Chapter 2 Neurobiologic Theories and Psychopharmacology

Chapter 2:
Neurobiologic Theories and

Psychopharmacology
Central Nervous System
❖ Brain (See Figures 2.1 and 2.2)

o Cerebrum
o Cerebellum
o Brain stem
o Limbic system
❖ Spinal cord
❖ Nerves that control voluntary acts (neurotransmitters)
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Cerebrum
❖ Two hemispheres
❖ Four lobes:
o Frontal lobe (thought, body movement, memories,
emotions, moral behavior)
o Parietal lobe (taste, touch, spatial orientation)
o Temporal lobe (smell, hearing, memory, emotional
expression)
o Occipital lobe (language, visual interpretation)

Cerebellum
❖ Below cerebrum
❖ Center for coordination of movements, postural
adjustments
❖ Reception, integration of information from all body areas
to coordinate movement, posture

Brain Stem
❖ Midbrain: reticular activating system (motor activity,

sleep, consciousness, awareness) and extrapyramidal
system
❖ Pons: primary motor pathway
❖ Medulla oblongata: vital centers for cardiac, respiratory
function
❖ Nuclei for cranial nerves III through XII
❖ Locus ceruleus: norepinephrine-producing neurons
(stress, anxiety, impulsive behavior)

Limbic System
❖ Above brain stem

o Thalamus (activity, sensation, emotion)
o Hypothalamus (temperature regulation, appetite
control, endocrine function, sexual drive, impulsive
behavior)
o Hippocampus (emotional arousal, memory)
o Amygdala (emotional arousal, memory)

Neurotransmitters #1
❖ Chemical substances to facilitate neurotransmission (see

Figure 2.3)
❖ Important in right proportions to relay messages (see
Figure 2.4)
❖ Play role in psychiatric illness and psychotropic
medications, including their actions and side effects.

❖ Excitatory or inhibitory (see Table 2.1)

o Excitatory
▪ Dopamine: complex movements, motivation,
cognition, regulation of emotional response
▪ Norepinephrine: attention, learning, memory,
sleep, wakefulness, mood regulation
▪ Epinephrine: flight-or-fight response
▪ Glutamate: major neurotoxic effects at high levels

❖ Excitatory or inhibitory (see Table 2.1) (cont.)

o Inhibitory
▪ Serotonin: food intake, sleep, wakefulness,
temperature regulation, pain control, sexual
behaviors, regulation of emotions
▪ GABA: modulation of other neurotransmitters
o Excitatory or inhibitory
▪ Acetylcholine: sleep-and-wakefulness cycle;
signals muscles to become alert
❖ Histamine: neuromodulator

Question #1
Is the following statement true or false?

❖ The cerebellum consists of four lobes.

Answer to Question #1
False
❖ Rationale: The cerebrum consists of four lobes. The
cerebellum is located below the cerebrum.

Brain Imaging Techniques
❖ Computed tomography (CT)

❖ Magnetic resonance imaging (MRI)
❖ Positron emission tomography (PET)
❖ Single photon emission computed tomography (SPECT)
❖ Limitations
o Use of radioactive substances; expense of
equipment; client’s inability to tolerate technique
o Changes nondetectable with current techniques

Neurobiologic Causes
❖ Genetics and heredity: play role but not solely genetic

o Twin, adoption, and family studies are used.
❖ Psychoimmunology: compromised immune system
possibly contributing, especially in at-risk populations
❖ Infections: particularly viruses during fetal development,
possibly play role

Nurse’s Role in Research and Education
❖ Ensure all clients, families are well informed.

❖ Help distinguish between facts and hypotheses.
❖ Explain if or how new research may affect client’s
treatment or prognosis.

Question #2

❖ Single photon emission computed tomography is
considered the best type of brain imaging technique to
diagnose disease.

False
❖ Rationale: Single photon emission computed tomography
(SPECT) is not considered the major type of brain
imaging used to diagnose disease. In fact, many of the
changes in the brain are not currently detectable with
any of the current techniques.

Psychopharmacology #1
❖ Psychotropic drugs
❖ Efficacy (maximum therapeutic effect)
❖ Potency (amount of drug needed for maximum effect)
❖ Half-life
❖ Approved use

Psychopharmacology #2
❖ Off-label use (effective for disease different from one

involved in original testing)
❖ Black box warning (serious or life-threatening side
effects)

Principles of Psychopharmacology
❖ Effect on target symptom

❖ Adequate dosage for sufficient time
❖ Lowest effective dose
❖ Lower doses for older adults
❖ Tapering rather than abrupt cessation to avoid rebound
or withdrawal
❖ Follow-up care
❖ Simple regimen to increase compliance

Antipsychotic Drugs #1
❖ Antipsychotic agents—neuroleptics (see Table 2.3)

o Conventional (e.g., chlorpromazine, fluphenazine,
thioridazine, haloperidol, loxapine)
o Second generation (e.g., clozapine, risperidone,
olanzapine)
o Third generation (dopamine system stabilizers; e.g.,
aripiprazole)

Antipsychotic Drugs #2
❖ Use: treatment of psychotic symptoms

❖ Mechanism of action: block dopamine receptors

Antipsychotics: Side Effects #1
❖ Extrapyramidal syndrome (EPS):

o Acute dystonia
▪ Torticollis, opisthotonus, oculogyric crisis
▪ Treatment: anticholinergic drugs or
diphenhydramine (see Table 2.4)
o Pseudoparkinsonism (stooped posture, mask-like
faces, shuffling gait)
o Akathisia (restlessness, anxiety, agitation)

❖ Neuroleptic malignant syndrome (NMS)

❖ Tardive dyskinesia (irreversible involuntary movements)
❖ Anticholinergic effects (dry mouth, constipation, urinary
hesitancy or retention)

❖ Other side effects:

o Increased prolactin levels
o Weight gain (second-generation agents, except
ziprasidone)
o Prolonged QT interval (thioridazine, droperidol,
mesoridazine)
o Agranulocytosis (clozapine)

Antipsychotics: Client Teaching
❖ Adherence to regimen
❖ Side effects, management
o Thirst/dry mouth (sugar-free candy, liquids)
o Constipation (dietary fiber, stool softeners)
o Sedation (safety measures)
❖ Actions for missed dose (dose if within 4 hours of usual
time)
❖ CBC, ANC with clozapine

Question #3
❖ 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.

Antidepressants #1
❖ Use: major depressive illness, anxiety disorders,

depressed phase of bipolar disorder, psychotic depression

Antidepressants #2
❖ Four groups (see Table 2.5):

o Tricyclic and related cycle antidepressants (TCAs)
o Selective serotonin reuptake inhibitors (SSRIs)
o MAO inhibitors (MAOIs)
o Others (venlafaxine, bupropion, duloxetine,
trazodone, nefazodone)

Antidepressants #3
❖ Mechanism of action: interact with monoamine

neurotransmitter systems, especially norepinephrine and
serotonin
❖Preferred drugs for clients at high risk for suicide

Antidepressants: Side Effects #1
❖ SSRIs
o Anxiety, agitation, akathisia, nausea, insomnia,
sexual dysfunction
o Weight gain
❖ TCAs
o Anticholinergic effects
o Orthostatic hypotension, sedation, weight gain,
tachycardia
o Sexual dysfunction

❖ MAOIs
o Daytime sedation, insomnia, weight gain, dry mouth,
orthostatic hypotension, sexual dysfunction
o Hypertensive crisis (with foods containing tyramine)

❖ Other agents
o Sedation, headache (nefazodone, trazodone)
o Loss of appetite, nausea, agitation, insomnia
(bupropion, venlafaxine)
o Priapism (trazodone)

Antidepressants: Drug Interactions
❖ Serotonin syndrome
o MAOI + SSRI
o Agitation, sweating, fever, tachycardia, hypotension,
rigidity, hyperreflexia
o Coma, death (extreme reactions)

Antidepressants: Client Teaching
❖ Time of dosage
o SSRI first thing in morning
o TCAs at night
❖ Actions for missed dose
o SSRI up to 8 hours after missed dose
o TCAs within 3 hours of missed dose
❖ Safety measures
❖ Dietary restrictions if taking MAOI (see Box 2.1)

Mood-Stabilizing Drugs #1
❖ Lithium, some anticonvulsants (carbamazepine, valproic

acid; gabapentin, topiramate, oxcarbazepine, and
lamotrigine)
❖ Use: treatment of bipolar disorders

Mood-Stabilizing Drugs #2
❖ Mechanism of action
o Normalize reuptake of certain neurotransmitters
(lithium)
o Increase levels of GABA (valproic acid, topiramate)
o Kindling process (valproic acid, carbamazepine)

Mood-Stabilizing Drugs: Side Effects #1
❖ Lithium
o Nausea, diarrhea, anorexia, fine hand tremor,
polydipsia, polyuria, metallic taste, 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

Mood-Stabilizing Drugs: Side Effects #2
❖ Carbamazepine: rash, orthostatic hypotension

❖ Valproic acid: weight gain, alopecia, hand tremor
❖ Topiramate: dizziness, sedation, weight loss

Mood-Stabilizing Drugs: Client Teaching
❖ Periodic monitoring of blood levels

o 12 hours after last dose taken
❖ Drug with meals
❖ Safety measures

Question #4

❖ 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 occurs if the client is taking MAOI
and ingests foods containing tyramine.

Antianxiety Drugs
❖ Use: treatment of anxiety and anxiety disorders,

insomnia, OCD, depression, posttraumatic stress
disorder, alcohol withdrawal
❖ Benzodiazepines, buspirone (see Table 2.6)
o Mediation of GABA (benzodiazepines)
o Partial agonist activity at serotonin receptors
(buspirone)

Antianxiety Drugs: Side Effects
❖ Benzodiazepines
o Physical, psychological dependence
o CNS depression
o Hangover effect
o Tolerance
❖ Buspirone
o Dizziness, sedation, nausea, headache

Antianxiety Drugs: Client Teaching
❖ Safety measures
❖ Avoidance of alcohol
❖ Avoidance of abrupt discontinuation

Stimulants #1
❖ Amphetamines (methylphenidate amphetamine,

dextroamphetamine)
❖ Use: treatment of ADHD in children and adolescents,
residual attention-deficit disorder in adults, narcolepsy

Stimulants #2
o Cause release of norepinephrine, dopamine,
serotonin presynaptically
o Direct agonist effects postsynaptically
o Block reuptake of neurotransmitters

Stimulants: Side Effects and Client Teaching
❖ Side effects
o Anorexia, weight loss, nausea, irritability
o Growth and weight suppression
❖ Client teaching
o Dose after meals
o Avoidance of caffeine, sugar, chocolate
o Proper storage out of reach of children

Disulfiram #1
❖ Use: aversion therapy for alcoholism

❖ Mechanism of action: inhibition of enzyme involved with
alcohol metabolism
o Adverse reaction with alcohol ingestion
❖ Side effects: fatigue, drowsiness, halitosis, tremor,
impotence

Disulfiram #2
❖ 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

Question #5
❖ 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 disorder.

Cultural Considerations #1
❖ More rapid response to antipsychotics, TCAs for African

Americans than whites
o Greater risk of side effects
❖ Slower metabolism of antipsychotics, TCAs for Asians
o Lower doses to produce the same effects

❖ Lower doses of antidepressants for Hispanics than whites

to achieve desired effects
❖ Lower doses of lithium for Asians and African Americans
than whites to produce desired effects

❖ Increased frequency of herbal medicine use

o St. John’s wort
o Kava
o Valerian
o Ginkgo biloba
❖ Increased risk for interactions

Common Barriers to Maintaining
Medication Management
❖ Long-term, chronic illness requires ongoing treatment.

❖ Symptoms of poor insight and confusion
❖ “Faulty” thinking
❖ Major side effects/interactions of meds
❖ Stereotyping and discrimination against mental illness

Self-Awareness Issues
❖ View chronic mental illness as having remissions and

exacerbations, just as chronic physical illnesses do.
❖ Remain open to new ideas that may lead to future
breakthroughs.
❖ Understand that medication noncompliance is often part
of the illness, not willful misbehavior.

Chapter 2 Neurobiologic Theories and Psychopharmacology

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Chapter 2 Neurobiologic Theories and Psychopharmacology

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Chapter 2:

Neurobiologic Theories and

❖ Brain (See Figures 2.1 and 2.2)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Midbrain: reticular activating system (motor activity,

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Above brain stem

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Chemical substances to facilitate neurotransmission (see

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Excitatory or inhibitory (see Table 2.1)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Excitatory or inhibitory (see Table 2.1) (cont.)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Is the following statement true or false?

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Computed tomography (CT)

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❖ Genetics and heredity: play role but not solely genetic

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Ensure all clients, families are well informed.

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Is the following statement true or false?

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Off-label use (effective for disease different from one

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❖ Effect on target symptom

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Antipsychotic agents—neuroleptics (see Table 2.3)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Use: treatment of psychotic symptoms

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Extrapyramidal syndrome (EPS):

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❖ Neuroleptic malignant syndrome (NMS)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Other side effects:

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Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Which of the following drugs would be classified as a

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Use: major depressive illness, anxiety disorders,

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❖ Four groups (see Table 2.5):

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Mechanism of action: interact with monoamine

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

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❖ Lithium, some anticonvulsants (carbamazepine, valproic

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Copyright © 2017 Wolters Kluwer • All Rights Reserved

❖ Carbamazepine: rash, orthostatic hypotension