-emission tomography (PET) and single-photon emission computed tomography (SPECT) Localize brain regions associated with perceptual, cognitive, emotional, and behavioral functions. Provide evidence of metabolic changes in unmedicated individuals with depression, schizophrenia, or obsessive-compulsive disorder (OCD). Functional magnetic resonance imaging (fMRI) Demonstrates cognitive function. Maps effects of psychotropic medications. Antipsychotic medications are now prescribed at a fraction of the dosages that were once considered standard, in large part because of imaging studies. Copyright © 2017, Elsevier Inc. All Rights Reserved. 7 PET Scan Copyright © 2017, Elsevier Inc. All Rights Reserved. 8 Identical Twins (31-year-old men) Note reduced brain activity in frontal lobes of twin with schizophrenia. Figure 4-4 in text. 8 Objective 3: Explain the basic process of neurotransmission and synaptic transmission. Copyright © 2017, Elsevier Inc. All Rights Reserved. 9 An essential feature of neurons is their ability to initiate signals and conduct an electrical impulse from one end of the cell to the other called neurotransmission. The brain is composed of a vast network of more than 100 billion interconnected nerve cells (neurons) and supporting cells. An essential feature of neurons is their ability to initiate signals and conduct an electrical impulse from one end of the cell to the other called neurotransmission. 9 Once an electrical impulse reaches the end of a neuron, a neurotransmitter is released, crossing the synapse to attach to receptors on the postsynaptic cell to inhibit or excite it. Copyright © 2017, Elsevier Inc. All Rights Reserved. 10 Activities of Neurons Electrical signals within neurons are then converted at synapses into chemical signals through the release of molecules called neurotransmitters, which then elicit electrical signals on the other side of the synapse. Once an electrical impulse reaches the end of a neuron, the neurotransmitter is released from the axon terminal at the presynaptic neuron and diffuses across a synapse to a postsynaptic neuron. Here it attaches to specialized receptors on the cell surface and either inhibits or excites the postsynaptic neuron. 10 Copyright © 2017, Elsevier Inc. All Rights Reserved. 11 Insufficient Transmission An insufficient degree of transmission may be caused by a deficient release of neurotransmitters from the presynaptic cell or by a decrease in receptors. Copyright © 2017, Elsevier Inc. All Rights Reserved. 12 Excessive Transmission Excessive transmission may be due to excessive release of a transmitter or to increased receptor responsiveness, as occurs in schizophrenia. 12 A. Normal transmission B. Deficient neurotransmitter C. Deficient receptors Copyright © 2017, Elsevier Inc. All Rights Reserved. 13 Transmission of Neurotransmitters Figure 4-7 in text. 13 Copyright © 2017, Elsevier Inc. All Rights Reserved. 14 Destruction of Neurotransmitters After attaching to a receptor and exerting its influence on the postsynaptic cell, the transmitter separates from the receptor and is destroyed. First way: Immediate inactivation of the neurotransmitter at the postsynaptic membrane. Copyright © 2017, Elsevier Inc. All Rights Reserved. 15 Destruction of Neurotransmitters (Cont.) Second way: After interacting with the postsynaptic receptor, the neurotransmitter is released and taken back to the presynaptic cell. The action is called the reuptake of the neurotransmitter. 15 Transmission of Neurotransmitters Concept Copyright © 2017, Elsevier Inc. All Rights Reserved. 16 All activities of the brain involve actions of neurons, neurotransmitters, and receptors. These are the targets of pharmacologic intervention. Thought disorders such as schizophrenia are physiologically associated with the excess transmission of the neurotransmitter dopamine. Most psychotropic drugs act by either increasing or decreasing the activity of certain neurotransmitter-receptor systems. Neurotransmitters (Monoamines) Copyright © 2017, Elsevier Inc. All Rights Reserved. 17 SEROTONIN Decrease: Depression Increase: Anxiety states HISTAMINE High levels associated with anxiety and depression NOREPINEPHRINE Decrease: Depression Increase: Anxiety states DOPAMINE Decrease: Parkinson disease, depression Increase: Schizophrenia, mania Neurotransmitters (Amino Acids) Copyright © 2017, Elsevier Inc. All Rights Reserved. 18 GLUTAMATE: Is the major mediator of excitatory signals in the central nervous system Is involved in most aspects of normal brain function, including cognition, memory, and learning GAMMA-AMINO BUTYRIC ACID (GABA): Decrease: Anxiety disorders, schizophrenia, mania, Huntington chorea Increase: Reduction of anxiety, schizophrenia, mania Neurotransmitters (Cholinergics) Copyright © 2017, Elsevier Inc. All Rights Reserved. 19 ACETYLCHOLINE: Increase: Depression Decrease: Alzheimer disease, Huntington chorea, Parkinson disease Neurotransmitters (Peptides-Neuromodulators) Copyright © 2017, Elsevier Inc. All Rights Reserved. 20 Substance P Regulation of mood and anxiety Somatostatin Decrease: Alzheimer disease Increase: Huntington disease Neurotensin Decreased levels in spinal fluid of patients with schizophrenia Role in pain management Copyright © 2017, Elsevier Inc. All Rights Reserved. 21 Psychotropic Drugs Antianxiety Hypnotics Anti-depressants Alzheimer Agents Herbal Treatments ADHD Agents Anti-psychotics Anti-convulsants Mood Stabilizers Antidepressant Drugs— Monoamine Oxidase Inhibitors Monoamines: Organic compound, including neurotransmitters that are further divided into subgroups Catecholamines (e.g., norepinephrine, epinephrine, dopamine) Indolamines (e.g., serotonin) Many drugs and food substances Monoamine oxidase (MAO): Enzyme that destroys monoamines Monoamine oxidase inhibitors (MAOIs): Drugs that increase concentrations of monoamines by inhibiting the action of MAO Copyright © 2017, Elsevier Inc. All Rights Reserved. 22 Antidepressant Drugs— Monoamine Oxidase Inhibitors (Cont.) phenelzine (Nardil) tranylcypromine (Parnate) EMSAM (selegiline transdermal system) delivers monoamine oxidase inhibitors (MAOIs) through the skin. Hypertensive crisis: Occurs if patient ingests tyramine found in some over-the-counter (OTC) medications, beer, wine, aged cheese, organ meats, avocadoes, and other foods (see Slide 25). Dietary restriction of tyramine must be maintained for 2 weeks after stopping MAOIs. Copyright © 2017, Elsevier Inc. All Rights Reserved. 23 Objective 4: Explain the relevance of pharmacokinetic and pharmacodynamic drug interactions in the delivery of safe, effective nursing care. Psychotropic Drug Interactions Drug interactions alter and modify the effects of psychotropic drugs. Pharmacokinetic interactions: Are the effects of drugs on the plasma concentrations of each other. Pharmacodynamic interactions: Are the combined effects of drugs. Copyright © 2017, Elsevier Inc. All Rights Reserved. 24 Objective 5: Discuss the rationale for special dietary and drug restrictions with MAOIs. Hypertensive crisis: Occurs if patient ingests tyramine found in some OTC medications, beer, wine, aged cheese, organ meats, avocadoes, and other foods (see Slide 23). Dietary restriction of tyramine must be maintained for 2 weeks after stopping MAOIs. For a more detailed description of how MAOIs work, visit the Evolve web site at: http://evolve.elsevier.com/Varcarolis/ essentials Copyright © 2017, Elsevier Inc. All Rights Reserved. 25 Antidepressant Drugs Tricyclic (cyclic) antidepressants (TCAs): amitriptylene (Elavil), nortriptyline (Pamelor) Increase norepinephrine. Side effects include anticholinergic effects. Selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) Increase serotonin. Side effects include fewer anticholinergic effects than tricyclic agents; N/V. Serotonin-norepinephrine reuptake inhibitors (SNRIs): venlafaxine (Effexor), duloxetine (Cymbalta) Increase serotonin and norepinephrine. Side effects include fewer anticholinergic effects. Serotonin-norepinephrine disinhibitors (SNDIs): mirtazapine (Remeron) Increase serotonin and norepinephrine. Combined with SSRIs to augment efficacy or counteract serotonergic side effects. Copyright © 2017, Elsevier Inc. All Rights Reserved. 26 NOTE: Because MAOIs block the enzyme that metabolizes monoamines, they may occasionally be used to increase the levels of serotonin and norepinephrine in intractable depression. However, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the more commonly used antidepressants because of the vasopressor effects that occur when MAOIs are combined with other sympathomimetics (amines that stimulate the sympathetic nervous system). 26 Antidepressant Drugs (Cont.) Norepinephrine-dopamine reuptake inhibitors (NDRIs): bupropion (Wellbutrin) Do not act on serotonin system. Inhibit nicotin acetylcholine receptors to reduce addictive effects. Serotonin antagonist/reuptake inhibitors (SARIs): trazodone (Desyrel): Not the first choice for antidepressant treatment, but useful for insomnia. Can cause priapism. Selective norepinephrine reuptake inhibitors (NRIs): atomoxetine (Strattera): Treat ADHD when stimulants are not tolerated, but no significant antidepressant benefits. Copyright © 2017, Elsevier Inc. All Rights Reserved. 27 Antianxiety or Anxiolytic Drugs: Benzodiazepines Anxiety: diazepam (Valium), clonazepam (Klonopin), alprazolam (Xanax) Lorazepam (Ativan) and alprazolam (Xanax) reduce anxiety without being as soporific (sleep producing) at lower therapeutic doses. Insomnia: flurazepam (Dalmane), triazolam (Halcion) Copyright © 2017, Elsevier Inc. All Rights Reserved. 28 Benzodiazepines promote activity of GABA by binding to a specific receptor on the GABAA receptor complex. 28 Antianxiety and Hypnotic Drugs: Nonbenzodiazepines buspirone (Buspar): An anxiolytic agent with less potential for dependence “Z-hypnotics” (nonbenzodiazepine agents): Short-acting sedative and hypnotic sleep agents Provide sedative effects without the antianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines: zolpidem (Ambien) zaleplon (Sonata) eszopiclone (Lunesta) Melatonin-Receptor Agonist ramelteon (Rozerem): A hypnotic drug that acts similar to melatonin; is thought to regulate circadian rhythms Copyright © 2017, Elsevier Inc. All Rights Reserved. 29 Mood Stabilizers lithium (Eskalith, Lithobid): Stabilizes depression and mania (bipolar disorder). Narrows the therapeutic index. Has a potential for toxicity. Toxic effects can include tremor, ataxia, confusion, convulsions, and N/V. Copyright © 2017, Elsevier Inc. All Rights Reserved. 30 Anticonvulsant Mood Stabilizers valproate (Depakote/Depakene) Is very effective in managing impulsive aggression. carbamazepine (Tegretol) Is administered for acute mania. lamotrogine (Lamictal) Is administered for maintenance therapy. Watch for rash; may indicate Stevens-Johnson syndrome. Copyright © 2017, Elsevier Inc. All Rights Reserved. 31 Off-Label Mood Stabilizers Off-Label Mood Stabilizers oxcarbazepine (Trileptal) gabapentin (Neurontin) topiramate (Topamax) Copyright © 2017, Elsevier Inc. All Rights Reserved. 32 Antipsychotic Drugs/ First-Generation Agents (FGA) chlorpromazine (Thorazine) fluphenazine (Prolixin) haloperidol (Haldol) Copyright © 2017, Elsevier Inc. All Rights Reserved. 33 Positive Symptoms Schizophrenia Antipsychotic Drugs/ First-Generation Agents (FGA) (Cont.) Also called dopamine receptor agonists (DRAs) Bind to dopamine type 2 (D2) receptors Reduce dopamine transmission Copyright © 2017, Elsevier Inc. All Rights Reserved. 34 Extrapyramidal Side Effects and Adverse Reactions Conventional antipsychotic drugs Dystonia (muscle stiffness) Akathisia (restlessness) Tardive dyskinesia (TD) Drug-induced parkinsonism Neuroleptic malignant syndrome (NMS); rare but life-threatening Orthostatic hypotension Copyright © 2017, Elsevier Inc. All Rights Reserved. 35 Specific Adverse Reactions Blocking muscarinic cholinergic receptors Blurred vision, dry mouth, constipation, and urinary hesitancy Antagonism of the histamine1 receptors Sedation and weight gain Blocking α1 receptors for norepinephrine Drop in blood pressure, or orthostatic hypotension Antagonism of either α1 receptors or 5-HT2 receptors Ejaculatory dysfunction Copyright © 2017, Elsevier Inc. All Rights Reserved. 36 Blocking muscarinic cholinergic receptors can result in blurred vision, dry mouth, constipation, and urinary hesitancy. Antagonism of the histamine1 receptors causes sedation and weight gain. Blockage at the α1 receptors for norepinephrine can affect vasodilation and a consequent drop in blood pressure, or orthostatic hypotension. Antagonism of either α1 receptors or 5-HT2 receptors may result in ejaculatory dysfunction. 36 Audience Response Question Blocking muscarinic cholinergic receptors may result in which one of the following? Sedation Weight gain Blurred vision Orthostatic hypotension Copyright © 2017, Elsevier Inc. All Rights Reserved. 37 Answer Blocking muscarinic cholinergic receptors may result in which one of the following? Sedation Weight gain *C. Blurred vision Orthostatic hypotension Copyright © 2017, Elsevier Inc. All Rights Reserved. 38 Blocking muscarinic cholinergic receptors can result in blurred vision, dry mouth, constipation, and urinary hesitancy. Antagonism of the histamine1 receptors causes sedation and weight gain. Blockage at the α1 receptors for norepinephrine can affect vasodilation and a consequent drop in blood pressure, or orthostatic hypotension. Antagonism of either α1 receptors or 5-HT2 receptors may result in ejaculatory dysfunction. 38 Audience Response Question Extrapyramidal side effects are the result of which one of the following? A. Too much serotonin B. Dopamine blocking C. Too little serotonin D. Too few receptors Copyright © 2017, Elsevier Inc. All Rights Reserved. 39 Answer Extrapyramidal side effects are the result of which one of the following? A. Too much serotonin *B. Dopamine blocking C. Too little serotonin D. Too few receptors Copyright © 2017, Elsevier Inc. All Rights Reserved. 40 Second-Generation (AGA) Atypical Antipsychotic Drugs Produce fewer extrapyramidal side effects (EPS) Target negative and positive symptoms of schizophrenia clozapine (Clozaril) risperadone (Risperdal) quetiapine (Seroquel) olanzapine (Zyprexa) iloperidone (Fanapt) lurasidone HCl (Latuda) ziprasidone HCl (Geodon) aripiprazole (Abilify) paliperidone (Invega) Copyright © 2017, Elsevier Inc. All Rights Reserved. 41 Copyright © 2017, Elsevier Inc. All Rights Reserved. 42 Adverse effects of receptor blockage of antipsychotic agents Figure 4-13 in text. 42 Objective 6: Compare and contrast the side effect profiles of conventional antipsychotic drugs with the side effect profiles of the atypical antipsychotic drugs. Conventional EPS: Dystonic reaction Akathisia Drug-induced parkinsonism Tardive dyskinesia Orthostatic hypotension NMS Atypical Risk of metabolic syndrome: Increased weight Increased blood glucose Increased triglyceride levels Insulin resistance Lower risk of EPS Copyright © 2017, Elsevier Inc. All Rights Reserved. 43 Objective 7: Identify the main neurotransmitters affected by the following psychotropic drugs and their subgroups (see below): Copyright © 2017, Elsevier Inc. All Rights Reserved. 44 NOTE: Ask students to identify one neurotransmitter for each group listed here. (Answers in next screen.) 44 ANTIDEPRESSANT ANTIANXIETY SEDATIVE HYPNOTIC MOOD STABILIZER ANTIPSYCHOTIC ANTICHOLINESTERASE Objective 7: Identify the main neurotransmitters affected by the following psychotropic drugs and their subgroups (see answers below) (Cont.): Copyright © 2017, Elsevier Inc. All Rights Reserved. 45 ANTIDEPRESSANT: serotonin ANTIANXIETY: GABA SEDATIVE HYPNOTIC: histamine MOOD STABILIZER: norepinephrine ANTIPSYCHOTIC: dopamine ANTICHOLINESTERASE: acetylcholine Objective 8: Discuss the relationship between the immune system and the central nervous system in mental health and mental illness. Psychoneuroimmunology (PNI) Research: Focuses on the relationship between the immune system and central nervous system Investigates the role in psychiatric disorders Examples: Cytokine-induced depression and stress-related disorders Neuroinflammatory processes Cognitive deficits in Alzheimer disease Sleep-wake cycles Copyright © 2017, Elsevier Inc. All Rights Reserved. 46 Objective 9: Describe how genes and culture affect an individual’s response to psychotropic medication. Cultural and ethnic beliefs: Mental illness and pharmacotherapy Cross-cultural psychopharmacology: Effects and responses that exist among ethnic groups Pharmacogenetics: How genes influence drug metabolism Copyright © 2017, Elsevier Inc. All Rights Reserved. 47 Audience Response Question Genetics play which role in response to psychotropic drugs? Different ethnic groups have different responses. Genetics are not associated with drug response. Response to psychotropic drugs may be related to genetics. Genetics are related to the disease process and not the drug response. Copyright © 2017, Elsevier Inc. All Rights Reserved. 48 Answer Genetics play which role in response to psychotropic drugs? Different ethnic groups have different responses. Genetics are not associated with drug response. *C. Response to psychotropic drugs may be related to genetics. Genetics are related to the disease process and not the drug response. Copyright © 2017, Elsevier Inc. All Rights Reserved. 49 Audience Response Question Psychogenetics may one day lead to which of the following? (Select all that apply.) Personalized medications Safer drugs Targeted pharmacologic therapies determined by genetically inherited factors Increased number of receptors Copyright © 2017, Elsevier Inc. All Rights Reserved. 50 Answer Psychogenetics may one day lead to which of the following? (Select all that apply.) *A. Personalized medications *B. Safer drugs *C. Targeted pharmacologic therapies determined by genetically inherited factors Increased number of receptors Copyright © 2017, Elsevier Inc. All Rights Reserved. 51 ReceptorNorepinephrine A Normal B Deficient neurotransmitter C Deficient receptor Dopamine receptorDopamine A Normal B Excess neurotransmitter C Excess receptors GABA receptor Benzodiazepine receptorBenzodiazepine GABA DopamineDA Presynaptic cell Postsynaptic cell Dopamine receptor Antipsychotic drug DA DA DADA DA DA