Introduction to
Psychopharmacology
September 14, 2004
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.
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.
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.
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.
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
…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
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)
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.
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.
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
ACCOMMODATIONS FOR
DEPRESSIVE DISORDER
• Flexibility in work schedule
• Time for treatment
(medical/psychological)
• Reduction of workload during active
stage of disorder
Bipolar Disorder
• Affects approximately 1.2% of the
population.
• Characterized by mood shifts from
depression to mania.
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)
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.
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?
Side Effects of Bipolar Medications
•
•
•
•
•
•
Headache
Fatigue
Drowsiness
Dizziness
Blurred vision
Joint aches
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
Accommodations
• Similar modifications for a person
with depressive disorders
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
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
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
“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 one’s thoughts are being
removed from one’s mind
“Positive Symptoms”
• Hallucinations (occurs for all senses)
• Loosening of Associations- cognitive
slippage and neologisms
“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
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 Parkinson’s meds or treatment
for Tardives Dyskinesia (except Clozapine)
Vocational Implications
• Confused thinking or strange,
grandiose ideas
• Heightened anxieties, fears, anger, or
suspicions
• Blaming others
• Social withdrawal, diminished
friendliness, and increased selfcenteredness
Vocational Implications
• Denial of obvious problems and strong
resistance to offers of help
• Substance abuse
• Side effects from the meds for
treatment
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
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.
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.
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.
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.
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.
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)
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
As a counselor…
Do not tell an employer or anyone else the
person’s 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.