St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Neuroscience of Psychiatry and Psychiatric Nursing Pathophysiology of Mental
Illnesses

[Classification and Diagnosis in Psychiatry]

I.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition (DSMIV-TR).
Published in 2000 by the American Psychiatric Association.
Official Classification System used by all mental health professionals to diagnose psychiatric
disorders.
Contains diagnostic criteria for 17 major categories of mental disorders.
A similar system is used in Europe called the International Statistical Classification of
Diseases and Related Health Problems (ICD)
Both ICD and DSM-IV-TR use the same numerical codes for each disorder.

Group of Conditions in DSM-IV-TR

Disorders usually first diagnosed in infancy, childhood, and adolescence
Delirium, Dementia, amnestic, and other cognitive disorders
Mental Disorders due to general medical condition
Substance related disorders
Schizophrenia and other psychotic disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and gender identity disorders
Eating Disorders
Sleep Disorders
Impulse-control disorders not elsewhere classified
Adjustment Disorders
Personality Disorders
Other conditions that may not be a focus of clinical attention
In addition to DSM-IV-TR classifications, other terms are used in psychiatry to describe mental
illness as follows:
A. Psychotic Loss of reality testing with delusions and hallucinations (e.g
Schizophrenia).
B. Neurotic No loss of reality testing; based on mainly intrapsychic conflicts or life events
that cause anxiety; symptoms include obsession, phobia, and compulsion.
C. Functional No known structural damage or clear-cut biological cause to account for
impairment.
D. Organic Illness caused by a specific agent producing structural change in the brain;
usually associated with cognitive impairment, delirium, or dementia (NOT USED IN
DSM-IV-TR)
E. Primary No known cause; also called idiopathic (similar to functional)

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
F. Secondary Known to be a symptomatic manifestation of a systemic, medical, or
cerebral disorders.

II.

Schizophrenia and Other Psychotic Disorders

- Covers disorders manifested by disturbances of thinking and misinterpretation of
reality, often with delusions and hallucinations.

1. Schizophrenia
- Characterized by changes in:
Affect (ambivalent, constricted, inappropriate responsiveness; loss of empathy
with others)
Behavior (withdrawn, aggressive, bizarre)
Thinking (distortion of reality, sometimes with hallucinations and delusions)
Cognition
Five Types:
A. Disorganized (Hebephrenic) Type
- Disorganized thinking, giggling, shallow and inappropriate affect, silly and
regressive behavior and mannerisms, frequent somatic complaints, and
occasional transient and unorganized delusions and hallucinations.
B. Undifferentiated Type
- Disorganized behavior with prominent delusions and hallucinations
C. Catatonic Type
A. Excited Subtype characterized by excessive and sometimes violent motor activity.
B. Withdrawn Subtype characterized by generalized inhibition, stupor, mutism,
negativism, waxy flexibility, and in some cases a vegetative state.
D. Paranoid Type
- Characterized by persecutory or grandiose delusions and sometimes by
hallucinations or excessive religiosity, and the patient is often hostile and
aggressive.
E. Residual signs of schizophrenia, after a psychotic schizophrenic episode, in
patients who are no longer psychotic. (occurs during the residual phase as a form of
Postpsychotic Depressive Disorder of Schizophrenia)
2. Delusional (Paranoid) Disorder
- Associated with persistent delusions (eromatic, grandiose, jelous, persecutory
somatic, unspecified)
Paranoia rare condition characterized by gradual development of an elaborate
delusional system with grandiose ideas; it has a chronic course; the rest of the
personality remains intact.
3. Brief Psychotic Disorders less than 4 weeks in duration brought on by an external
stressor.
4. Schizophreniform Disorder similar to schizophrenia, with delusions, hallucinations,
and incoherence, but lasts less than 6 months.
5. Schizoaffective Disorder characterized by a mixture of schizophrenic symptoms and
pronounce elation (bipolar type) or depression (depressive type)

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
6. Shared Psychotic Disorder same delusion occurs in two persons, of of whom is less
intelligent than or more dependent on the other (aka share delusional disorder, folie a
deux)
7. Psychotic disorder resulting from a general medical condition hallucinations or
delusions that result from a medical illness (meningitis)
8. Substance-induced psychotic disorder caused by psychoactive or other substances
(e.g cocaine)
9. Atypical Psychosis related to:
Specific Culture Koro found in South and East Asia, fear of shrinking penis
Certain Time or Event post-partum psychosis 48-72 hours after childbirth

III.

Personality Disorders
- Disorders characterized by deeply ingrained, generally lifelong maladaptive
patterns of behavior that are usually recognizable at adolescence or earlier.

1. Paranoid characterized by unwarranted suspicion, hypersensitivity, jealousy, envy,

excessive self-importance, and a tendency to blame and ascribe evil motives to others.
2. Schizoid characterized by shyness, oversensitivity, seclusiveness, avoidance of close
or competitive relationships, eccentricity, daydreaming, an ability to express hostility and
aggression; no loss of capacity to recognize reality.
3. Schizotypal similar to schizoid, but the person exhibits loss of reality testing, has odd
beliefs, and is aloof and withdrawn.
4. Obsessive-compulsive characterized by excessive concern with conformity and
standards of conscience; patient may be rigid, overconscientious, overdutiful,
overinhibited, and unable to relax. (Three Ps Punctual, Parsimonious, Precise)
5. Histrionic characterized by emotional instability, excitability, overreactivity, vanity,
immaturity, dependency, and self-dramatization that is attention seeking and seductive.
6. Avoidant characterized by low levels of energy, easy fatigability, lack of enthusiasm,
inability to enjoy life, and oversensitivity to stress.
7. Antisocial covers persons in conflict with society. Incapable of loyalty and are selfish,
callous, irresponsible, impulsive, and unable to feel guild or learn from experience; low
level of frustration tolerance and tendency to blame others.
8. Narcissistic characterized by grandiose feelings, sense of entitlement, envy,
manipulativeness, lack of empathy, and need for attention and admiration.
9. Borderline characterized by instability, impulsiveness, chaotic sexuality, suicididal
acts, self-mutilating behavior, identity problems, ambivalence, and feeling of emptiness
and boredom.
10. Dependent characterized by passive and submissive behavior; person is insure of
himself or herself and becomes entirely dependent on others.

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
[Psychiatric History and Mental Status]
I.

Psychiatric History

Record of the patients life

Allows us psychiatric health professionals to understand who the patient is, where the patient
has come from, and where the patient is likely to go in the future.
Patients life story in the patients own words from his or her own point of view
May include information about the patient from other sources such as parents or spouse.
A THOROUGH PSYCHIATRIC HISTORY IS ESSENTIAL IN MAKING A CORRECT
DIAGNOSIS AND FORMULATING A SPECIFIC TREATMENT PLAN
II.

Mental Status Examination

Description of the patients appearance, speech, actions, and though during the
interview.
Systematic format for recording findings about thinking, feeling, and behavior.
A PATIENTS HISTORY REMAINS STABLE, WHEREAS THE MENTAL STATUS CAN
CHANGE DAILY OR HOURLY
Only phenomena observed at the time of interview are recorded in the mental status.

III.

Components of a Psychiatric History

A. Identification
1. Name, Age, Marital Status, Sex, Occupation, Language, Race, Nationality,
Religion.
2. Previous admissions to a hospital for the same or different condition.
3. Person in whom the patient lives.
B. Chief Complaint
1. Describes why the patient was admitted, preferably in the patients or
significant others own words.
C. History of Present Illness
1. Chronological background and development of the symptoms or behavioral
changes that culminated in the patient/significant other seeking assistance.
2. Patients life circumstance at the time of onset
3. Personality when well; how illness has affected life activities and personal
relations changes in personality, interest, mood, attitude towards others,
dress, habits, level of tenseness, irritability, activity, attention, concentration,
memory, speech.
4. Psychophysiological symptoms nature and details of dysfunction; pain
location, intensity, fluctuation.
5. Level of Anxiety generalized and nonspecific (free floating) or specifically
related to particular situations, activities, or objects.
6. How Anxieties are handled avoidance, repetition of feared situation.
7. Use of drugs or other activities for allevation.
D. Past Psychiatric and Medical History
1. Emotional or Mental Disturbances extent of incapacity, type of treatment,
names of hospitals, length of illness, effect of treatment.
2. Psychosomatic Disordres: arthritis, chronic fatigue, recurrent colds, skin
conditions.
3. Medical Conditions customary review of systems, sexually transmitted
diseases, alcohol or other substance abuse
4. Neurological Disorder headache, craniocerebral trauma, loss of
consciousness, seizures, tumors.

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
E. Family History
1. Elicited from patient and from someone else, because quite different
descriptions may be given of the same people and events.
2. Ethnic, national, and religious traditions.
3. List of other people in the home and descriptions of them personality and
intelligence and their relationship to the patient.
4. Role of illness in the family
F. Personal History (Anamnesis)
NOTE: early developmental history may not be as relevant for adults as for
children and adolescents.
1. Early Childhood (through 3 years of age)
2. Middle Childhood (3-11 years of age)
3. Late Chilldhood (prepuberty thorugh adolescence)
4. Adulthood

IV.
Mental Status
A. Appearance
1. Personal identification
- Brief nontechnical description of the patients appearance and behavior, as a
novelist may write it.
- Attitude towards examiner (cooperative, attentive, interested, frank, seductive,
defensive, hostile, playful, ingratiating, evasive, or guarded)
2. Behavior and Psychomotor Activity:
- gait, mannerisms, tics, gestures, twitches, touching examiner, echopraxia,
clumsy, rigid, retarded, hyperactive, agitated, combative or waxy.
3. General Description
- Posture, bearing, clothes, grooming, hair, nails; healthy, sickly, angry, frightened,
apathetic, perplexed, poised, old looking, young looking, effeminate, masculine
- Signs of Anxiety moist hands, perspiring forehead, restlessness, tense posture,
strained voice; shifts in level of anxiety during interview or with particular topic.
(50% of Eye Contact is Normal)
B. Speech:
- Rapid, slow, pressured, hesitant, emotional, monotonous, loud, whispered,
slurred, mumbled, stuttering, echolalia, intensity, pitch, ease, spontaneity,
manner, reaction time, vocabulary.

C. Mood and Affect

1. Mood
- Pervasive and sustained emotion that colors the persons perception of the world.
- How the patient say he or she feels: depressed, despairing, irritable, anxious,
terrified, angry, euphoric, empty, guilty, futile, anhedonic.
2. Affect
- Outward expression of the patients inner experiences
- Whether the emotional expression is appropriate to the though content, culture,
and setting of the examination.
D. Thinking and Perception
1. Form of Thinking Flight of Ideas, Loose Assocations, Icoherent Speech (Word
Salad)
2. Content of Thinking obcessions, compulsions, phobias, plans about
suicide/homicide
3. Thought Disturbances delusions, ideas of reference, thought broadcasting, though
insertion
4. Perceptual Disturbances hallucinations and illusions
5. Dreams and Fantasies includes nightmares, recurrent, favorite, or unshakable
daydreams.

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
E. Sensorium
1. Alertness
2. Orientation
3. Concentration and Calculation
4. Memory
V.

Maltaxial Classification

A.
Axis I: All Clinical Syndromes and other conditions that may be focus of clinical attention (e.g
Mood Disorders, Schizophrenia)
Axis II: Includes personality disorders and mental retardation (Including Defense Mechanisms)
NOTE: Axis I and II can coexist. The Axis I or II condition that is responsible for bringing the
patient to the facility is called the principle or main diagnosis.
Axis III: Includes any general medical conditions (e.g Epilepsy, Cardiovascular Disease,
Endocrine Disorder)
NOTE: if a medical disorder is considered the cause of the psychiatric disorder, it is listen in Axis
I
Axis IV: use to describe psychosocial and environmental problems relevant to the illness (e.g
Divorce, Injury, Death of Loved One)
Axis V: Assessment of Global Functioning exhibited by the patient during the interview. (e.g
Social, Occupational, and Psychological Function)
Continuum from 100 (Superior Functioning) to 1 (Grossly Impaired Functioning)

Code
1

DSM-IV-TR Severity of Psychosocial Scare in Adults

Term
Acute Events
NONE

No acute events that

may be relevant to

Enduring
Circumstances
No enduring
circumstances that

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Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
the disorder.
may be relevant to
the disorder.
MILD
Broke up with
Family arguments,
boyfriend or
job dissatisfaction,
girlfriend, started or
residence in high
graduated from
crime neighborhood
school, child left
home
MODERATE
Marriage; Marital
Marital Disorder;
Separation; loss of
Serious Financial
job; retirement;
Problems; Trouble
miscarriage
with Boss; Being A
Single Parent
SEVERE
Divorce: Birth of First Unemployment;
Child
poverty,
EXTREME
Death of Spouse;
Serious chornic
Serious Physical
illness in self or child;
Illness Diagnosed;
ongoing physical or
Victim of Rape
sexual abuse
CATASTROPHIC
Death of Child;
Captivity as Hostage;
Suicide of Spouse;
Concentration Camp
Devastating Natural
Experience
Disaster
INADEQUATE
INFORMATION / NO
CHANGE IN
CONDITION

4
5

CLINICAL NOTES:
-

It is possible for a patient to have more than one diagnosis/problem.

In some cases, it may not be possible to determine which diagnosis is the main
one because each may have contributed equally to the need for treatment. (e.g
Amphetamine dependence accompanied by Schizophrenia)

B. Severity of Disorder
1. Mild few if any symptoms are present and no more than minor impairment in social
or occupational functioning.
2. Moderate symptoms or functional impairment between mild and severe are
present.
3. Severe many symptoms or particularly severe symptoms are present that result in
marked impairment in social or occupational functioning.
4. In Partial Remission the full criteria for the disorder were previously met, but
currently only some of the symptoms or signs of the disorder remain.
5. In Full Remission there are no longer symptoms or signs of the disorder.

VI.
Laboratory Test
A. Renal and Hepatic Tests
- Serum Blood Urea Nitrogen (BUN) and creatinine are monitored in patients
taking lithium (Escalith)
- If Elevated see 2-hour creatinine clearance, and ultimately a 24-hour creatinine
clearance.
Other Test for Patients Taking Lithium: (ALL: Prior to Treatment and Yearly)
1. Complete Blood Count
2. Serum Electrolytes

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
3. Fasting Blood Glucose
4. Electrocardiogram
5. Pregnancy Testing for Women of Childbearing Age
B. Liver Function Tests
- Total Bilirubin and Direct Bilirubin are elevated in hepatocellular injury and
intrahepatic bile stasis, which can occur with phenothiazine or tricyclic
medications and with alcohol and other substance abuse.
- Must be monitored routinely when using drugs such as carbamazepine (Tegretol)
and valproate (Depakene)
C. Urine Testing for Substance Abuse
- A number of substances may be detected in patients urine if the urine is tested
within a specific (and variable) period after ingestion)
- Knowledge of substance testing is crucial for health professionals in view of
mandatory or random substance testing.
Substance
Alcohol
Amphetamine
Cannabis
Cocaine
MORPHINE

Length of Time Detected in Urine

7-12 Hours
48 Hours
3 Days to 4 Weeks (depending on use)
6-8 Hours (metabolites 2-4 days)
48-72 Hours

VII.
Test Related to Psychotropic Drugs
1. Antipsychotics
- NO SPECIFIC TEST
- Primarily Metabolized in the Liver
- Primarily Excreted in Urine
- Peak Plasma Concentration: 2-3 Hours (Oral Dose)
- Elimination Half-Life: 12-30 Hours (or much longer)
- Steady State: atleast 1 week at constant dose
NURSES NOTES:
With the exception of clozapine (Clozaril) all antipsychotics acutely cause elevation in serum
prolactin. GYNECOMASTIA!
Clozapine: Risk for Agranulocytosis (1-2%), Assess Baseline WBC Count before initiation of
Treatment. RISK FOR INFECTION!
A normal prolactin level often indicates either noncompliance or nonabsorption
Side-Effects:
-

Leukocytosis
Leukopenia
Impaired Platelet Function
Mild Anemia (Both Aplastic and Hemolytic)
Agranulocytosis
ECG Changes Prolonged QT Interval; Flattened, Inverted, or bifid T Waves;
and U Waves.

2. Tricyclic and Tetracylic Drugs

- Assess ECG Pattern before starting regiment of cyclic drugs to assess for
conduction delays.
- May lead to Heart Blocks at Therapeutic Levels
- NOTE: imipramine(Tofranil), desipramine (Norpramin), nortriptyline (Pamelor) in
the treatment of depressive disorders.
Determining Blood Concentrations:
Blood Draw: 10-14 Hours after the last dose

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Time: Morning after a bedtime dose
Conditions: Patient must be receiving stable daily dosage for atleast 5 days for the test to be
valid.
3. Monoamine Oxidase Inhibitors (MAOIs)
- Instructed to avoid tyramine-containing foods because of danger of potential
hypertensive crisis.
- Baseline Normal Blood Pressure (BP) must be recorded.
- BP must be monitored during treatment.
- MAY ALSO CAUSE ORTHOSTATIC HYPOTENSION
- RELATIVELY FREE OF OTHER SIDE EFFECTS
4. Lithium
- Baseline thyroid function test (T3, T4)
- Electrolyte Monitoring (Sodium)
- WBC Count
- Renal Function Test (Specific Gravity, BUN, Creatinine)
- Baseline ECG
Rationale:
Lithium can cause:
A. Renal Concentrating Effect: Interferes with action of Antidiuretic Hormone
(ADH)/Vasopressin on collecting tubules DEHYDRATION!
B. Hypothyroidism
C. Leukocystosis
NURSES NOTES:
Sodium Depletion: can cause toxic lithium levels; hyponatremia causes increased
resorption of lithium in the kidney tubules; approximately 95% of lithium is excreted in urine.
LOW THERAPEUTIC INDEX!
Maintenance Level: 0.3 to 1.2 mEq/L
Acutely Manic Patients Tolerate: 1.5-1.8 mEq/L
Toxicity Levels: 2.0 mEq/L >
REGULAR MONITORING OF LITHIUM LEVELS:
BLOOD DRAW 8-12 HOURS AFTER LAST DOSE; MORNING

Pharmacologic Function:
Decreases Norepinephrine Release - Decreases Mania
Increases Serotonin Synthesis Alleviates Depression
Lithium itself may have antipsychotic activity
EFFECTIVE ANTISUICIDE DRUG
Indication:
Prophylactic treatment of manic episodes (direct antimanic effects may take up to 2 weeks)
Coupled with antipsychotics for treatment of acute manic episodes
5. Provocation of Panic Attacks with Sodium Lactate
- Up to 72% of patients with panic disorder have a panic attack when administered
an intravenous (IV) injection of sodium lactate.
- Therefore: LACTATE PROVOCATION IS USED TO CONFIRM A DIAGNOSIS
OF PANIC DISORDER
NURSES NOTES:
- Can trigger flashbacks in patients with PTSD PROVIDE SAFETY and
REASSURANCE!

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Can trigger Hyperventilation PROVIDE A PAPER BAG/COVER MOUTH WITH
BOTH HANDS

EMERGENCY DRUG: alprazolam (Xanax) and Trycylic Drugs [imipramine(Tofranil),

nortriptyline(Pamelor)]

FUNCTIONAL AND BEHAVIORAL NEUROANATOMY AND NEUROPHYSIOLOGY

-The HUMAN BRAIN is the organ that is the basis of what persons sense, do, feel, and
think; or put in more formal terms, our sensory, behavioral, affective, and cognitive
experiences and attributes.
- Neurotransmitter release occurs is one of the major mechanisms for intraneuronal
communications, and also for the effects of psychotropic drugs.
REGIONAL FUNCTIONS OF THE HUMAN BRAIN
Frontal lobes
Voluntary movement
Language production (left)
Motor prosody (right)
Comportment
Executive function
Motivation
Temporal lobes
Audition
Language comprehension (left)
Sensory prosody (right)
Memory
Emotion
Parietal lobes
Tactile sensation
Visuospatial function (right)
Reading (left)
Calculation (left)
Occipital lobes
Vision
Visual perception

MOTOR SYSTEMS AND MOTOR CORTEX

Body muscles movements are controlled by the lower motor neurons, which extend axons as
long as 1 meter to the muscle fibers. Lower motor neuron firing is regulated by the summation
of upper motor neuron activity.
At the top of the motor hierarchy is the corticospinal tract, which controls fine movements.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
The upper motor neurons of the corticospinal tract reside in the posterior frontal lobe, in a
section of cortex known as the motor strip Broadmann Area 4.
Planned movements are conceived in the association areas of the brain and, in consultation
with the basal ganglia and cerebellum, the motor cortex directs their smooth execution.
The skillful use of the hands is called praxis, and deficits in skilled movements are termed
apraxias.
The three levels of apraxia are limb-kinetic, ideomotor, and ideational
Limb-kinetic apraxia
- is the inability to use the contralateral hand in the presence of preserved
strength.
Ideomotor apraxia
- is the inability to perform an isolated motor act on command, despite preserved
comprehension, strength, and spontaneous performance of the same act.
-

simultaneously affects both limbs and involves functions so specialized that they
are localized to only one hemisphere.

Ideational apraxia
- occurs when the individual components of a sequence of skilled acts can be
performed in isolation, but the entire series cannot be organized and executed as
a whole.
-

For example, the sequence of opening an envelope, removing the letter,

unfolding it, and placing it on the table cannot be performed in order, even though
the individual acts can be performed in isolation.

Typical Finding in: Dementia of Alzheimers Type

[Basal Ganglia]
- A subcortical group of gray matter nuclei, appear to mediate postural tone.
The four functionally distinct ganglia are the striatum, the pallidum, the substantia nigra, and
the subthalamic nucleus.
Collectively known as the corpus striatum, the caudate and putamen harbor components of
both motor and association systems.
A. Caudate Nucleus plays an important role in the modulation of motor acts. Anatomical
and functional neuroimaging studies have correlated decreased activation of the caudate
with obsessive and compulsive behavior.
When functioning properly, the caudate nucleus acts as a gatekeeper to allow the motor system
to perform only those acts that are goal directed.
When it fails to perform its gatekeeper function, extraneous acts are performed as in obsessive
compulsive disorder or in the tic disorders, such as Tourette's disorder.
Overactivity of the striatum owing to lack of dopaminergic inhibition (e.g., in parkinsonian
conditions) results in bradykinesia, an inability to initiate movements.
B. Substantia Nigra is named the black substance because the presence of melanin pigment
causes it to appear black to the naked eye.
Produces the neurotransmitter Dopamine

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Parkinsonism is characterized by rigidity and tremor and is associated with depression in
more than 30 percent of cases.
Together, the nuclei of the basal ganglia appear capable of initiating and maintaining the full
range of useful movements.
Workers have speculated that the nuclei serve to configure the activity of the overlying motor
cortex to fit the purpose of the association areas. In addition, they appear to integrate
proprioceptive feedback to maintain an intended movement.
[Cerebellum]
- Activated several milliseconds before a planned movement.
- Ablation of the cerebellum renders intentional movements coarse and tremulous.
- Modulates the tone of agonistic and antagonistic muscles by predicting the relative contraction
needed for smooth motion. This prepared motor plan is used to ensure that exactly the right
amount of flexor and extensor stimuli is sent to the muscles.
- Active even during the mere imagination of motor acts, when no movements ultimately result
from its calculations.
LANGUAGE
- clearest known example of hemispheric lateralization is the localization of
language functions to the left hemisphere.
- Starting with the work of Pierre Broca and Karl Wernicke in the 19th century,
researchers have drawn a detailed map of language comprehension and
expression
- Because of the major role of verbal and written language in human
communication, the neuroanatomical basis of language is the most completely
understood association function.
Prosody - the emotional and affective components of language, or body language.
Garbled Word Salad or Illogical Utterances disruption of the right hemisphere (affects
quality of language)
Language disorders, also called aphasias (8 Types in which one or more of the language
pathway are injured have been defined), are readily diagnosed in routine conversation,
whereas perceptual disorders may escape notice, except during detailed neuropsychological
testing.

Aphasia Type
Brocas
Wernickes
Conduction
Global

Common Aphasias Revelant to Nursing Practice (4)

Spontaneous
Auditory
Repitition
Speech
Comprehension
Nonfluent
Good
Poor
Fluent
Poor
Poor
Fluent
Good
Poor
Nonfluent
Poor
Poor

[Neurophysiology and Neurochemistry]

[Neurotransmitters]
Criteria for a Neurotransmitter
1. The molecule is synthesized in the neuron.

Naming
Poor
Poor
Poor
Poor

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2. The molecule is present in the presynaptic neuron and is released on depolarization
in physiologically significant amounts.
3. When administered exogenously as a drug, the exogenous molecule mimics the
effects of the endogenous neurotransmitter.
4. A mechanism in the neurons or the synaptic cleft acts to remove or deactivate the
neurotransmitter.

Presynaptic

Components:
The
presynaptic terminals contain
the synthetic machinery responsible for the
synthesis of all

neurotransmitters.
Synapse:
Although it makes up less than 1 percent of the total volume of the brain, the synaptic
compartment the space between the presynaptic and postsynaptic membranes contains the
mixture of neurotransmitters with the greatest influence on thought and behavior.
Postsynaptic Components
Neurotransmitter receptors are the sites of action for many of the psychotherapeutic and
psychoactive drugs
Chemical neurotransmission is the process involving the release of a neurotransmitter by one
neuron and the binding of the neurotransmitter molecule to a receptor on another neuron.
-The process of chemical neurotransmission is affected by most drugs used in psychiatry.
- Typical Antipsychotics, but not the serotonin-dopamine antagonists, are believed to exert their
effects mainly by blocking dopamine type 2 (D2) receptors
- Virtually all antidepressants are believed to exert their effects by increasing the amount of
serotonin or norepinephrine, or both, in the synaptic cleft
- Almost all benzodiazepine anxiolytics are believed to exert their effects on the GABAA
receptors.
Monoamine Receptors: Overview

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Transmitter
Subtype
Proposed Clinical
Relevance
Serotonin
5-HT1A
Antidepressant action; partial
agonist; anxiolytic
5-HT1B
Possible role in locomotor
activity, aggression
5-HT2A
Target of hallucinogens,
atypical antipsychotics
5-HT2C
Regulation of appetite,
anxiety, seizures; target of
hallucinogens, antipsychotics
5-HT4
Modulation of cognition,
anxiety
5-HT6
Target of hallucinogens,
atypical antipsychotics

Transmitter

Subtype

Dopamine

D2

D4

Transmitter

Subtype

Histamine

H1

Proposed Clinical
Relevance
Target of therapeutic and
extrapyramidal effects of
dopamine receptor
antagonists (typical
antipsychotics)
Target of serotonin-dopamine
antagonists (atypical
antipsychotics)

Proposed Clinical
Relevance
Antagonists produce
sedation, weight gain

[Dopamine]
When the D2 receptors are blocked by classic antipsychotic drugs, parkinsonian side effects
emerge.
Absence of D2 receptor activity dampen motor activity excessively, resulting in the bradykinesia
that typifies parkinsonism. At the other extreme, excess dopamine activity may result in
extraneous motor acts, such as tics.
Dopamine acts as a release-inhibiting factor by inhibiting the release of prolactin from the
anterior pituitary.

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College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Patients who take dopamine receptor antagonists often have roughly threefold elevated
prolactin levels because the blockade of dopamine receptors in the tract eliminates the inhibitory
effect of dopamine.
One enzyme involved in the metabolism of dopamine is monoamine oxidase (MAO)
D2 receptor antagonists (i.e., typical antipsychotic drugs) reduce the positive symptoms of
schizophrenia, such as hallucinations and delusions, but may worsen the negative symptoms,
such as social ambivalence and catatonia.
Psychopharmacology of Dopamine
In the past, the potency of antipsychotic compounds has been correlated with their affinity for
the D2 receptor.
Blockade of dopamine receptors, particularly the D2 receptor, has been associated with the
efficacy of antipsychotic drugs, long-term administration of dopamine receptor antagonists
results in an upregulation in the number of dopamine receptors present. This upregulation may
be involved in the development of tardive dyskinesia.
A new class of highly effective antipsychotic agents, called the serotonin-dopamine
antagonists because they block predominantly the serotonin type 5-HT 2 and, to a lesser extent,
the D2 receptors,
-Greatly reduced risk of development of parkinsonian side effects and tardive
dyskinesia.
-Do they treat the positive symptoms of schizophrenia, effectively treated by pure D 2 receptor
antagonists (psychosis, hallucinations, agitation), they also improve the negative symptoms of
schizophrenia (blunted affect, ambivalence, catatonia).
Other Drugs That Increase Dopamine:
Amphetamines
Cocaine
Psychopathology of Dopamine:
The dopamine hypothesis of schizophrenia grew from the observations that drugs that block
dopamine receptors (e.g., haloperidol) have antipsychotic activity and drugs that stimulate
dopamine activity (e.g., amphetamine) can induce psychotic symptoms in nonschizophrenic
persons when given in sufficiently high doses.
The dopamine hypothesis remains the leading neurochemical hypothesis for schizophrenia, but
room is being made for a role for serotonin, based on the therapeutic success of the serotonindopamine antagonists.
Dopamine may also be involved in the pathophysiology of mood disorders.
Dopamine activity may be low in depression and high in mania.
Amphetamines, which potentiate dopamine activity, are highly effective antidepressants.
[Serotonin]
-

precursor amino acid is tryptophan

dietary variations in tryptophan can measurably affect serotonin levels in the
brain.

The diversity of serotonin receptors has initiated a significant effort to study the distribution of
serotonin receptor subtypes in pathological states and to design subtype-specific drugs that
may be of particular therapeutic benefit in specific conditions.
buspirone (BuSpar), a clinically effective anxiolytic, is a potent 5-HT1A agonist, and other 5HT1A agonists are being developed for the treatment of anxiety and depression.

St. Michaels College of Iligan City Inc.

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Clozapine, the prototypical serotonin-dopamine antagonist antipsychotic agent, has significant
activity as an antagonist of 5-HT2 receptors, and this observation has initiated a major effort to
study the role of this serotonin receptor subtype and to develop drugs that are 5-HT2
antagonists for the treatment of schizophrenia.
Antagonists of the 5-HT3 receptor are also under study as potential antianxiety and
antipsychotic compounds.
The distributed serotonin receptors are sometimes responsible for the side effects of
serotonergic drugs, many of which nonspecifically raise serotonin levels and thus
indiscriminately increase receptor activation.
Basal Ganglia Akathisia and Agitation
Brainstem (Vomiting Center) Nausea and Vomiting
Brainstem (Sleep Center) Insomnia or Somnolence
Limbic System Initial Increase in Anxiety
Spinal Cord Sexual Dysfunction
Intestines Gastrointestinal Upset and Diarrhea (MOST COMMON!)
Cranial Blood Vessels Headache
Psychopharmacology of Serotonin
The tricyclic drugs and the MAOIs, respectively, block the uptake and the metabolism of
serotonin and norepinephrine, thus increasing the concentration of both neurotransmitters in the
synaptic cleft.
Fluoxetine is one of the selective serotonin reuptake inhibitors (SSRIs) that are used in the
treatment of depression.
Other drugs in that class include paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox),
and citalopram (Celexa), all of which are usually associated with minimal adverse effects,
especially in comparison with the tricyclic drugs and the MAOIs.
Venlafaxine blocks the reuptake of both serotonin and norepinephrine. With respect to
serotonin, both trazodone (Desyrel) and nefazodone block the reuptake of serotonin and directly
antagonize 5-HT2 receptors, with the net effect stimulating 5-HT1 receptors.
Trazodone and nefazodone and the 5-HT1 receptor agonist buspirone are the first of what will
likely be a series of drugs that target subtypes of serotonin receptors.
Psychopathology of Serotonin
The principal association of serotonin with a psychopathological condition hypothesis is simply
that depression is associated with too little serotonin and that mania is associated with too
much serotonin.
The permissive hypothesis postulates that low levels of serotonin permit abnormal levels of
norepinephrine to cause depression or mania.
Early theories about the causes of anxiety focused on the GABA system because the first
effective anxiolytics were the benzodiazepines, which potentiate GABAergic neurotransmission.
The success of SSRIs and buspirone, which are effective antianxiety agents, the theory of
anxiety needed room for a role for serotonin.
Schizophrenia was previously thought to result from an imbalance of dopamine, but since the
therapeutic success of the serotonin-dopamine antagonists, schizophrenia is now thought to
result from misregulation of both dopamine and serotonin function.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
[Norepinephrine and Epinephrine]
- Norepinephrine is the more important and more abundant of the two related
neurotransmitters in the brain.
- Norepinephrine and epinephrine, along with dopamine, constitute the
catecholamines. As discussed above, the catecholamines are synthesized from
tyrosine.
- Metabolized by MAO.
- Receptors are called Adrenergic/Noradrenergic Receptors
Psychopharmacology of Norepinephrine
The psychiatric drugs that are most associated with norepinephrine are the classic
antidepressant drugs, the tricyclic drugs and the MAO inhibitors (MAOIs), and, more recently,
venlafaxine (Effexor), mirtazapine (Remeron), bupropion, and nefazodone (Serzone).
The tricyclic drugs, venlafaxine, bupropion, and nefazodone, block the reuptake of
norepinephrine (and serotonin) into the presynaptic neuron, and the MAOIs block the
catabolism of norepinephrine (and serotonin).
Immediate effect of tricyclic drugs and MAOIs is to increase the concentrations of
norepinephrine (and serotonin) in the synaptic cleft.
Adrenergic Antagonists; propranolol(Inderal) have been used to treat:
Social phobia (e.g., performance anxiety),
Akathisia (a movement disorder associated with antipsychotic compounds)
Lithium-induced tremor.
Antidepressants take 2 to 4 weeks to exert their therapeutic effects
Psychopathology of Norepinephrine
The biogenic amine hypothesis of mood disorders was based on the observation that the
tricyclic drugs and the MAOIs are effective in alleviating the symptoms of depression.
Drugs that affect both neurotransmitters are effective, and drugs that affect primarily
norepinephrine for example, desipramine (Norpramin) and drugs that affect primarily serotonin
for example, fluoxetine are also effective.
[Gama-Aminobutyric Acid (GABA]
- is the primary neurotransmitter in intrinsic neurons that function as local
mediators for the inhibitory feedback loops
- is thought to suppress seizure activity, anxiety, and mania, considerable effort
has been devoted to synthesizing drugs that potentiate GABA activity.
- GABA receptor has binding sites for the benzodiazepines, and the barbiturates.
carbamazepine (Tegretol) and valproic acid (Depakote) treatment of rapid cycling bipolar I
disorder

Disorders in Psychiatry:
[Schizophrenia]
Definition: syndrome of unknown etiology characterized by disturbances in cognition, emotion,
perception, thinking, and behavior.
A. Clinical Course: Chronic
Phases: Prodromal Phase, Active Phase, Residual Phase
Active Phase: has symptoms such as hallucinations, delusions, and disorganized thinking.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Prodromal and Residual Phases: active symptoms such as odd beliefs and magical thinking
as well as self-care and interpersonal deficits.
B. Epidemiology:
1 in 100 will develop the disorder during his or her lifetime
Gender: Equally prevalent in Men and Women
Peak Age of Onset: 15 35 Years (50% Below 25 Years Old)
NURSING NOTES:
LEADING CAUSE OF DEATH: SUICIDE!
PATIENT MAY EMERGE FROM CATATONIC STATE SUDDENLY AND WITHOUT
WARMING BE QUITE VIOLENT
EVEN THOUGH A PATIENT IS IN A CATATONIC OR WITHDRAWN STATE, THEY ARE
OFTEN VERY AWARE OF THE ENVIRONMENT AND COGNIZANT OF WHAT IS
BEING SAID AROUND THEM
DURING COURSE OF ILLNESS BIZARRE DELUSIONS AND HALLUCINATIONS
TEND TO DIMINISH IN INTENSITY WHEREAS POOR HYGIENE, FLATTENED
EMOTIONAL RESPONSE, AND VARIOUS ODITIES OF BEHAVIOR TEND TO
INCREASE.
EFFORTS TO CONVINCE THE PATIENT THAT THE DELUSION IS NOT REAL
GENERALLY LEAD TO MORE TENACIOUS ASSERTIONS OF DELUSIONAL IDEAS.
ACKNOWLEDGE THE PATIENTS FEELINGS SIMPLY AND CLEARLY
C. Biological Etiology:
1. Dopamine Hypothesis
- Increased Limbic Dopamine Activity Positive Symptoms
- Decreased Frontal Dopamine Activity Negative Symptoms
2. Gama-Aminobutyric Acid (GABA) Hypothesis
- Decreased GABA activity results in increased Dopamine activity.
3. Serotonin Hypothesis
- Serotonin metabolism apparently abnormal in some chronically schizophrenic
patients.
- Antagonism of serotonin 5-HT2 receptor reduces psychotic symptoms and
development of movement disorders related to D2 antagonism.
- Research on mood disorders has implicated serotonin activity in suicidal and
impulsive behavior, which schizophrenic patients also exhibit.
D. Diagnosis, Signs, and Symptoms
- Diagnosis is based on observation and description of patient.
- NO PATHOGNOMOIC SIGNS OR SYMPTOMS.
E. DSM-IV-TR
- Atleast two (2) of the following five signs or symptoms must be present for at
least 1 month.
1. Hallucinations
2. Delusions
3. Disorganized Speech
4. Disorganized Behavior
5. Negative Symptoms (flat affect, abulia)
SIGNS AND SYMPTOMS MUST BE PRESENT FOR ATLEAST 6 MONTHS FOR THE
DISORDER TO BE CONFIRMED.

Delusions

Positive and Negative Symptoms

Positive Symptoms
Negative Symptoms
Affective Flattening

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Hallucinations
Alogia
Disorganized Behavior
Avolition
Anhedonia

F. TREATMENT
1. Choice of Drug
a. First-Generation Antipsychotics (Typical Antipsychotics or Dopamine Receptor
Antagonist)
- Classic antipsychotics drugs, which are often effective in treatment of positive
symptoms of schizophrenia.
High Potency: e.g Haloperidol
- More likely to cause Extrapyramidal Side Effects (Akathisia, Acute Dystonia,
Pseudoparkinsonism)
Low Potency e.g chlorpromazine (Thorazine)
- More sedating, hypotensive, anticholinergic
Adverse Reaction: Tardive Dyskinesia
b. Second-Generation Antipsychotics (Atypical, Novel, Serotonin-Dopamine
Antagonist)
- Usually preferred and used more frequently than first generation antipsychotics.
- Equally if not more effective and with fewer side effects.
- Provide potent 5-HT2 receptor blockade and varying degrees of D2-Receptor
blockade.
- IMPROVE BOTH POSITIVE AND NEGATIVE SYMPTOMS.
- FEWER EPS
- DO NOT ELEVATE PROLACTIN LEVELS
- LESS LIKELY TO CAUSE TARDIVE DYSKINESIA
Clozapine
-

MOST ATYPICAL
Minimal or No EPS
Seldom causes Tardive Dyskinesia
Highly Sedating
Can cause weight gain.

Apriprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), paliperidone (Invega),

clozapine (Clozaril), ziprasidone (Geodon), asenapine (Saphris)
NOTE: FIRST LINE TREATMENT OF SCHIZOPHRENIA

[Mood Disorders]
Mood pervasive and sustained feeling tone that is experienced internally and that influences a
persons behavior and perception of the world.
a. Normal
b. Elevated
c. Depressed
Affect is the external expression of mood
Healthy persons experience a wide range of moods and have an equally large repertoire of
affective expressions; they feel in control of their moods and affects.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Mood Disorders encompasses a large spectrum of disorders in which pathological mood
disturbances dominate the clinical picture.
Include the following 7 disorders:
1. Major Depressive Disorders
2. Bipolar Disorders (Types I and II)
3. Dysthymic Disorder
4. Cylothymic Disorder
5. Mood Disorders due to general medical condition
6. Substance-induced mood disorder
I.
Epidemiology
A. Incidence and Prevalence
- Mood Disorders are Common
- Major Depressive Disorder has the highest lifetime prevalence (almost 17%) of
any psychiatric disorder.
B. Sex
-

Major Depression more common in Women

Bipolar I equal in Men and Women
Manic Episodes more common in Women
Depressive Episodes more common in Men

C. Age
-

Age of onset for Bipolar I is usually about age 30.

D. Sociocultural
- Depressive Disorders are more common among single and divorced persons
compared to married persons.
- NO CORRELATION WITH SOCIOECONOMIC STATUS
- NO DIFFERENCE BETWEEN RACES OR RELIGIOUS GROUPS
II.
Etiology
A. Neurotransmitters
1. Serotonin has become the biogenic amine neurotransmitter most commonly
associated with depression (Serotonin Depletion).
- Serotonergic Agents are effective treatments.
2. Norepinephrine Abnormal Levels (Usually Low) of norepinephrine metabolites
are found in Blood, Urine, and CSF of depressed patients.
- Venlafaxine (Effexor) increases both Serotonin and Norepinephrine and is
used in depression for that reason.
3. Dopamine dopamine activity may be reduced in depression and increased in
mania.
- Drugs that reduce dopamine concentrations [e.g reserpine (Serpasil)] and
diseases that that reduce dopamine secretion (e.g Parkinsons Disease) are
associated with depressive symptoms.
- Drugs that increase dopamine concentrations such as, tyrosine, amphetamine,
buproprion (Wellbutrin) reduce the symptoms of depression.
- Dopamine D1 Receptors may be hypoactive in depression.
III.
Bipolar Disorder
Two Main Types:
Bipolar I characterized by occurrence of manic episodes with or without major depressive
episode.
Bipolar II characterized by atleast one (1) depressive episode with or without hypomanic
episode

St. Michaels College of Iligan City Inc.

College of Nursing
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Nursing Board Notes:
History of:
(1) One Full-Blown Manic Episode = Bipolar I
(1) One Major Depressive Episode = Bipolar II
A. Depression (Major Depressive Episode)
a. Depressed Mood: subjective sense of sadness, feeling blue or down in the dumps
for a prolonged period of time.
b. Anhedonia: inability to experience pleasure
c. Social Withdrawal
d. Lack of Motivation, little tolerance to frustration
e. Vegetative Signs
(1) Loss of Libido
(2) Weight Loss and Anorexia
(3) Weight Gain and Hyperphagia
(4) Low Energy Level; Fatigability
(5) Abnormal Menses
(6) Early Morning Awakening (Terminal Insomnia)
Approximately 75% of depressed patients have sleep difficulties; either insomnia
or hypersomnia.
(7) Diurnal Variation (symptoms worse in the morning)
f. Constipation
g. Dry Mouth
h. Headache
Nursing Assessments:
a. General Appearance and Behavior:
- Psychomotor retardation or agitation
- Poor Eye Contact
- Tearful
- Downcast
- Inattentive to Personal Appearance
b. Affect: Constricted or Labile
c. Mood: Depressed, Irritable, Frustrated or Sad
d. Speech: little or no spontaneity; monosyllabic; long pauses; soft, low monotone.
e. Thought Content:
- Suicidal Ideation: 60% of depressed patients
- Suicide Act: 15% commit suicide
- Pervasive Feelings of Hopelessness
- Worthlessness
- Guilt
- Poverty of Thought Content and paucity of speech
- MOOD CONGRUENT HALLUCINATIONS AND DELUSIONS
f. Cognition:
- Distractible
- Difficulty Concentrating
- Complaints of Poor Memory
- Apparent Disorientation
- Abstract Thought My Be Impaired
g. Insight and Judgment
- May be impaired due to cognitive distortions of personal worthlessness
Features:
Content of delusions and hallucinations(when present)
Congruent with Depressed Mood
Most Common Delusions: guilt, poverty, deserved persecution, nihilistic(end of world)
delusions.
B. Mania (Manic Episode)
- Persistent elevated mood

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Manifestations:
a. Erratic and Disinhibited Behavior
(1) Excessive Spending or Gambling
(2) Impulsive Travel
(3) Hypersexuality, promiscuity
b. Overextended in activities and responsibilities
c. Low frustration tolerance with irritability and outburst of anger.
d. Vegetative Signs:
(1) Increased Libido
(2) Weight Loss, Anorexia
(3) Insomnia (expressed as no need to sleep)
(4) Excessive Energy
Nursing Assessments:
a. General Appearance and Behavior
- Psychomotor Agitation
- Seductive
- Colorful Clothing
- Excessive Makeup
- Inattention to personal appearance or bizarre combination of clothes
- Intrusive
- Entertaining
- Threatening
- Hyperexcited
b. Affect: Labile, Intense (may have rapid depressive shifts)
c. Mood: Euphoric, Expansive, Irritable, Demanding, and Flirtatious
d. Speech: pressured, loud, dramatic, exaggerated; may become incoherent
e. Thought Content:
- Highly Elevated Self-Esteem
- Grandiose
- Extremely Egocentric
- Delusions and less frequently Hallucinations (mood congruent themes of inflated
self-worth and power, most often grandiose and paranoid)
f. Thought Process:
- flight of ideas (if severe can lead to incoherence)
- racing thoughts
- neologisms
- clang associations
g. Sensorium
- Highly Distractible
- Difficulty Concentrating
- Memory Generally Intact
- Abstract Thinking Generally Intact
h. Insight and Judgment: extremely impaired; often total denial of illness and inability to
make any organized rational decisions.
NURSING BOARD NOTES:
If delusions are mood incongruent, it is most likely SCHIZOPHRENIA.
Schizophrenia can look like a manic, major depressive, or mixed episode with psychotic
features.
Treatment: [DEPRESSIVE DISORDER]
1. Selective Serotonin Reuptake Inhibitor (SSRI)
Early Transient Side Effects:
- Anxiety
- GI Upset
- Headache
- Sexual Dysfunction

St. Michaels College of Iligan City Inc.

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Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
Insomnia

Nurses Notes:
- Early anxiogenic effects of SSRI may aggrevate suicidal ideation and can be
managed by either: A. Reducing the Dose or B. Adding an Anxiolytic
- Insomnia can be managed with a benzodiazepine, zolpiden (Ambien), trazodone
(Desyrel), or mirtazapine (Remeron)
- TRYCYCLICS AND MAOIs are generally considered second or third line agents
because of their side effects and potential lethality in overdose.
- Increased risk of suicide as suicidally depressed patients begin to improve. They
have the physical energy to carry out the act, whereas before, they lacked the
will to do so. Paradoxical Suicide
- Ask about suicide ideas, especially plans to harm oneself. ASKING ABOUT
SUICIDE DOES NOT PLANT IDEAS.
- Do not hesitate to ask pateints if they want to die a straightforward approach
is the most effective
- Always ask about past suicide attempts, which can be related to future attempts

2. Buproprion
- Noradrenergic, dopaminergic drug with stimulant like properties.
- Generally well tolerated and may be particularly useful for depression marked by
anergy and psychomotor retardation.
- DEVOID OF SEXUAL SIDE EFFECTS
- MAY EXACERBATE ANXIETY AND AGITATION
- DOPAMINERGIC PROPERTIES MAY EXACERBATE PSYCHOSIS
3. Venflaxine and Duloxetine
- Serotonine-Norepinephrine Reuptake Inhibitors
- Particularly effective in Severe or Refractory cases of depression
- SIDE EFFECTS SIMILAR TO SSRI.
4. Tricyclics
- Highly effective but require dose titration.
- Side Effects:
(1) Anticholinergic Effects
(2) Cardiac Conducting Delays
(3) Orthostasis
- Secondary Amines: nortriptyline (OFTEN BETTER TOLERATED) than
- Tertiary Amines: amitriptyline (Elavil)
5. Augmentation Strategies in treatment-resistant or partially responsive patients:
- Lithium
- Amphetamines
- Buspirone
- Buproprion + SSRI
6. Monoamine Oxidase Inhibitor (MAOI)
- Safe with reasonable dietary restriction of tyramine-containing substances.
- Major depressive episodes that have atypical features or psychotic features or
that are related to Bipolar I disorder may preferentially respond to MAOI.
NURSES NOTES:
- MUST NOT BE ADMINESTERED 2-5 WEEKS AFTER DISCONTINUATION OF
AN SSRI OR OTHER SEROTONINERGIC DRUG
(1) Fluoxetine (Prozac) 5 Weeks
(2) Paroxetine (Paxil) 2 Weeks
(3) Clomipramine (Anafranil) must not be administered 2 weeks after
discontinuation of an MAOI
TREATMENT: [BIPOLAR DISORDER]

St. Michaels College of Iligan City Inc.

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Prepared By: Joshua James L. Diao, MN, CRN, RM, RN
a. Mood Stabilizers
1. Lithium
2. Divalproex (Depakote)
- First choice of drugs used for bipolar disorders but second generation
antipsychotics such as Olanzapine (Zyprexa) are also used.
3. Electroconvulsive Therapy highly effective in all phases of bipolar disorder.
4. Carbamazepine a well established treatment drug
Nurses Notes:
Carbamazepine, Divalproex, Valproic Acid (Depakene) may be more effective than lithium in
treatment of mixed or dysphoric mania, rapid cycling, and psychotic mania, and in the treatment
of patients with history of multiple manic episodes or comorbid substance abuse.
b. Sedative Drugs
- Treatment of acute manic episdoes.
- Clonazepam
- Lorazepam (Ativan)
Nurses Notes:
DO NOT STOP TREATMENT ABRUPTLY TAPER THE DOSE!

c. Lithium
- Mainstay treatment of bipolar disorders
- Blood Level: 0.8 1.2 mEq/L controls acute symptoms
- Response Time: 4-7 Days
Typical Side Effects:
Thirst
Polyurea (Nephrogenic Diabetes Insipidus)
Tremors
Metallic Taste
Cognitive Dulling
GI Upset
Hypothyroidism
Nurses Notes:
Pre-Treatment Workup:
(1) Complete Blood Count
(2) Electrocardiogran (ECG)
(3) Thyroid Function Tests
(4) Blood Urea Nitrogen
(5) Creatinine / Creatinine Clearance
(6) Pregnancy Test
NARROW THERAPEUTIC INDEX HIGH RISK FOR TOXICITY: WATCH OUT FOR
DEHYDRATION AND HYPONATREMIA! (MONITOR URINE SPECIFIC GRAVITY AND
ELECTROLYTE LEVELS)
PATIENTS WITH DEPRESSIVE BREAKTHOUGH ON LITHIUM SHOULD BE ASSESSED FOR
LITHIUM INDUCED HYPOTHYROIDISM

PSYCHOPHARMACOLOGY NOTES:
Acute Anxiety benzodiazepines
Chronic Anxiety benzodiazepines + antipsychotics
Benzodiazepine Overdose: flumazenil (Romazicon) Benzodiazepine Antagonist

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Prepared By: Joshua James L. Diao, MN, CRN, RM, RN

NERVOUS SYSTEM:
A. Central Nervous System (CNS)
B. Peripheral Nervous System (PNS)
I.

Central Nervous System

- Brain in the cranial cavity
- Spinal Cord in the vertebral canal
1. Organized into regions of gray matter and white matter.
2. Gray Matter contains cell bodies of neurons, their dendrites, and the proximal parts of
their axons.
Groups of anatomically or functionally similar neuron cell bodies in the gray matter may be
found in a nucleus, lamina, or layer.
3. White Matter contains axons of neurons
Groups of anatomically or functionally similar axons may be found in a peduncle,
funiculus, fasciculus, lemniscus, or a tract.
II.

Peripheral Nervous System

- Spinal Nerves (31 Pairs)
- Cranial Nerves (12 Pairs)
- Autonomic Nerves
1. Nerves usually contain different combination of axons of motor neurons and processes
of sensory neurons.
Groups of neuronal cell bodies in the PNS are found in sensory or autonomic ganglia.
2. Thirty-one pairs of Spinal Nerves (Enter or Exit Segmentally from the Spinal Cord)

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- 8 Cervical
- 12 Thoracic
- 5 Lumbar
- 5 Sacral
- 1 Coccygeal
a. Spinal Nerves supply structures in the limbs, trunk, neck; all branches of spinal
nerves both contain motor and sensory fibers.
b. Cutaneous Branches of a Spinal Nerve supply a specific dermatome, the area of
skin supplied by the branches of a single spinal nerve
c. Muscular Branches of Spinal Nerve supply a specific myotome, the muscle mass
supplied by the branches of a single spinal nerve.
3. Twelve Pairs of Cranial Nerves (emerge mainly from the parts of the CNS above the
spinal card and have Roman Numeral Designations.
a. Cranial Nerves mainly supply structures of the head, visceral part of the neck, viscera in
the thorax and abdomen.
b. Cranial Nerves and their branches have motor fibers or sensory fibers or both in different
combinations.
Sensory:
Motor:
Mixed Sensory and
I Olfactory
III Occulomotor
Motor:
II Optic
IV Trochlear
V Trigeminal
VIII Vestibulocochlear
VI Abducens
VII Facial
XI Spinal Accesory
IX Glossopharyngeal
XII Hypoglossal
X Vagus

4. Autonomic Nerves are organized into Sympathetic and Parasympathetic divisions that
provide motor innervation to smooth muscle, glands, and cardiac muscle.
a. SNS and PNS use 2 neurons in series to innervate target structures.
b. The cell body of the first neuron (preganglionic neuron) is found in the gray matter of
the CNS; the second neuron (postganglionic neuron) is in an autonomic ganglion in
the PNS.
c. Preganglionic sympathetic neuron cell bodies are found in the thoracic and upper
lumbar segments of the spinal cord from T1 through L2.
d. Preganglionic parasympathetic cell bodies either are found in the brainstem and exit
the brain in 1 of 4 (III, VII, IX, or X) or are found at sacral cord segments S2, S3, S4 and
exit the spinal cord with the ventral roots of S2 through S4 spinal nerves.
Sympathetic Division functions as an
emergency or catabolic system involved in
fight or flight responses and has a
widespread distribution.

Parasympathetic Division functions to

conserve energy and restore body
resources and has a restricted distribution.

St. Michaels College of Iligan City Inc.

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Prepared By: Joshua James L. Diao, MN, CRN, BS-MT, RM, RN
CRANIAL AND SPINAL NERVES

Autonomic
Nerves

III. There
are 6
major components of the CNS, 5 of which develop from the 5 secondary vesicles of the
neural tube.
A. The 5 secondary vesicles are the telencephalon, diencephalon, mesencephalon,
metencephalon, and myelencephalon.
B. The telencephalon gives rise to the 2 cerebral hemispheres, the preoptic area, and most of
the basal ganglia.
1. Each hemisphere is divided into 4 lobes: frontal, parietal, occipital, and temporal.
2. Each hemisphere is highly convoluted by gyri that are separated by sulci; the central sulcus
and the lateral fissure are deep grooves that partially separate each hemisphere into the frontal,
parietal and temporal, and occipital lobes.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, BS-MT, RM, RN
C. The diencephalon gives rise to 4 thalamic subdivisions: (dorsal) thalamus, hypothalamus,
epithalamus, and subthalamus.
1. The optic nerve [cranial nerve (CN) II] and the optic cup, including the retina, are outgrowths
of the diencephalon.
2. The neurohypophysis, or posterior lobe of the pituitary, is an outgrowth of the hypothalamus.
D. The mesencephalon, metencephalon, and myelencephalon give rise to the midbrain,
pons, and medulla, respectively, which form the 3 parts of the brainstem.
1. The brainstem contains sensory and motor neurons of most of the cranial nerves (III through
XII, excluding CN XI, which is a misplaced spinal nerve).
2. The brainstem contains a core of diffusely organized neurons in the reticular formation.
3. The cerebellum is derived from the metencephalon and overlies the pons and medulla.
E. The spinal cord is the sixth component of the CNS that extends inferiorly from the
medulla but is not derived from a secondary vesicle; the dorsal and ventral roots of 31 pairs of
spinal nerves emerge segmentally from the spinal cord.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, BS-MT, RM, RN

IV. The
functions to
trauma and
A. The
a
of
by

CNS
circulates
ventricles
and through
the
subarachnoid
space.

ventricular system
protect the brain from
transport CSF.
brain and spinal
cord float within
protective bath
CSF, which is
secreted
continuously
the choroid
plexus into
the
ventricles
inside the
and
through the

B. Each
part of the CNS contains a
ventricle or a
channel that interconnects
ventricles;
there are 2
lateral ventricles, a third and fourth

ventricle
1. Each lateral ventricle is located within a
cerebral hemisphere.
a. The lateral
ventricles are C shaped and follow, roughly,
the form of the cerebral hemispheres. They have parts situated in each of the 4 anatomic lobes.
b. The body of each lateral ventricle is in the parietal lobe, the anterior horn extends into the
frontal lobe, the inferior horn is in the temporal lobe, and the posterior horn is in the occipital
lobe.
c. Each lateral ventricle communicates with the third ventricle by way of an interventricular
foramen (of Monro); the interventricular foramen is at the junction of the anterior horn and the
body of each lateral ventricle.
2. The third ventricle is found in the midline between parts of the diencephalon and
communicates with the fourth ventricle by way of the cerebral aqueduct (of Sylvius), which
passes through the midbrain.
3. The fourth ventricle is located between the dorsal surfaces of the pons and upper medulla
and the ventral surface of the cerebellum.
4. The fourth ventricle is continuous with the central canal in the lower medulla, which extends
through the length of the spinal cord.
5. The fourth ventricle contains the only openings where CSF can exit the ventricular system
and enter the subarachnoid space; there are 2 lateral foramina of Luschka and a single foramen
of Magendie in the midline.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, BS-MT, RM, RN

[Sedative-Hypnotic-Anxiolytic Drugs] GABA Drugs

-

Benzodiazepines (BZs), Barbiturates, and Alcohols

Cause dose-dependent CNS depression that extends from anesthesia to
respiratory depression and death.
Benzodiazepines reach a plateau in CNS depression; Barbiturates and Alcohol
do not.

St. Michaels College of Iligan City Inc.

College of Nursing
Prepared By: Joshua James L. Diao, MN, CRN, BS-MT, RM, RN