Introduction to Psychopharmacology

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Introduction to Psychopharmacology

• September 14, 2004

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Schedule of Drugs

• Developed in 1970 by the DEA to aid in the
  regulation of controlled substances.
• Drugs are placed on 1 of 5 schedules in
  accordance with 1) accepted medical use and 2)
  abuse / addiction potential.
• A schedule 1 drug (crack, heroin, marijuana) has
  no accepted medical use and is considered to have
  a high abuse / addiction potential. Whereas a
  schedule 5 drug (cough syrup) is widely accepted
  for medical use and is considered to have a
  little to no abuse / addiction potential.
• Schedule 2 and 3 drugs are ones typically used to
  treat psychosis and mood disorders. For these
  drugs, you need a prescription to have then in
  your possession.

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Blood / Brain Barrier

• BBB is semi-permeable
• Protects the brain from foreign substances in
  the blood that may injure the brain.
• Protects the brain from hormones in the rest of
  the body.
• Maintains a constant environment for the brain.

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CNS Neurotransmitters

• 4 Main Classes
• Acetylcholine (excitation)
• Monoamines (inhibition)
• Norepinephrine
• Dopamine
• Serotonin
• Amino Acids (excitation / inhibition)
• GABA
• Glycine
• Glutamate
• Aspartate
• Peptides (excitation)
• Substance P
• Enkephalins
• Monoamines are implicated in mood disorders,
  psychosis and anxiety. These neurotransmitters
  are found in the limbic system, a part of the
  brain associated with the the regulation of
  sleep, appetite, and emotional responses.

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Mood Disorders

• There are two major types of mood disorders
  Depressive Disorders and Bipolar Disorders
• Depression affects females approximately 2x more
  than males
• Most common psychological disorder in the U.S.

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What Defines Depression?

• AFFECTIVE depressed mood, feelings of sadness,
  dejection, and excessive/prolonged mourning,
  feelings of worthlessness, and a loss of joy for
  living
• BEHAVIORAL social withdrawal, lowered work
  productivity, low energy levels is the dominant
  behavioral symptom

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continued

• COGNITIVE feelings of futility, emptiness, and
  hopelessness, profound pessimistic beliefs about
  the future, disinterest, decreased energy, and
  motivation towards work and life in general
• PHYSIOLOGICAL change of appetite, weight
  change, constipation, sleep disturbance,
  menstrual abnormalities, and lack of libido

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Medications

• 3 classes of meds for depression
• Tricyclics - effect norepinephrine - include
  Elavil, Emitrip, Pertofrane, and Janimine
• MAO inhibitors - effect norepinephrine - include
  Marplan, Nardil, Parnate
• 2nd Generation of medications (including SSRIs) -
  effect seretonin - include Wellbutrin, Prozac
  (SSRI), Zoloft (SSRI), and Paxil (SSRI)

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How they work

• Tricyclics and SSRI work the same, but for a
  different monoamine (norepinephrine and serotonin
  respectively). Each 1) prevents the reuptake in
  the synapse allowing the neurotransmitter more
  time to be absorbed into the second neuron and 2)
  increases the number of receptor cites the
  neurotransmitter can be absorbed through.
• MAO inhibitors prevent the MAO enzyme from
  breaking norepinephrine down allowing it to
  remain in the synapse.

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Why was there a need for a new generation?

• Tricyclics can cause dry mouth, excessive sweat,
  blurred vision, sexual dysfunction.
• MAO inhibitors have less effects, but can damage
  the liver, cause severe low blood pressure, or be
  fatal. So they are not prescribed nearly as much
  as tricyclics.
• SSRI can cause a person to become nervous, angry,
  or weak however the side effects last a shorter
  amount of time.
• SSRI usually take 2 weeks to build up effective
  levels whereas tricyclics and MAO inhibitors take
  approx. 4 weeks. Furthermore the side effects of
  SSRIs usually last a shorter time.

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Vocational Implications

• Client exhibits decreased motivation for work
  productivity
• Client exhibits decreased energy
• Both lead to employee loss of time at work
• Sleep disturbance can also cause absenteeism
• Cognitive difficulties, i.e. concentration,
  memory, decision-making
• Can be associated with other illnesses (cancer,
  diabetes, cardiac problems)
• Side effects from medication

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ACCOMMODATIONS FOR DEPRESSIVE DISORDER

• Flexibility in work schedule
• Time for treatment (medical/psychological)
• Reduction of workload during active stage of
  disorder

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Bipolar Disorder

• Affects approximately 1.2 of the population.
• Characterized by mood shifts from depression to
  mania.

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Bipolar

• Symptoms for a manic episode include elevated
  persistence, irritability, grandiosity, decreased
  need for sleep, distractibility, and
  social/occupational impairment
• Usually accompanied by
• psychosis altered mental state
• (auditory and visual hallucinations)
• delusions believing something about
• yourself that is not true (ability to fly)

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Bipolar

• Bipolar can easily be misdiagnosed as
  schizophrenia and depression because of the
  similar symptoms one can have.
• Remember a person with bipolar disorder is
  unlikely to seek treatment while in the manic
  phase unless Baker Acted (committed).
• A typical cycle for Bipolar ranges from several
  weeks to a several months. No one is depressed,
  then manic in one or two days.

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Medications for Bipolar

• People with bipolar usually take a medication to
  even out their mood.
• Lamictal and Tegretol are most commonly used.
  Lithium is the old standby medication, but not
  that common anymore.
• Why would med compliance be more difficult in a
  person who is in a manic phase of his disorder?

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Side Effects of Bipolar Medications

• Headache
• Fatigue
• Drowsiness
• Dizziness
• Blurred vision
• Joint aches

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Vocational Implications

• Very similar to depression, but during stages of
  mania
• Work relationship difficulties
• Concentration difficulties
• Lack of focus or attention
• Side effects to medication

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Accommodations

• Similar modifications for a person with
  depressive disorders

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Schizophrenia

• Group of disorders characterized by severely
  impaired cognitive processes, personality
  disintegration, affective disturbances, and
  social withdrawal
• 4 main types of schizophrenia paranoid,
  disorganized, catatonic, and residual
• Approximately 1 of the population
• Not a result of poor parenting, the brain just
  develops differently
• Is NOT Multiple Personality Disorder

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Schizophrenia

• Paranoid Schizophrenia extreme suspicion,
  persecution, or grandiosity, or a combination of
  these feelings
• Disorganized Schizophrenia incoherent speech
  and thought, but may not have delusions

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Schizophrenia

• Catatonic Schizophrenia withdrawal, mute,
  negative, and often assumes unusual body
  positions
• Residual Schizophrenia no longer experiences
  delusions or hallucinations, but no longer has
  motivation in life

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Positive Symptoms

• Delusions
• Delusions of Grandeur- belief that one is a
  famous or powerful person
• Delusions of Control- belief that other people,
  animals, or objects are trying to control of one
• Delusions of Thought Broadcasting- belief that
  one can hear the thoughts of the individual
• Delusions of Persecution- belief that others are
  plotting against one, maybe trying to kill one
• Delusions of Reference- belief that one is always
  the center of attention, or all things revolve
  around oneself
• Thought Withdrawal- belief that ones thoughts
  are being removed from ones mind

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Positive Symptoms

• Hallucinations (occurs for all senses)
• Loosening of Associations- cognitive slippage and
  neologisms

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Negative Symptoms

• Anhedonia - inability to feel pleasure
• Avolition - inability to take action or become
  goal-oriented
• Alogia - a lack of meaningful speech
• Flat Affect- little or no in situations where
  strong reactions are expected

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Medications

• Medications- Haldol, Thorazine, Zyprexa,
  Clozaril, and other neuroleptics
• Effect the dopamine and serotonin levels
• Side effects can occur from these meds, such as
  Parkinson-like symptoms, blurred vision, weight
  gain, skin problems, dystonia (muscle
  contraction), ticks, and tremors
• Leads to taking Parkinsons meds or treatment for
  Tardives Dyskinesia (except Clozapine)

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Vocational Implications

• Confused thinking or strange, grandiose ideas
• Heightened anxieties, fears, anger, or suspicions
• Blaming others
• Social withdrawal, diminished friendliness, and
  increased self-centeredness

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Vocational Implications

• Denial of obvious problems and strong resistance
  to offers of help
• Substance abuse
• Side effects from the meds for treatment

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Accommodations

• Flexible scheduling
• Additional time to learn new responsibilities or
  self-paced workload
• Reduced distractions and/or stimulus in workplace
• Allowed use of white noise, or environmental
  sound machine
• Increased natural lighting (artificial lighting
  is no good!)
• Daily to-do list
• Allow employee to tape record meetings and other
  important information
• Sensitivity training for the other employees
• Limit change in the workplace KEEP THINGS
  STRUCTURED

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Anxiety

• Generalized Anxiety Disorder (GAD)
• GAD is characterized by excessive, unrealistic
  worry that lasts six months or more in adults,
  the anxiety may focus on issues such as health,
  money, or career. In addition to chronic worry,
  GAD symptoms include, excessive sweating,
  muscular aches, jumpiness, insomnia, abdominal
  upsets, dizziness, and irritability.

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Anxiety

• Panic Attacks
• People with panic disorder suffer severe attacks
  of panic-which may make them feel like they are
  having a heart attack or are going crazy-for no
  apparent reason. Symptoms include heart
  palpitations, chest pain or discomfort, sweating,
  trembling, tingling sensations, feeling of
  choking, fear of dying, fear of losing control,
  and feelings of unreality. Panic disorder often
  occurs with agoraphobia, in which people are
  afraid of having a panic attack in a place from
  which escape would be difficult, so they avoid
  these places.

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Anxiety

• Social Anxiety Disorder
• Social Anxiety Disorder (SAD) is characterized by
  extreme anxiety about being judged by others or
  behaving in a way that might cause embarrassment
  or ridicule. This intense anxiety may lead to
  avoidance behavior. Physical symptoms associated
  with this disorder include heart palpitations,
  faintness, blushing and profuse sweating.

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Medications for Anxiety

• Most anti-depressant meds are also used to treat
  anxiety (especially SSRIs)
• In addition to the these medications,
  benzodiazepines, including Valium (GAD) and Xanax
  (panic disorder) are used to treat anxiety.

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Side Effects

• High-potency benzodiazepines relieve symptoms
  quickly and have few side effects, although
  drowsiness can be a problem. Because people can
  develop a tolerance to them and would have to
  continue increasing the dosage to get the same
  effect, benzodiazepines are generally prescribed
  only for short periods of time.

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Vocational Limitations

• Job seeking
• New tasks tend to be problematic
• Avoiding highly charged work environments
• Depending on the type of anxiety disorder,
  certain work places and / or functions are
  limited. (i.e. someone with social anxiety would
  be uncomfortable doing public speaking)

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Accommodations

• Scheduled weekly visits with supervisor
• Provide space enclosures or a private office
• Divide large assignments into smaller tasks and
  goals
• Allow telephone calls during work hours to
  doctors and others for needed support
• Provide praise and positive reinforcement
• Provide a self-paced work load and flexible hours

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As a counselor

• Do not tell an employer or anyone else the
  persons diagnosis. When you talk to an employer
  you can tell him or her that your client has
  certain limitations. Empower the client to make
  his or her own choices about whom he or she
  discloses information to.
• Be careful how you reinforce medication
  compliance. Be sure to reinforce the fact that
  the person has taken the responsibility to take
  his or her meds.