N 149 Psychiatric

Mental Health
Nursing
UCSF

School of Nursing

Kevin McGirr, RN,MS,MPH

 Mental Illness:
The historical response

Ignorance, mystification or revelation?

 Repeating Themes
 Integration or pre-institutionalization
 Exclusion and Segregation

 Morality

 Criminalization and Incarceration

 Reform

 Medicalization


 Potions, Lotions and
Notions
 Bodily humors

 Bleeding, Purging and Blistering

 Evil spirits

 Deification

 Insulin shock 1935

 Lobotomy 1936

 ECT 1937

 Cold wraps

 Emil Kraeplin

 DSM I 1952


 Hildegard Peplau
 By the 1920s, psychiatric nursing became an
official and separate curriculum at most
colleges and universities, and by 1950, the
National League for Nursing required nursing
schools to include psychiatric nursing in
their clinical practice for national
accreditation. The role of the psychiatric
nurse expanded when the Community
Mental Health Act of 1963 encouraged
deinstitutionalization and psychiatric drugs
that allowed patients to live on their own
became more common.
Early “Enlightenment”
 Phillipe Pinel: late 18th century
 Benjamin Rush: Moral Treatment
 Dorothea Dix and Linda Richards
 Clifford Beers: A Mind That Found Itself
 Mental Hygiene Movement



 Moral Treatment
 Control the patient without punishment

 Constructing order

 Compassionate Discipline

 •Introduce “regularity” a chaotic life

 •Calm, silence, and regular routine


 McLean’s Hospital
1882
 1st school to prepare nurse for the care of the
mentally ill – 2 year program
 Few psychological skills were taught, care was
primarily custodial (e.g. medication,
nutrition, hygiene, & ward activities)
 Principles of medical/surgical nursing were
adapted to the psychiatric setting

 Linda Richards
 American reformer Dorothea Dix noted
that mentally ill patients were treated
like animals in 19th-century America,
and she opened 32 state asylums to
care for them. English reformer and
nursing pioneer Florence Nightingale
fought for quality care for the
mentally ill. She collaborated with her
American colleague, Linda Richards
and inspired Richards to open Boston
City College in 1882.
 Johns Hopkins 1913
 1st SON to develop a course for psychiatric
nursing that was incorporated into the
nursing curriculum
 Muddling through…
 Sigmund and his disciples: Construction of
the Self
 Peplau: Interpersonal Relations Model
 Mental Health Act 1946
 National Institute of Mental Health 1949
 Chlorpromazine
 Mental Health Study Act 1955 & 1963
 Deinstitutionalization

 The battle
continues….
 Anti-psychiatry
 Community Mental Health
 Patients Rights
 Community Support Programs 1977
 Managed Care
 New Freedom Commission 2002: stigma, consumer
driven, disparities, research, service and
technology
 Mental Health Parity Act 1996 and 2008
 Proposition 63
 Enlightenment for
real?
 Psychoanalysis and psychological disrobing

 Social iatrogenesis and the contribution of culture

 Community Mental Health

 Community Support Programs

 Assertive Community Treatment

 Psychopharmacology for the masses

 De-stigmatizing mental health

 Evidence Based Practices

 Decade of the brain

 Education and skills approach

 Wellness and Recovery



 The end…..


Or just the beginning…….


 Legal Context of Mental
Health Treatment


 Protecting Individuals and Society

 Foundations of
Individual Rights
 4th Amendment: unreasonable search and seizure


 5th Amendment: double jeopardy, self incrimination and due
process


 14th Amendment: equal protection


 California Constitution


 Lanterman Petris Short (LPS) Act: 1967-1972


 LPS
 To provide prompt evaluation and treatment.
 To guarantee public safety.
 To safeguard individualized treatment, supervision
and placement.
 To encourage full use of existing agencies,
professional personnel and public funds.
 To protect mentally and developmentally disabled
persons from criminal acts.

 LPS and Involuntary
Detention
 Restrict persons authorized to initiate involuntary
detention.
 Specify criteria under which persons with mental
illness may be committed.
 Establish mandatory time frames for each escalating
period of involuntary detention.
 Provide opportunity to challenge each stage of
commitment by providing access to administrative
and judicial review.
W & I 5325.1



 Patients’ Rights
 A right to treatment services which promote the potential of the person to function independently. Treatment
should be provided in ways that are least restrictive of the personal liberty of the individual.

 A right to dignity, privacy and humane care.

 A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication,
abuse, or neglect. Medication shall not be used as punishment or for the convenience of staff, as a
substitute for program, or in quantities that interfere with the treatment program.

 A right to prompt medical care and treatment.

 A right to religious freedom and practice.

 A right participate in appropriate programs of publicly supported education.

 A right to social interaction and participation in community activities.

 A right to physical exercise and recreational opportunities.

 A right to be free from hazardous procedures.


 Denial of Rights
 Seclusion or restraint must be closely
monitored
 Denial of any right must be documented and
substantiated by staff
 Riese Decision
The court stated that to have some irrational fears


about medication is acceptable and disagreement

between the doctor and the patient did not show
that the patient lacked capacity. That the individual
is using rational thought unless there’s a clear
connection between delusion and/or hallucinations
and the reason to refuse antipsychotic medication.



 Competency Hearing


An administrative law judge will determine the



client’s ability to refuse pharmacological

treatment, e.g, patient awareness of their
illness; ability to understand risk and benefits;
ability to evaluate and make a decision
 Emergency
Intervention
WIC 5008 m


"Emergency" means a situation in which action to



impose treatment over the person's objection is

immediately necessary for the preservation of life
or the prevention of serious bodily harm to the
patient or others, and it is impracticable to first gain
consent. It is not necessary for harm to take place
or become unavoidable prior to treatment.
 Patients Rights
Responsibility
 To receive, investigate and resolve patients’ rights complaints.

 Monitor facilities for compliance with patients’ rights laws and regulations and are a
resource for service providers for information, technical assistance and training.

 Provide referrals to specialists in housing, benefits, and legal services as needed.

 Provide training and education.

 Advocates focus on the resolution of the complaint. Advocates work for the
expressed interest of the individual and support them using self-advocacy to
accomplish their goal.

 Advocates outreach to vulnerable clients, visiting them at facilities and clinics and
where they reside.

WIC 5520

 5150 criteria
 Danger to Self

 Danger to Others

 Grave Disability

Contextual considerations

 Danger to Self
 This criteria may be either a deliberate intention to injure oneself
(i.e.overdose) or disregard of personal safety to the point
where injury is imminent (i.e. wandering about in heavy
traffic).
 The danger must be present, immediate, substantial, physical
and demonstrable.
 Words or actions showing intent to commit suicide or bodily
harm.
 Words or actions indicating grossdisregard for personal safety.
 Words or actions indicating a specific plan for suicide.
 Means are readily available to carry out a plan



 Danger to Others
 Should be based on words or actions that indicate the person in
question either intends to cause harm to a particular
individual or intends to engage in dangerous acts with gross
disregard for the safety of others.
 Threats against particular individuals
 Attempts to harm certain individuals
 Means available to carry out threats or to repeat attempts
(firearms other weapons)
 Expressed intention or attempts to engage in dangerous activity



 Grave Disability
 A condition in which a person, as aresultof amental disorder, is unable to provide his or her basic personal
needs for food, clothing and shelter.

 Refusal of medical treatment is not in and of itself evidence of grave disability.

 Although consideration of past events may be necessary, evaluation must be based on individual’s current
condition.

 If friends or family are willing to provide for the person’s basic needs, then the criteria for grave disability is
not met.

 signs of malnourishment (loss of weight) or dehydration

 inability to articulate plan for getting food

 no food in house or food there but rotten

 irrational beliefs about the food (e.g., it is poisoned or tainted in some way)

 inability to formulate a reasonable plan for shelter


 Does NOT meet
criteria for a 5150
 Willful or volitional behavior
 Criminal behavior
 Conscious acting out secondary to disappointment, anger,
hate, passion, fanaticism or prejudice
 Simply having a psychiatric diagnoses

 Implications of
Involuntary Detention
 With no other illness you do you use police power to detain people to
evaluate and then involuntarily treat them.
 Being picked up by police in handcuffs
 Individuals may feel they have been kidnapped
 Clients report experiencing severe loss of self-esteem and trust in the
provider
 Clients have complained of being in crisis and approaching their outpatient
clinic for support to get help, only to be 5150’d when they would have
accepted help voluntarily.
 Clients feel powerless being unable to address their responsibilities: pets,
bills, parking, counseling appointment, court appearances,
employment, etc..


 Beyond 5150
 5250: 14 day hold
 Temporary Conservatorship: 30 days
 Permanent Conservatorship: 1 year


For any of the above, the individual may:


 Request to see the patients rights advocate

 File a Writ of Habeas Corpus
 Certification Review /Probable Cause Hearing


 Risk of Violence
 Male

 Youth

 History of violence

 Diagnosis: MDE, BAD, Schizophrenia. Personality Disorder

 Positive psychotic symptoms

 Not in treatment

 When combined with substance abuse

 Abuse as a child

 Current social and economic disenfranchisement

 Failure to involuntarily treat


 HIPAA
Disclosure requires specific release from the client


except for those:

 Providing treatment within a safety net
 Those who have a need to know
 Information pertaining to treatment
 Treatment, Payment or Operations
 Emergency
 Law enforcement
 Accounting disclosure
 Mood Disorders


 Disturbance in Mood
 Evolving Case Study
 Jane is a 32 yo Asian female who is admitted to
the locked psychiatric unit. Jane told her
outpatient therapist that she had been
suicidal for the past three weeks

 Scenario I
 What are the possible reasons why Jane might
be placed on a locked unit?
 Are there any parameters within the State of
California for placing a client on a locked
unit? What are they?
 Are there protections for such individuals?
What are they?
 As a nurse who is responsible for admitting Jane
to the unit what might be some of your
initial activity and interaction with Jane?

 Scenario II
 Her husband and a sister accompany Jane.
They report that Jane has been acting
different over the past month. They note
that she has been sleeping less, speaking in
a very voluble and garrulous manner, pacing
a lot, and indicating that she has a special
relationship with President Obama. Her
husband is particularly concerned as he
thinks she has been “sleeping” around.

 Questions
 Given that a mental status exam is a routine
part of a psychiatric admission, what parts
of the mental status exam are indicated
above?
 What other questions will you begin to
formulate for Jane or her husband and
sister? How would handle asking questions
of her husband and sister?
 What are the possible diagnoses for Jane and
what are the criteria for those diagnoses?

 Scneario III
 Given some more information, we learn that
Jane was on some unknown medication
“years ago for her mood.” She has been in
therapy due to interpersonal difficulties at
home and at work. We find out that she has
tangential thinking, racing thoughts,
decreased need for sleep, delusions of
grandeur, impulsive spending, excessive
drinking and sexual activity with strangers.

 Questions
 What is the possible diagnosis at this point?
 What are the criteria for this diagnosis?
 What are the possible medications for this
disorder?
 What are the side effects of these medications?
 What are the nursing indications for
administration?
 Under what circumstances might we administer
this medication on an involuntary basis?

 Scenario IV
 Jane has now been admitted to the unit, she is
on suicide precautions, ordered to receive
olanzapine 5 mg. po BID; Ativan 1.0 mg prn
q 4 hours and Benedryl prn for side effects.
She has been pacing around the unit a
significant amount, receiving about two
hours of uninterrupted sleep, entering other
patients’ rooms, claiming to be influential
with all level of local and national politicians
and declining regular meals but hording food
in her room.

 Task
 Using Orem’s model propose a plan of
intervention for each domain

 Scenario V
 Jane has been in the hospital for four days now
and is sleeping about 6 hours, no longer
going into other patients’ rooms, no longer
claiming to have special influence in high
places and is now denying suicide ideation.

 Questions
 How do we evaluate suicidal risk?

 Assuming Jane was hospitalized on an

involuntary basis, what is the criterion for
her to convert to a voluntary patient?
 How might we modify the Orem care plan?

 How do we begin to prepare Jane for discharge?

What issues might we address with Jane?

 Big picture for
uni-polar depression

 Incidence: 7% annual for MDD and 3% for

dysthmia
 Prevalence; 17% lifetime
 Worldwide disability: one of the top
illnesses
 Onset: childhood; older adults at greatest
risk
 Demographics: 2:1, F/M
 Association with suicide: 9%
 Treatment efficacy: up to 80%

 Etiology
 Diathesis
 Genetic
 CNS impairment
 Psychological: psychodynamic,
attachment, object relations, learned
helplessness
 Environmental loss and stress
 Types
 Major Depression

 Dysthymia

 Bipolar I

 Bipolar II

 Seasonal Affective Disorder

 Post partum depression

Other Mood Disorders



 Mood Disorder due to specific medical condition

 Substance Induced Mood Disorder


 Major Depression


Two or more weeks of depressed mood that last all



day and at least four impairments in

physiological, cognitive or behavioral impact
 MDE Specific Criteria
Five (or more) of the following for 2-weeks:


1. Depressed mood each and most of the day

2. Diminished interest in pleasurable activities

3. Appetite and weight change

4. Sleep change

5. Psychomotor agitation or retardation

6. Fatigue and loss of energy

7. Feeling of worthlessness and guilt

8. Diminished ability to think or concentrate

9. Passive or active Suicide Ideation


 Specifiers


 Mild, Moderate, Severe Without Psychotic Features, Severe

With Psychotic Features, In Partial Remission, In Full Remission
 Chronic
 With Postpartum Onset

Specifiers (describing course of recurrent episodes)



 Longitudinal Course Specifiers (with our without full

interepisode recovery)
 With Seasonal Pattern
 With Rapid Cycling


 MDE Illness Course
 Duration is variable
 Untreated, typically lasts for 6 months or longer
 In the majority of cases there is complete
remission of sxs and functioning returns to
premorbid levels
 In about 20-30% of cases, some depressive sxs
persist for months to years and may be
associated with significant disability and
distress
 About 5-10% of individuals may still meet all
criteria for MDD for 2 or more years

 Dysthymic Disorder


Chronic depression for much of the day for a two



year period and at least two impairments in

physiological, cognitive or behavioral impact
 Dysthmyia: specific
criteria
A. Depressed mood for most of the day, for more days than
not, and indicated either by the subjective account
or observed by others for at least 2 years.

B. Presence, while depressed, of two (or more) of the

following:

1. Poor appetite
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making
decisions
6. Feelings of hopelessness

 Big Picture for BAD
w Prevalence; Type I = 1%; Type II = 4%
w Worldwide disability: one of the top illnesses
w Onset: 20s; possible in children and
adolescence
w Demographics: I. 1:1, II. 2:1, F:M; + family
hx;
w Association with suicide: 15 -20%
w Treatment efficacy: following an average of 7-9
episodes
 Bipolar I
w Classic manic-depressive form of the
illness
w Most severe type of bipolar disorder.
w Characterized by at least one manic episode
or mixed episode.
w Major Depression not required for diagnosis
but most do experience a MDE
w Typical course of Bipolar I Disorder
involves recurring cycles between mania
and depression.
w
 Bipolar II

 Hypomania and depression

 Episodes of hypomania and severe

depression; must have experienced
 At least one hypomanic episode and one
major depressive episode in a lifetime.
 Presence of a manic episode, dx changes to
Bipolar I Disorder.

 Cyclothymia
w Milder form of bipolar disorder consisting
of cyclical mood swings. The
w Highs and lows are not severe enough to
qualify as either mania or major
depression.
w Dx includes periods of hypomania and mild
depression over a two-year time span.
w Increased risk for developing bipolar
disorder, hence monitoring and/or tx is
advised.
w
 Rapid Cycling
w Subtype of bipolar disorder characterized by four
or more episodes of mania, hypomania, or
depression within one year.
w Shifts from low to high can occur over a matter of
days or hours.
w Can occur within any type of bipolar disorder.
w Usually develops later in the course of bipolar
disorder.
 Complications and
Concomitants
Differential Diagnosis


 Substance abuse
 Physical illness
 Medication
 Injury
 Schizophrenia or schizoaffective illness
 Grief

 Impact of Affective
Illness on Functioning
 Affective
 Cognitive
 Physiological
 Behavioral

 Affective
 Sad
 Hopeless
 Teary
 Anhedonia
 Irritable
 Expansive
 Euphoric
 Flattening


 Cognitive

 Concentration/ Distractibility
 Morbidity
 Grandiosity
 Paucity
 Negative: worthless, guilt, suicide ideas
 Tangential
 Flight of ideas
 Decreased judgment
 Physiological
 Psychomotor slowing or activation
 Sleep disturbance
 Appetite disturbance
 Amenorrhea
 Behavioral
 Suicide attempt or gesture

 Withdrawn

 Intrusive

 Hyper-social or hypersexual

 Rapid speech / Paucity of Speech

 Over dressing and frequent dress change

 Neglects self care

 Takes to the bed

 Decreased impulse control

 Unable to perform role function

 Suicide
 CDC ranks suicide for all Americans as the
11th cause of death down from #8 in 1999.
 About 30,000 die from suicide each year and
there are about 500,000 ER visits
associated with suicide attempts per year
 More people die from suicide then homicide;
more on west coast than east coast

 Risk Factors
 Gender 3:1 female to male attempts

 Age

 Race

 Genetics

 Mental Health or Substance Abuse disorder

 Education

 Religion

 Mental state

 Physical Health

 Isolation/ Marital Status

 History of attempt: 25 attempts for every completed

 San Francisco
Statistics
 ‘96: 139

 ‘97: 111

 ‘98: 90

 ‘99: 101

 ‘00: 111
 San Francisco
Locations
 Private residence

 GGB

 Residential or low income hotels

 Supervised care facilities (including Jail)

 Methods
Nationwide: firearms


Poison: street drugs



Hanging


Firearms


Jumping from the bridge


Assessment of
Suicidal Risk
 Mental Status
 Appearance

 Behavior

 Attitude and relationship with examiner

 Speech

 Mood/Affect

 Thought Process

 Thought Content

 Suicide ideation
 Plan
 Means
 Loss
 Future


 Electroconvulsive
Treatment
 Controversial
 Indications
 Administered w/ general anesthesia + muscle
relaxant
 Electrodes placed unilateral or bilateral
 Sz is induced for up to a minute
 6 -12 treatments up to 3x /week
 Remission and Maintenance
 Memory loss


 Nursing Interventions


Integrating Orem on the Affective, Physiological,



Cognitive and Behavioral domains

 Affective
 Safety

 Support

 Empathy

 Validation
 Physiological
 Adequate intake

 Hygiene

 Sleep

 Activity and Rest: movement

 Breathing

 Relaxation


 Cognitive
 Delusions: support and reality testing
 Offering hope
 Addressing negative thinking
 Identification
 Challenging
 Reframing
 Detaching
 Stopping, substitution distraction
 Guided imagery



 Behavior
 Limit setting
 Contracting
 Monitoring
 Isolation or seclusion
 Group interaction
 Regulation of contacts
 Mobilization
 Personality Disorders


What is the difference between a personality



disorder and personality trait?

 Patterns of….
 Perceiving, navigating and coping patterns
 Enduring


When the following exists, we consider a



personality disorder
 Intensive
 Maladaptive and inflexible
 Troublesome

 Diagnostic Criteria
 Behavioral pattern that deviates from the norm
in perception, response, control of impulse
and interpersonal function
 Enduring: not a response to a specific situation
 Impairs functioning

 Three Clusters
A. Paranoid, Schizoid, Schizotypal

B. Antisocial, Borderline, Histrionic, Narcissistic

C. Avoidant, Dependent, Obsessive Compulsive

 Paranoid Personality

 Suspiciousness and distrust
 Perception of hidden meaning
 Guarded
 Argumentative and defensive


 Difference with CPS are hallucinations and delusions and the

complexity of those delusions
 Schizoid

 Limited emotional expression

 Asocial

 Eccentricities


 Schizotypal
 Peculiar beliefs

 Strange or odd appearance

 Blunted affect

 Asocial


 Avoidant
 Fearful

 Apprehensive

 Risk averse
 Dependent
 Submission

 Significant lack of self confidence

 Fearful of being alone

 Over reliance on others

 Obsessive Compulsive
 Perfectionist
 Preoccupation with rules
 Difficulty with decisions
 Fear of making mistakes
 Rigidity

Distinction with OCD is the intense focus and


inability to control the thinking and resulting

behavior
 Antisocial
 Lacking superego

 Inability to experience guilt or remorse

 Insensitive to others

 Violation of social norms, rules & morals

 Can be charming and manipulative

 Histrionic
 Attention seeking

 Extroverted and flamboyant

 Dramatic

 Self absorbed
 Narcissistic
 Inflation of self import

 Very sensitive to criticism

 Easily emotionally injured

 Self absorbed and lacking in empathy

 Borderline
 Unstable self image

 Mood dysregulation

 Over and undervaluing of others

 Uses splitting as a defense

 Impulsive

 Interpersonal drama
 Symptom Focus
 Mistrust
 Anger or belligerence
 Impulsivity
 Inappropriate behavior or insensitivity
 Manipulation
 Poor coping
 Oversensitivity
 Mal-adaptation
 Interventions
Personal reaction Explanation and Interpretation
Use of self Relaxation

Validation of patient feelings Cognitive reframing

Reality check Problem solving

Boundaries Motivational interviewing

Judicious feedback and (FRAMES)

confrontation Consequences

Appealing to rationality Patience

Assertion and enhancement of

esteem
 Dialectical Behavior
Therapy
 Mindfulness
Interpersonal effectiveness
Emotional regulation
Distress tolerance
 Substance Abuse and
Pharmacology
 Who uses

 Context

 Neuroanatomy

 Neuron

 Neurotransmitters

 Mechanism of Action, Pharmacokinetics, pharacodynamics

 Side effect

 Med classes

 Consideration and Strategies

 Dual Diagnosis
 Context
 Serendipity and medication discovery
 Evolutionary: expanding role of pharmacy and increased use
 Controversial: influence of pharmaceuticals, family and
consumer concerns
 Effectiveness: percentage of responders
 Adverse effects
 Placebo: drug, set and setting
 Costs
 Patients rights/ rights to refuse
 Who prescribes?
 Formulary
 Role of FDA
 Substance Use


 Who is using what?
Results from the 2006 National Survey on Drug Use and Health:


 Usage
 2006 CY Lifetime
 Cigarettes: 35% 71%
 Alcohol: 66% 83%
 Illicit drugs 14% 45%*


 *Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin,
inhalants, stimulants, PCP, ecstasy, or prescription-type psychotherapeutics
used nonmedically.


 Nicotine Dependence
Based on SAMHSA's National Survey on Drug Use


and Health, of the 61.6 million persons aged 12

or older who in 2006 smoked cigarettes in the
past month, 57.7% (35.5 million) met the
criteria for nicotine dependence in the past
month
 Facts about Nicotine
Abuse and Dependence
w 450,000 annual deaths
w Approximately 20% of general population use
tobacco
w Persons with Behavioral Health disorders smoke
at a much greater rate; up to 67% for
persons with psychotic disorders
w Persons with chronic psychiatric or substance
abuse disorders smoke 44% of all cigarettes
w Estimates of a 20% decrease in life expectancy
for persons with SMI
Other Substance Abuse
and Dependence



In 2007, an estimated 22.3 million persons
(9.0 percent of the population aged 12 or
older) were classified with substance
dependence or abuse in the past year based
on criteria specified in DSM-IV.



Of these, 3.2 million were classified with
dependence on or abuse of both alcohol and
illicit drugs, 3.7 million were dependent on
or abused illicit drugs but not alcohol, and
15.5 million were dependent on or abused
alcohol but not illicit drugs.

 Co-occurence
According to SAMHSA


 22% of persons with severe mental illness (SMI)

also qualify for substance abuse or
dependence
 Basic CNS Anatomy
 Basic function: receive
information (sensory),
interpret, respond (motor)
Nerve cells
Glial cells
Vascularization

 Neuro-anatomy


 Autonomic Nervous System; processes info from the

hypothalamus thru the med ob, spinal cord to the
muscles and includes the sympathetic and
parasympathetic systems. Sympathetic: exp of
energy versus Parasympathetic which conserves
energy particularly for vital functions
 The peripheral nervous system branches from the
spinal cord to control voluntary muscle function.
 The peripheral system includes the pyramidal system
which manages fine motor coordination as
opposed to the extra pyramidal which manages
gross motor function. This is controlled by the
cerebellum

 Nerve Cell
 Central body is lipid, separated by a membrane from
the surrounding
 Ionic fluid containing + and – charges (electrical
conductivity)
 Stimulus of the nerve cell changes the internal –
charge to a +; 200 charges/second
 Passing thru the membrane the cell body sends
signals along the axon (the long limb)
 Terminating at the pre-synapse or dendrites
 Between the dendrites of one nerve cell and the next
is the synaptic cleft

Nerve Cell continued

 Pre-synapse contains neurotransmitters which stimulate

dendrites in the post synapse.
 The stimulated neurotransmitters are released into the
synaptic cleft attaching to receptors (dendrites of the
receptor cell); hormones & peptides are active in this
synapse
 Axon terminal contain vesicles which contain
neurotransmitter protein molecules produced by the
cell body. The communication of these molecule
occurs thru very specific receptorsor binding on the
post -synaptic side hence chemical changes.
 The neurotransmitter does NOT actually move into the next
cell. It merely pierces the membrane to cause
electrical conductivity
 Once it has done its action, it then is wasted or stored in the
pre synaptic area (AKA re-uptake)
 Mechanism of Action
 Impact of pre-synaptic neurotransmitter
 Impact at post-synaptic receptor binding
 Interference with re-uptake process
 Alteration of receptor manufacture
 As an agonist working like a neuro transmitter
binding to a receptor and stimulating nerve cell
activity
 As an antagonist performing the converse of agonist
by NOT stimulating

 Neurotransmitters
 Acetylcholine: arousal, attention, memory, motivation,
m-s, released by the Autonomic Nervous System in
the parasmypathetic; excitatory
 Neuroepinephrine: excitatory, in the sympathetic,
regulating anxiety and tension
 Dopamine: inhibiting, abnormalities in the limbic sys
implicate schizophrenia
 Serotonin: inhibiting, calming the nervous system,
regulating consciousness, mood, appetite, sleep and
sexual behavior
 Gaba (gamma-aminobutric acid):very inhibiting;
controlling neural excitement. Very responsive to
anti-anxiety agents and etoh
 Glutamate: pre-cursor of gaba; excitatory.
Overstimulation here has been implicated in various
dx, e.g, alzheimers and schizophrenia

 Pharmacokinetics
 Administration
 Absorption thru the bloodstream.
 Distribution thru the blood stream, by dissolution in the
plasma or binding to plasma proteins.
 Metabolism: breakdown into derivatives or metabolites.
 Excretion usually thru the kidneys once it moves from
lipid to water solubility
 Blood level refers to the amount of availability of the
drug in the body. The steady state is achieved when
there is a consistent amount of the drug in the
plasma. The peak is the immediate and greatest
concentration of the drug in the body.
 Half life: biochemists refer to the time it takes for a 50%
drop of a drug from its peak level.

 Pharmacodynamics
 Therapeutic index is the ratio of the lowest average
concentration needed to produce a desired effect
to the lowest average concentration that produces
a toxic effect
 Potency is measured in mg, grm, mcg, ml, cc
 Dose response: as the dose increases, the effect also
increases to a point sometimes known as the
therapeutic window.
 Lag time is the time it takes for a drug to be effective.
 Tolerance: once achieved, response decreases
 Adverse effects

Side Effects
 Anticholinergic drying thru suppression of
the pyramidal nerve paths. They block
cholinergic receptors
 EPS:
 Akithisia (restless)
 Akinesia (inability to initiate
movement)
 Dystonias (cramped/twisted
muscular experience)
 Parkinson (tremor and fine motor
discoordinatio, shuffling gate,
drooling)
 Tardive Dyskinesia (involuntary
Side Effects continued

 NMS: hyperthermia, rigidity and fluctuating

LOC
 Cardio-vascular: tachycardia, orthostasis,
EKG changes, arrythymias, dizziness,
headache
 Sedation
 Sexual dysfunction: desire and capacity
(ANS disruption)
 Metablolic syndrome: increase cholesterol,
weight gain, diabetes
 GI: cramps, n &v, diarrhea
 Side Effects (con’t)
 CNS: memory impairment, seizures,
confusion, disorientation
 Serotonin syndrome*
 Teratogenic
 Dermatological
 *confusion, hypomania, hallucinations,
agitation, headache, coma, shivering,
sweating, fever, hypertension,
tachycardia, nausea, diarrhea

 Helping Patients with
Side Effects
 Severity of side effects
 Severity of the illness
 Patient ability to tolerate
 Time
 Therapeutic index and dose adjustment
 Availability of other agents

 Medication Classes
 Anxiolytics

 Antidepressants

 Mood stablizers

 Antipsychotics


 Antidepressants
 MAOIs

 TCAs

 SSRIs

 SNRIs

 Atypical
 Monamine Oxidase
Inhibitors
 Mechanism of action is theinhibition of enzymes that metabolize
neuroepinephrine and serotonin. Also inhibits dopamine
 The major concern with the MAOIs is the dietary restriction which if
not followed cd cause a hypertensive crisis. MAO interacts with
tyramine, an amino acid derivative. Some of these foods are
chocolate, cheeses, red wine, banana skins, caffeine, beer, certain
pickled foods
 Most common: nardil ( phenelzine); Parnate ( tranylcypromine);
Marplan (Isocarboxazid).
 These meds tend not to be sedative and have no ACH s/e
 Doses are usually 15 mg to 90 mg.



 Tricyclic / Tetracyclic
 These drugs have a long half life hence can usually be Rx in
daily dosing. They are notable for their anticholinergic SE,
orthostasis, and sedation. Dosing usually begins fairly low
and will be titrated as the patient appears to tolerate the SE.
therapeutic effects will occur in 2 – 6 weeks. Known to be
effective in 60% of consumers. Although clients may need to
start and d/c a number of trials before they experience
benefit.


 SE: can include anxiety, sedation, short term memory loss,
sexual dysfunction, weight gain.


 SSRIs
Prozac, Paxil, Luvox, Lexapro, Zoloft came on the


market in the 80s. Fluoxetine being the first. A

little better in efficacy. Longer half –life. Better
SE profile. Generally do not have ach s/e. Lower
sedating are paxil (paroxetine) and effexor
(venalfaxine) and lower toxicity. These drugs are
sometimes given at the therapeutic dose as opposed
to titration. The SSRIs in particular have also been
known to be effective with OCD, anxiety, PMS and
eating d/o
 SNRI


Serotonin and nor-epinephrine re-uptake



inhibitors (cymbalta/duloxetine,
effexor/venalfaxine)
 Atypical
Work on differing combinations of neurotransmitter


blockade. May also have varying half-life.

Wellbutrin is very popular and is particularly
known for its stimulating effect acting as a
dopamine agonist and indirectly increase in
neurepinephrine. Also know for its relative absence
of sexual S/E. There is some concern for its
lowering of the sz threshold.
 Mood Stablizers
 Lithium
 Anticonvulsants
 Antidepressants
 Antipsychotics

 Lithium
 First used in the early 19th century for kidney stones and gout.

 1940s an Austrian MD inadvertently discovered Li use in mania by studying the uric acid content of
persons with mania

 widespread use in 1970.

 effective in a good percentage of persons with BAD but it also highly toxic

 needs to be taken in multiple daily doses due to it relatively short half life.

 Tim release preparations that provide opportunity for TID or BID dosing.

 Toxicity requires regular monitor of kidney and thyroid function at the start of treatment and in
relatively frequent intervals following.

 Once stabilized, q 6 or 12 mos is sufficient.

 Important for the pt to not take medication for 12 hours before lab assay

 Not given in the acute phase as it takes a few weeks to stablize a pt. Anti-psychotic medications are
almost always given during the acute phase and becoming first line for many pts


 Anticonvulsants
An increasing a number of medications that were


initially indicated for sz d/o and have been found

to be helpful in the tx of BAD. In general they
work faster, have a higher therapeutic index (and
therefore less toxic). There mechanism of action is
not fully understood except that it appears that like
in sz d/o, the limbic system is vulnerable to a
kindling effect that causes excitatory neuronal
firing of Na ions hence mania
 Specific
anticonvulsant agents
 Tegretol (carbamazepine): requires monitoring of the
WBC. Use can cause a decrease in the WBC
(leukopenia).
 Valproic Acid (depakote): blocking Na channels and
impacting GABA; weight gain is a s/e
 Neurontin (Gabepentin) acting somewhat as an agonist for
GABA; also used for pain, anxiety; its use in BAD is
considered to be off-label
 Lamactil (Lamotrigine) : may act as a Na ion channel
blocker; is approved for BAD; there is a black box
warning for possible cause of Stevens Johnson
syndrome

 Antipsychotic Meds
Phenothiazines ( three subclasses)


 Discovered in the 1950s and heralded for their facilitation of deinstutionalization

 CPZ or thorazine was the first
 The less potent and are effective largely due to their sedating effects
 Notorious for their EPS (akithesia, Parkinson, TD, muscle dystonias) & anti-cholinergic,
photosensitivity, wt gain, sunburn and sexual side effects. The most serious side
effect is NMS.
 Efficacy may be as low as 30% although newer anti-psychotics have been touted as being
more efficacious, as high as 65%.


 Haldol
 Haldol which is probably the medication that was
most used in emergency situations
 Potency is measured the degree of dopamine
receptor blockade. Occupancy at the D2
receptors is cited as the mechanism of action
for decreasing the positive symptoms of
schizophrenia
 The more potent the drug, the greater the
potential for EPS but less anticholinergic
S/E.
 Long acting agents that are injected in fat
tissue, usually the gluteus or deltoid
 Newer Generation
 Newer meds act on a wider variety of
neurotransmitters and quickly bind and release
from the D2 receptors. Effectiveness is also
attributed to 5HT2 (serotonin) blockade hence
some impact on negative ss.
 Improved s/e profile, less EPS
 May impact perceptual, thought, motor, affective
and interpersonal disturbances

 Newer Generation
 Clozaril: effective and promised to impact
negative sx. SE: Agranulacytosis
 Risperidone
 Olanzapine: metabolic syndrome
 Quetiapine: smaller contribution to metabolic
syndrome
 Others: ziprasidone, aripiprazole
 EPS and Parkinson
Treatment
 Amantadine

 Bromocriptine

 Cogentin

 Artane

 Benedryl


 General
Considerations
 Gender, size, race and ethnicity, personality, medical illness, psychiatric dx
 What is recovery: optimism and strengths based
 Trial and error
 Education
 Provider relationship: partnering with the client; being open and direct; de-
mystifying the process; being aware of the power dynamics; to be
available and to be used as a resource
 Use of family and supports
 Inventory of all that the individual is placing in their body
 Effectiveness
 Side effect
 Drug interactions
 Client choice and negotiation
 Non-compliance
 Monitoring, evaluation and laboratory assay


 Barriers to
Compliance
 Highest with anti-psychotics

 Effectiveness

 Lack of insight, denial

 Disorganization and lack of structure

 Sedation and sexual side effects

 Strategies to improve
compliance
 Patient inclusion and negotiation

 Depot

 Reminders and Structure

 Motivation and rewards

 Directly observed therapy


 Substance Abuse
Criteria
Defined as a maladaptive pattern of substance use leading to


clinically significant impairment or distress as manifested by

one (or more) of the following, occurring within a 12-month
period:

1. Recurrent substance use resulting in a failure to fulfill major role



obligations at work, school, or home

2. Recurrent substance use in situations in which it is physically



hazardous

3. Recurrent substance-related legal problems (such as arrests for



substance related disorderly conduct)

4. Continued substance use despite having persistent or recurrent



social or interpersonal problems caused or exacerbated by the

effects of the substance (for example, arguments with spouse
about consequences of intoxication and physical fights).
 Substance
Dependence Criteria
Three of more of the following in a 12 month period:


 1. Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of the

substance to achieve intoxication or the
desired effect or
(b) Markedly diminished effect with continued use
of the same amount of the substance.
 2. Withdrawal, as manifested by either of the following:
 (a) The characteristic withdrawal syndrome for the
substance or
 (b) The same (or closely related) substance is taken to
relieve or avoid withdrawal symptoms.
 3. The substance is often taken in larger amounts or over a
longer period than intended.
Dependence Criteria
Continued
 4. There is a persistent desire or unsuccessful efforts
to cut down or control substance use.
 5. A great deal of time is spent in activities necessary
to obtain the substance, use the substance, or
recover from its effects.
 6. Important social, occupational, or recreational
activities are given up or reduced because of
substance use.
 7. The substance use is continued despite knowledge
of having a persistent physical or psychological
problem that is likely to have been caused or
exacerbated by the substance
 Treatment for
Substance Abuse
 Etoh Withdrawal Guidelines
 Psychosocial approaches
 Case management
 CBT
 Motivational Interviewing
 Harm Reduction
 Mutual Help Groups
 Traditional 12-step programs
 Alternatives
 Alcohol Withdrawal
Minor Withdrawal Symptoms:


-occur within 6 hours of cessation



-Insomnia, tremulousness, mild anxiety, GI upset,



diaphoresis, HA, palpitations, and anorexia.

-Usually resolves within 24-48 hrs.



-Varies from episode to episode




 Seizures
-Within 48 hours of last drink


-Generalized tonic-clonic seizures



-3% of chronic alcoholics develop this



-3% of those who seize develop Status Epilepticus




 Alcoholic Hallucinosis
- 12- 24 hr. onset after last drink


- Usually visual


- Resolves within 24-48 hr.



- NOT synonymous with DT’s



*other signs may or may not be present



 * time course is different

not usually associated with clouding of sensorium



 Delirium Tremens
-
 5% of patients

- Typically begins between 48 & 96 hours

- Typically lasts 1-5 days

-

 DT Symptoms
 Hallucinations

 Disorientation

 Tachycardia

 Hypertension

 Low Grade Fever

 Agitation

 Diaphoresis

 Hyperventilation and Respiratory alkalosis which result in reduced cerebral blood

flow

 Clouding of the Sensorium


 Intervention
 Very frequent monitoring

 Low stimulus environment

 MVI, Thiamine, Folate

 Clinical Institute
Withdrawal Assessement
Guidelines
Mild Symptoms (CIWA-score <8-10) reasonable option


is non-pharmacological supportive therapy and

continued monitoring.
Moderate Symptoms (score 8-15) symptomatic


administration of medications, with hourly

assessment. Regimen recommended :
 1. Librium 50-100 mg OR
 2. Valium 10-20 mg OR
 3. Ativan 2-4 mg.

 CIWA (con’t)
Severe Symptoms (score >15) - Fixed


scheduled in the amounts necessary to

control symptoms. Recommended:
 1. Librium: 50 mg q 6 hrs. x 4 doses then
25 mg q 6 hrs. x 4 doses
 2. Valium: 10 mg q 6 hrs. x 4 doses then
5 mg q 6x 8 doses
 3. Ativan: 2 mg q 6 x 4 doses then 1 mg
q6 x 8 doses.

 DT Management
 Pts. In DTs should receive IV diazepam 5-10 mg
every 5 minutes until pt. is alert but calm.
 Continue IV administration of Diazepam until
pt. is no longer delirious and absorption from
gut is reliable.

 N&V
Ask “Do you feel sick to your stomach? Have


you vomited?” Observation:

0 No nausea and no vomiting



1 Mild nausea with no vomiting



4 Intermittent nausea with dry heaves



7 Constant nausea, frequent dry heaves and



vomiting
 Sweats
Observation:


0 No sweat visible


1 Barely perceptible sweating, palms moist



4 Beads of sweat obvious on forehead



7 Drenching sweats

 Anxiety
Ask “Do you feel nervous, anxious or


shakey?” Observation:
 0 No anxiety, at ease
 1 Mildly anxious
 4 Moderately anxious, or guarded, so
anxiety is inferred
 7 Equivalent to acute panic states as
seen in severe delirium or
 Agitation
Observation:


0 Normal activity


1 Somewhat more than normal activity



4 Moderately fidgety and restless



7 Paces back and forth during most of the



interview, or constantly thrashes about

 Tactile disturbances
Ask “Have you any itching, pins and needles sensations, any


burning, any numbness or do you feel bugs crawling on or

under your skin?” Observation:

0 None


1 Very mild itching, pins and needles, burning or numbness



2 Mild itching, pins and needles, burning or numbness



3 Moderate itching, pins and needles, burning or numbness



4 Moderately severe hallucinations



5 Severe hallucinations


6 Extremely severe hallucinations



7 Continuous hallucinations

 Auditory
Ask “Are you more aware of sounds around you? Are they harsh? Do they


frighten you? Are you hearing anything that is disturbing you? Are you
hearing things you know are not there?” Observation:

0 Not present


1 Very mild harshness or ability to frighten



2 Mild harshness or ability to frighten



3 Moderate harshness or ability to frighten



4 Moderately severe hallucinations



5 Severe hallucinations


6 Extremely severe hallucinations



7 Continuous hallucinations

 Visual
Ask “Does the light appear to be too bright? Is its colour different? Does it


hurt your eyes? Are you seeing anything that is disturbing you? Are you
seeing things you know are not there?” Observation:

0 Not present


1 Very mild sensitivity



2 Mild sensitivity


3 Moderate sensitivity


4 Moderately severe hallucinations



5 Severe hallucinations


6 Extremely severe hallucinations



7 Continuous hallucinations

 Headache
Ask “Does your head feel different? Does it feel like there is a band


around your head?” Do not rate for dizziness or

lightheadedness. Otherwise, rate severity.

0 Not present


1 Very mild


2 Mild


3 Moderate


4 Moderately severe


5 Severe


6 Very severe


7 Extremely severe

 Orientation and
Sensorium
Ask “What day is this? Where are you? Who


am I?”

0 Orientated and can do serial additions



1 Cannot do serial additions or is uncertain



about the date

2 Disorientated for date by no more than 2



calender days

3 Disorientated for date by more than 2



calender days

4 Disorientated for place and/or person


 Tremor
Arms extended and fingers spread


apart. Observation:
0 No tremor


1 Not visible, but can be felt fingertip



to fingertip
4 Moderate, with patient’s arms


extended
7 Severe, even with arms not


extended
 Co-morbid
Pharmacological
Guidelines
 Treat both disorders: pharmacological and
psychosocial
 Differential diagnosis
 Patient motivation and benefit for use
 Consider using pharmacological antagonists
 Treat during withdrawal, of course considering
interactions
 Minimize use of meds that have a potential for abuse
and dependence
 Continue to treat the psychiatric disorder while the
client continues to use while maintaining safety
and evaluation of effectiveness
 Use of laboratory assay to determine interactions and
presence of other drugs

 Guidelines (continued)

 Atypical antipsychotics are preferred in tx of psychosis

 SSRIs and SNRIs may be very helpful in attenuating substance
use; buproprion may be helpful for craving
 Use of certain non-TCA antidepressants may be helpful for
sleep
 When benzos are necessary, the longer acting may decrease the
propensity for abuse (Librium and serax).
 Benzos are the tx of choice for etoh w/d
 Use of stimulants for adult ADD requires careful diagnosis.
Strattera should also be considered
 Naltrexone and Acamprosate may be used for craving
 Antabuse and modafinil has been shown to have some effect
in coke abuse
