Chapter 2:

Neurobiologic Theories and

Psychopharmacology
Neurobiologic Theories

Great strides are being made in

understanding the brain and mental
illness, but much is still unknown;
nurses need to keep abreast of
developments to provide effective
teaching
Central Nervous System
Consists of:
• Brain
– Cerebrum
– Cerebellum
– Brain stem
– Limbic system
• Spinal cord
• Nerves that control voluntary acts
Cerebrum
Divided into two hemispheres with four lobes
each:
 Frontal lobe (thought, body movement,
memories, emotions, moral behavior)
 Parietal lobe (taste, touch, spatial
orientation)
 Temporal lobe (smell, hearing, memory,
emotional expression)
 Occipital lobe (language, visual
interpretation)
Cerebellum

•Receives and integrates information

from all body areas to coordinate
movement and posture
Brain Stem
• Midbrain
– Pons
– Medulla oblongata
– Locus ceruleus
– Cranial nerve nuclei 3 through 12
Limbic System

• Above the brain stem and includes:

– Thalamus
– Hypothalamus
– Amygdala
 Neurotransmitters
Chemical substances manufactured in the
neuron to aid in transmission of information
• Either inhibitory or excitatory
Neurotransmitters include:
 Dopamine (control of complex movements,
motivation, cognition, regulation of
emotional responses)
 Norepinephrine (attention, learning,
memory, sleep, wakefulness, mood
regulation)
Epinephrine (flight-or-fight response)
 Serotonin (food intake, sleep, wakefulness,
temperature regulation, pain control, sexual
behaviors, regulation of emotions)
Neurotransmitters include: (cont’d)

Histamine (alertness, control of gastric

secretions, cardiac stimulation, peripheral
allergic responses)
• Acetylcholine (sleep and wakefulness cycle,
signals muscles to become alert)
 Glutamate (an excitatory amino acid)
 GABA (modulates other neurotransmitters)
Brain Imaging Techniques
Include:
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET)
• Single photon emission computed
tomography (SPECT)
We cannot yet diagnose mental illness with
these techniques alone.
Axial PET of Male Patient With Alzheimer’s
Causes of Mental Illness

• Genetics and heredity: play a role but

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

Psychopharmacology and medication

management are important in the
treatment of many mental illnesses.

Principles that guide the use of

medications include:
Effect on target symptom
 Adequate dosage for sufficient time
 Lowest dose needed for maintenance
Lower doses for the elderly
 Tapering rather than abrupt cessation
to avoid rebound or withdrawal
 Follow-up care
 Simplify the regimen for increased
compliance
Antipsychotic Drugs
conventional; atypical; new generation

Uses:
Schizophrenia, acute mania, psychotic
depression, drug-induced psychosis,
other psychotic symptoms
Action:
Treat psychotic symptoms, such as
delusions and hallucinations, by
blocking dopamine receptors
Conventional Antipsychotic Drugs
phenothiazines (Thorazine, Prolixin, Mellaril, Stelazine);
Navane, Haldol, Loxitane, Moban

Side Effects Patient Teaching

• Extrapyramidal side effects • Adhering to medication
(EPSs) regimen
• Pseudoparkinsonism • Managing side effects
• Dystonia – Thirst
• Akathisia – Constipation
• Anticholinergic side effects – Sedation
• Tardive dyskinesia (TD)
• Neuroleptic malignant
syndrome (NMS)
Atypical Antipsychotic Drugs
Clozaril, Risperdal, Zyprexa, Seroquel, Geodon

Side Effects Patient Teaching

• Fewer EPSs • Adhering to medication
regimen
• Weight gain
• Reducing sugar and caloric
• Agranulocytosis (Clozaril) intake
• Clozaril
– Weekly WBC monitoring
– Discontinue medication
and seek care at first
sign of infection
New-Generation Antipsychotic Drugs
aripiprazole (Abilify)

Side Effects Patient Teaching

• Headache • Adhering to medication
regimen
• Anxiety
• Nausea
Antidepressant Drugs
SSRIs; TCAs; MAOIs

Uses:
Major depression, panic disorder and other
anxiety disorders, bipolar depression,
psychotic depression
Action:
Interact with the monoamine
neurotransmitter systems in the brain,
particularly the neurotransmitters
norepinephrine and serotonin
SSRI Antidepressant Drugs
fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft),
citalopram (Celexa), escitalopram (Lexapro)

Side Effects Patient Teaching

• Anxiety • Take in the morning
• Agitation • Take with food
• Akathisia • Propanolol given for
akathisia
• Nausea
• Insomnia
• Sexual dysfunction
(anorgasmia/impotence)
TCA Antidepressant Drugs
imipramine (Tofranil), desipramine (Norpramin),
amitriptyline (Elavil), doxepin (Sinequan), clomipramine
(Anafranil)
Side Effects Patient Teaching
• Anticholinergic (blurred • Taking in the evening
vision, urinary retention, dry
mouth, constipation) • Using caution when driving

• Orthostatic hypotension
• Sedation
• Weight gain
• Tachycardia
• Sexual dysfunction
MAOI Antidepressant Drugs
phenelzine (Nardil), tranylcypromine (Parnate),
isocarboxazid (Marplan)

Side Effects Patient Teaching

• Sedation • Following tyramine-free diet
(avoid aged cheeses, aged
• Insomnia meats, beer and wine,
• Weight gain sauerkraut, soy)

• Dry mouth • Avoiding sympathomimetic

drugs
• Orthostatic hypotension
• Using caution when driving
• Sexual dysfunction
• Hypertensive crisis with
excessive tyramine or
sympathomimetic drugs
Mood Stabilizing Drugs
lithium; anticonvulsant medications (carbamazepine
(Tegretol), valproic acid (Depakote), lamotrigine
(Lamictal), gabapentin (Neurontin)

Uses:
Bipolar disorder
Action:
Act on the neurotransmitters of the
brain
Mood-Stabilizing Drugs
Side Effects (Lithium) Patient Teaching (Lithium)
• Nausea • Taking with food
• Diarrhea • Having monthly blood levels
drawn 12 hours after last dose
• Anorexia (maintain therapeutic levels
between 0.5–1.5 mEq/L)
• Fine hand tremor
• Polydipsia
• Polyuria
• Fatigue
• Weight gain
• Acne
Antianxiety Drugs
benzodiazepines; buspirone (BuSpar)

Uses:
Anxiety disorders, insomnia, OCD,
depression, PTSD, alcohol withdrawal
Action:
Moderate the actions of GABA
Antianxiety Drugs
Side Effects Patient Teaching
• Tolerance and dependence • Using caution during driving
due to slower reflexes and
• Drowsiness response time
• Sedation • Never discontinuing
• Poor concentration abruptly as
withdrawal
• Impaired memory can be fatal
• Clouded sensorium • Avoiding
alcohol
Stimulant Drugs
methylphenidate (Ritalin), pemoline (Cylert),
dextroamphetamine

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

Side Effects Patient Teaching

• Anorexia • Avoiding caffeine, sugar, and
chocolate
• Weight loss
• Taking after meals
• Nausea
• Long-term use can cause
• Irritability dependency
Disulfiram
Antabuse

Uses:
Aversion therapy for treatment of
alcoholism
Action:
Causes an adverse reaction when
alcohol is ingested
Disulfiram
Side Effects Patient Teaching
• Fatigue • Avoiding alcohol (including
products such as shaving
• Drowsiness cream, aftershave, cologne,
• Halitosis many OTC medications)

• Tremor • Family should never

administer without the
• Impotence person's knowledge
Cultural Considerations
Ethnic backgrounds influence responses to some
psychotropic medications:
• African Americans respond more rapidly to
antipsychotic and tricyclic antidepressant
medications than do whites and have a greater
risk of side effects
• Asians metabolize antipsychotic and tricyclic
antidepressants more slowly, requiring lower
doses to produce the same effects
• Hispanics require lower doses of antidepressants
than whites to achieve desired effects
• Asians and African Americans require lower doses
of lithium than whites to produce desired effects
Self-Awareness Issues

Viewing chronic mental illness as having

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