Chapter 2: Neurobiologic Theories and Therapies

Great strides are being made in understanding the brain and

mental illness, but much is still unknown; nurses need to keep abreast
of developments to provide effective teaching.

Central Nervous System

The central nervous system (CNS) consists of brain, spinal
cord, and associated nerves that control voluntary acts. Brain
structures include cerebrum, cerebellum, brain stem, and the limbic
system.

Cerebrum
Cerebrum is divided into two hemispheres with four lobes each:
•  Frontal lobe (organization of thought, movement,
memories, emotions, moral behavior; arousal; attention; problem-
solving and decision-making) - personality
•  Parietal (taste, touch, spatial orientation)
•  Temporal (smell, hearing, memory, expression of emotions)
•  Occipital (coordination of language generation, visual
interpretation)

Cerebellum
The cerebellum receives and integrates information from all
areas of the body to coordinate movements and postural
adjustments.

Brain Stem
The brain stem is midbrain (reticular activating and
extrapyramidal systems), pons (primary motor pathway), medulla
oblongata (respiration and cardiovascular function), locus ceruleus
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(stress, anxiety, impulsive behavior), and cranial nerve nuclei 3
through 12.

Limbic System
The limbic system is above the brain stem and includes
thalamus (regulation of activity, sensation, emotion),
hypothalamus (temperature regulation, appetite control,
endocrine function, sexual drive, impulsive behavior associated
with rage, anger, and excitement), and amygdala (emotional arousal
and memory).

Neurotransmitters
Neurotransmitters are chemical substances manufactured in the
neuron to aid in transmission of information. Neurotransmitters are
either inhibitory or excitatory and include:
•  Dopamine (control of complex movements, motivation,
cognition, regulation of emotional responses).
•  Norepinephrine (attention, learning, memory, sleep,
wakefulness, mood regulation)
•  Epinephrine (flight-or-fight response)
•  Serotonin (food intake, sleep, wakefulness, temperature
regulation, pain control, sexual behavior, regulation of emotions).
•  Histamine (alertness, control of gastric secretions,
cardiac stimulation, peripheral allergic responses)
•  Acetylcholine (sleep and wakefulness cycle signals
muscles to become alert).
•  Neuropeptides (enhance, prolong, inhibit, or limit the
effects of other neurotransmitter).
•  Gama Butyric Acid (GABA) modulates other
neurotransmitters)

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Brain Imaging Techniques
Brain imaging techniques include computed tomography
(CT), magnetic resonance imaging (MRI), positron emission
tomography (PET), and single photon emission computed
tomography (SPECT). We cannot yet diagnose mental illness
with these techniques alone.

Causes of Mental Illness

Genetics and heredity play a role in mental illness but alone
do not account for its development. Psycho immunology explores
whether or not a compromised immune system could contribute to
mental illness, especially in at-risk populations. Infections,
particularly viruses, may play a role in mental illness and are being
studied.

Psychopharmacology
Psychopharmacology and medication management are important
in the treatment of many mental illnesses. Drug efficacy,
potency, and half-life play an important role in the selection of drugs.
Many drugs used to treat mental illness are prescribed for off-label
uses. Several psychotropic drugs have black box warnings. Principles
that guide the use of medications include:
•  Effect on target symptoms
•  Adequate dosage for sufficient time
•  Lowest dose needed for maintenance
•  Lower doses for the elderly
•  Tapering rather than abrupt cessation to avoid
rebound or withdrawal
•  Follow-up care

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Antipsychotic Drugs
Antipsychotic drugs treat psychotic symptoms, such as
delusions and hallucinations, by blocking dopamine receptors.
They are used for schizophrenia, acute mania, psychotic
depression, drug-induced psychosis, and other psychotic
symptoms.
•  Newer, atypical antipsychotic such as clozapine (Clozaril),
risperidone (Risperdol), olanzapine (Zyprexa), and quetiapine
(Seroquel), block dopamine and inhibits reuptake of serotonin.
•  Dopamine system stabilizers are the newest type of
antipsychotic drugs aripiprazole (amplify).
•  Haloperidol (Haldol) and fluphenazine (Prolixin) are
available in sesame oil based depot injection form.
 Extrapyramidal side effects include acute
dystonic reactions, pseudoparkinsonism, and akathisia,
which are treatable with anticholinergic agents and
reversible.
•  Tardive dyskinesia (TD) is a nonreversible neurologic
side effect that develops after long term antipsychotic use. It
must be prevented or recognized early.
•  Neuroleptic malignant syndrome (NMS) is a
potentially fatal, idiosyncratic reaction to an antipsychotic drug. It is
associated with rigidity, fever, autonomic instability,
diaphoresis, high fever, pallor, delirium, and elevated CPK. All
drugs must be stopped immediately and life functions must be
supported usually in ICU.
 Anticholinergic side effects that occur with
antipsychotics (and antidepressant) usually diminish in
time. They include orthostatic hypotension, dry
mouth, constipation, urinary hesitation or retention,
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 blurred near vision, dry eyes, photophobia, nasal
congestion, and decreased memory.
•  Other side effects include weight gain, postural
hypotension, tachycardia; some caused serious effects of prolonged
QT interval.
•  Client teaching for antipsychotics: sugar-free
beverages or hard candy, increased fiber and water in diet,
avoidance of driving or potentially hazardous activities,
avoidance of alcohol consumption.

Antidepressant Drugs
Antidepressant drugs are used to treat major depression, panic
disorder and other anxiety disorders, bipolar depression, and
psychotic depression. They interact with the monoamine
neurotransmitter systems in the brain, particularly the
neurotransmitters norepinephrine and serotonin.
• Selective serotonin reuptake inhibitors (SSRIs) include
fluoxetine (Prozac), fluvoxamine (Luvox—used for OCD), paroxetine
(Paxil), sertraline (Zoloft), citalopram (Celexa), and Escitalopram
(Lexapro). SSRIs have the fewest side effects: commonly anxiety,
agitation, akathisia, nausea, insomnia, and sexual dysfunction.
• Tricyclic and tetracyclic antidepressants block the
reuptake of norepinephrine (and serotonin to some degree). Use of
these agents is associated with anticholinergic side effects
(usually more intense than those associated with SSRIs) as well as
sedation, weight gain, tachycardia, and sexual dysfunction.
• Monoamine oxidase inhibitors (MAOIs) interfere with
enzyme metabolism. They include phenelzine, tranylcypromine, and
isocarboxazid. Side effects include daytime sedation, insomnia, weight
gain, dry mouth, and orthostatic hypotension. The client taking MAOIs
must not eat foods containing tyramine to avoid a potentially
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fatal hypertensive crisis. These foods include aged cheese and
meat, broad beans, beer, sauerkraut, soy sauce, soybean
condiments, and concentrated yeast. MAOIs have a potentially
lethal interaction with many drugs, including OTC medications and
SSRIs (potentially resulting in serotonin, or serotonergic, syndrome).
• Suicide potential: Antidepressants can take weeks to
reach the level of maximum therapeutic benefit, so clients must
be assessed for suicide potential. After beginning antidepressants,
clients may realize enough energy to carry out a suicide plan.
In addition, MAOIs and cyclic antidepressants are potentially
lethal when taken in overdose; therefore, prescription amounts and
refills may need to be limited.
• Client teaching for antidepressants: Take at night if
sedation occurs, take at mealtime if nauseated, avoid driving if
sedated.

Mood-Stabilizing Drugs
Mood-stabilizing drugs are used to treat bipolar disorder by
acting on the neurotransmitters of the brain. These drugs include
primarily lithium and anticonvulsant medications, such as
carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine
(Lamictal), trileptal (Topamax), and gabapentin (Neurontin).
• Serum lithium levels are used to monitor effectiveness. The
ranges vary but usually fall within 0.5–1.5 mEq/L, depending on the
client. Levels are drawn less frequently once they have stabilized.
Common side effects of lithium include mild nausea or diarrhea,
anorexia, fine hand tremor, polydipsia, polyuria, a metallic
taste in the mouth, fatigue, weight gain, and acne. Toxic
effects of lithium are severe diarrhea, vomiting, drowsiness,
muscle weakness, and lack of muscle coordination. Lithium
levels above 3.0 mEq/L may require hemodialysis.
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• Side effects of anticonvulsant drugs include drowsiness,
sedation, dry mouth, and blurred vision. In addition, carbamazepine
(Tegretol) causes rashes and orthostatic hypotension; valproic acid
causes weight gain, alopecia, and hand tremors.
• Client teaching for mood stabilizers: Take with food, have
follow-up serum levels for lithium and valproic acid
(Depakote), avoid driving or hazardous activities.

Antianxiety Drugs
Anxiolytics, or antianxiety drugs, are used to treat anxiety
disorders, insomnia, OCD, depression, PTSD, and alcohol
withdrawal. Benzodiazepines are the antianxiety agents used most
frequently (buspirone (BuSpar) is the only common
nonbenzodiazepine in wide use). They moderate the actions of GABA.
• A wide variety of benzodiazepines are used. They vary in half-
life, how they are metabolized, and effectiveness. Some are used
primarily for insomnia due to sedation side effects.
• Common side effects are drowsiness, sedation, poor
coordination, memory impairment, clouded sensorium, and hangover
effect in the morning. The biggest problem is psychological
dependence: Long-term use can result in overuse or abuse.
• Client teaching for anxiolytics: Avoid alcohol, be aware of
sedating side effects when driving

Stimulant Drugs
Stimulant drugs are prescribed for ADHD, residual ADD in
adults, and narcolepsy. They include methylphenidate (Ritalin),
amphetamine (Adderall), dextroamphetamine (Dexedrine), and
pemoline (Cylert).
• Common side effects are anorexia, weight loss, nausea,
irritability. In growing children, “drug holidays” may be advised.
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• Client teaching for stimulants: awareness of abuse potential (by
persons other than client), taking after meals, avoidance of caffeine
and excessive sugar intake, keeping supply out of child’s reach.

Disulfiram (Antabuse)
Sensitizing agent that causes an adverse reaction when alcohol
is ingested. Vasodilation (facial and body flushing), throbbing
headache, sweating, dry mouth, nausea, vomiting, dizziness, and
weakness are common. In severe reactions, chest pain, dyspnea,
severe hypotension, confusion, and even death may occur. Education
is crucial because many common products (shaving lotion, cologne,
cough syrup, deodorant) contain alcohol; therefore, clients must read
labels carefully. Other side effects include fatigue, drowsiness,
halitosis, tremor, and impotence. Disulfiram may affect the metabolism
of other drugs, such as phenytoin, isoniazid, warfarin, barbiturates, and
long-acting benzodiazepines (diazepam, chlordiazepoxide).

Cultural Considerations
Persons of different ethnic backgrounds respond differently to
some psychotropic medications. African Americans respond more
rapidly to antipsychotic and tricyclic antidepressant medications than
do whites and have a greater risk of side effects. Asians metabolize
antipsychotic and tricyclic antidepressants more slowly, requiring lower
doses to produce the same effects. Hispanics require lower doses of
antidepressants than do whites to achieve desired effects. Asians and
African Americans require lower doses of lithium than do whites to
produce desired effects.

Self-Awareness Issues
• Viewing chronic mental illness as having remissions and
exacerbations, just as chronic physical illness disorder.
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• Remaining open to new ideas that may lead to future
breakthroughs
• Understanding that medication noncompliance is often part of
the illness, not willful misbehavior

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