Psychopharmacology
Chapter 5—Medication Nonadherence
Activation—acute onset anxiety
Chapter 6—Preliminary Diagnostic Considerations
Agonist—drug or chemical that acts on receptor to mimic the effects of a naturally occurring
substance or of another chemical
Antagonist—substance or drug capable of blocking the activity of an agonist without exerting
any effect itself.
Differential diagnosis—the process of considering diagnostic possibilities based on comparison
of signs and symptoms of two of more disorders or diseases.
Egodystonic—symptoms subjectively experienced by the patient as being aversive, undesirable
or alien.
Egosyntonic—signs or symptoms judged to be pathological by others but not experienced as
distressing by the patient.
Etiology—the study of the causes of disorders and diseases
Pathophysiology—the underlying physiological dysfunction or disease that contributes to the
manifest symptoms of the disease
Target symptoms—in this book the distinctive symptoms that are the focus of medication
treatment
Toxicity—serious medication related adverse effects associated with actual or potential damage
to tissue, organs, or the entire body system, the toxicity may be directly related to critically
elevate blood levels of a drug and may be acute or chronic.
Chapter 7—Depressive Disorders
Two ways to have a depressive disorder
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Reactive—reaction to the situations around you and events
Endogenous—just appears out of no where
Three groups of depressive disorders
1. Reactive dysphoria—relatively low-grade mood changes, sadness, disappointment,
despair—that occur in response to minor losses and disappointments. Considered to be
normal and appropriate and do not interfere with functioning
2. Grief—uncomplicated bereavement, more prolonged and intensely painful experience.
Considered to be normal and appropriate response to major losses such as a death of a
loved one or divorce. Lasts usually from 6-12 months or sometimes even years. Occurs in
waves, social and occupational functioning can be derailed temporarily
3. Clinical depression—characterized by their intensity, duration, impact on functioning,
and a host of symptoms. self-esteem almost always erodes, and true depression is a
clearly pathological condition. Results in tremendous personal suffering, can last for
months to years and severely affect normal daily functioning. About 25-30% of patients
who experience grief develop clinical depression
When grief becomes clinical depression
 Marked erosion of self-esteem
 Agitation
 Early morning awakening
 Serious weight loss
 Psychotic symptoms
 Suicidal ideation or attempts
 Anhedonia (loss of the ability to experience any pleasure)
 Marked impairment
Types of Clinical Depression
1. Major unipolar depression—reactive, biological, reactive-biological, atypical
2. Bipolar disorder—manic and depressive episodes
3. “minor” depressions—dysthymia, chronic residuals of partially recovered major
depressions
Medical disorders that can cause depression
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Addison’s disease
AIDS
Anemia
Asthma
Chronic fatigue syndrome
Chronic infection/inflammation
Chronic pain
Congestive heart failure
Cushing’s disease
Diabetes
Hypothyroidism
Infectious hepatitis
Influenza
Lyme disease
Malignancies (cancer)
Malnutrition
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Multiple sclerosis
Parkinson’s disease6
Premenstrual dysphoria
Porphyria
Restless leg syndrome
Rheumatoid arthritis
Sleep apnea
Syphilis
Systemic lupus erythematosus
Traumatic brain injury
Ulcerative colitis
Uremia
Biological depression 4 factors
1. Medical illness that leads to systemic changes and ultimately to brain dysfunction. It
should be noted that recently it has been found that thyroid dysfunction is a common
disorder underlying 5 to 10 percent of serious depressions. Because of this high
frequency, a thyroid panel is strongly recommended in all cases of serious depression.
2. Female sex-hormone fluctuation, especially noted postpartum, during menopause, and
premenstrually
3. Medications and recreation drugs
4. Endogenous biological depressions. These disorders appear to emerge spontaneously in
certain at-risk individuals in the absence of stressful events. The prevailing theory is that
such disorders likely reflect a genetically transmitted biological vulnerability that leads to
repeated dysfunction of selected neurons in the limbic system and resulting recurring
depressive episodes
CBT (cognitive behavioral therapy)—the gold stage of depression treatment
The depressive triad, negative view of themselves, world, view of the future.
Chapter 16 -antidepressants
Antidepressants—large important group of medications used to treat depression
MAOIS—monoamine oxidase—an enzyme used to break down catecholamines (dopamine,
norepinephrine, and serotonin)—has a long list of foods you must avoid while taking this
medication—the wine and cheese effect because certain wines and cheeses have these amines
that are harmful
Six major groups of antidepressants
1.
2.
3.
4.
Cyclic antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Norepinephrine reuptake inhibitors (NRIs)
5. Monoamine oxidase inhibitors (MAOIs)
6. Atypicals
Types of Cyclic Antidepressants
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Amitriptyline
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
Trazodone
Brand name
Elavil
Anafranil
Norpramin
Silenor
Tofranil
Pamelor, Aventyl
Oleptro
Side effects of tricyclic antidepressants—“dirty drug”
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anticholinergic—dry mouth, dry skin, blurred vision, constipation, paralytic ileus,
cessation of movement of the intestines, inability to urinate, ruptured bladder
adrenergic—sweating, sexual dysfunction, orthostatic hypertension
antihistaminic—sedation and weight gain
miscellaneous—lowered seizure threshold, cardiac arrhythmia, hepatitis, agranulocytosis,
rashes, sweating, anxiety, elevated heart rate.
Dirty drug—effects more receptors that just the intended one—hence the side effects
SSRIs--have the same effects as tricyclics but have less side effects and are safer in dosage
--the drugs have different half-lives which determine how long they take to work and how long
they stay in your system, they have sexual dysfunction side effects
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fluoxetine—Prozac
citalopram—Celexa
escitalopram—Lexapro
fluvoxamine—Luvox
paroxetine—Paxil
sertraline—Zoloft
SSRIs Side effects—tend to be related to increased serotonin activity
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nausea
gastrointestinal upset
sweating
anxiety
insomnia
headache
restlessness
sexual dysfunction
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dry mouth
sedation
blurred vision
After several months it can begin to cause loss of energy, passivity, apathy, decreased
pleasure, decreased libido
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)—dual action antidepressants
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Venlafaxine—Effexor
Desvenlafaxine—Pristiq
Duloxetine—Cymbalta
Levomilnacipran—Fetzima
Mirtazapine—Remeron
MAOIs—used mainly when other antidepressants have failed in the treatment of major
depression and panic disorder. Not used commonly due to the severity of the side effects
including hypertension, cerebral hemorrhage, or even death
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Phenelzine—Nardil
Tranylcypromine—Parnate
Three phases of treatment of major depression
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Acute treatment—begins with the first dose and extends until the patient is
asymptomatic
Continuation treatment—continue treatment for a minimum of six months to avoid a
relapse
Maintenance treatment—continued lifetime treatment
o First episode—at the end of the continuation phase, gradually reduce the dose
and assuming no return of depressive symptoms discontinue. Educate the patient
to be alert to nay signs of recurrence and should this occur, as soon as possible
reinstate treatment
o Second episode—with risk factors: recommend lifelong medication treatment to
prevent recurrence. Without risk factors: gradually discontinue medications
o Third or subsequent episodes: recommended lifelong medication treatment
Three side effects that can lead to patient discontinuation
1. Activation—acute onset side effect seen within the first few hours after starting an
antidepressant or when doses are increased. It presents with nervousness and anxiety
2. Switching—when a person being treated with an antidepressant is provoked into a manic
state. One significant difference between activation and switching is that generally
switching does not occur until after several weeks of antidepressant treatment
a. Inorgasmia—difficulty achieving an orgasm despite adequate arousal
3. Weight gain
Treatment resistant depression—refers to a depression that has failed to respond adequate
trials of two or more antidepressant
ECT (electroconvulsive therapy)—shock therapy for severe depression and mood disorders, or
depression with psychotic features such as delusions
Chapter 8—Bipolar Disorder
Hypomania—the stage between manic and neutral
Mania—the highest stage of “feeling good”
Bipolar 1—must meet the criteria for atleast one manic state
Bipolar 2—at least one hypomanic episode and at least one major depressive episode but has
NEVER reaches a full manic episode
Stages of Acute Mania
1. Stage 1 (corresponds with hypomania)
a. Increased psychomotor activity
b. Emotional lability
c. Euphoria or grandiosity
d. Coherent but tangential thinking
2. Stage 2 (frank mania)
a. Increased psychomotor activity
b. Heightened emotional lability
c. Hostility, anger, impulsivity
d. Assaultive or explosive behavior
e. Flight of ideas, cognitive disorganization
f. Possible grandiose or paranoid delusions
3. Stage 3 (exhibited by some patients)
a. Frenzied psychomotor activity
b. Incoherent thought processes
c. Ideas of reference, disorientation, delirium
d. Florid psychosis (indistinguishable from other psychotic disorders, although
usually mood congruent)
Medical conditions associated with mania
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Central nervous system trauma, for example, post-stroke
Metabolic disorders such as hyperthyroidism
Infections diseases such as encephalitis
Seizure disorders
Central nervous system tumor
Drugs that can induce mania
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Stimulants (amphetamines)
Antidepressants (especially tricyclic antidepressants)
SAM-e
Antihypertensives
Corticosteroids (prednisone) in higher doses
Anticholinergics (benztropine, trihexyphenidyl)
Thyroid hormones (levothyroxine)
Bipolar I Disorder—one or more manic episodes, there may be preceding or subsequent
episodes of hypomania or depression.
Bipolar II Disorder—one or more depressive episodes and at least one episode of hypomania
Rapid cycling—at least four episodes of mania, hypomania, or major depression in the previous
twelve months
Cyclothymia disorder—numerous periods of alternating depressive symptoms with hypomanic
symptoms of at least two years duration that do not meet criteria for either major depression or
hypomania
Criteria
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History of numerous periods of alternating depressive and hypomanic symptoms
Symptoms do not meet criteria for a hypomanic, manic, or depressive mode
Not due to organic factors, substance abuse, medical condition, or other
psychiatric disorder
Chapter 17—Bipolar Medication
Side effects of Lithium
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Gastrointestinal
o Nausea
o Vomiting
o Diarrhea
Nervous system and neuromuscular
o Headache
o Lethargy
o Muscle weakness
Endocrine
o Clinical hypothyroidism
o Goiter
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Renal
o Interference or alteration in normal kidney functioning can potentially lead to a
buildup of lithium
Hematological
o a benign reversible increase in white blood cell count occurs frequently with
lithium treatment
Cardiovascular
o Serious cardiac symptoms are rare but sometimes minor changes on an EKG are
present
Dermatological
o Rash
o Acne-like lesions
Weight gain
o Very common side effect, up to twenty pounds weight gain in 20% of patients
Teratogenicity
o Carries risk during pregnancy
Monitoring Blood Levels
o Necessary to maintain a safe and therapeutic dosage
Three anticonvulsants
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Carbamazepine—second line agent for mania as well as mixed episodes
o Side effects—sedation, dizziness, drowsiness, blurred vision, incoordination,
nausea, vomiting, diarrhea, abdominal pain, itching rash, hives
Divalproex—First line agents for mania, recommended for mixed episodes and rapid
cycling
o Side effects—fatigue, dizziness, nausea, vomiting, indigestion
Lamotrigine—used for acute maintenance therapy, first line treatment for bipolar
depression, second line treatment for rapid cycling
o Side effects—dizziness, headache ataxia, drowsiness, tremor nausea, vomiting,
Steven Johnson’s syndrome can occur in rare conditions
Chapter 12—PTSD
Symptoms of PTSD
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Persistent reexperiencing of the trauma
o Distressing intrusive recollections of the event (images, affects, conditions)
o Recurring nightmares regarding the trauma
o “flashbacks” or déjà vu (sensations as if the traumatic episode were happening in
the present)
Increased arousal
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o Sleep disturbances
o Startle response
o Irritability
o Hypervigilance
Transient psychotic symptoms
o Derealization
o Illusions
o Hallucinations (visual or auditory)
Avoidance
o Avoiding discussion of the traumatic events
o Avoiding activities or people and places that could provoke recollections of the
trauma
o General social withdrawal
Numbing
o Blunted affective responses
o Feelings of emptiness
o Feelings of estrangement or detachment
o Clouding of consciousness
Associated features
o Major depression
o Panic attacks
o Substance abuse (often seen as an attempt to “self-medicate” to reduce anxiety
or intrusive experiences)
Six models in which biology can potentially be altered by psychological stress
1. Attachment and the repetition compulsion—due to early severe child abuse or neglect
may leave not only emotional scars, but also neurobiology may be altered, can lead to
increased need for attachment
2. Attachment and impaired affect modulation—traumatic experience early in life which
may lead to inadequate attachment and bonding, especially true in neglected children
3. Hyperarousal—behavioral reactions—initially hypervigilance or arousal and ultimately
profound state of withdrawal
4. Intrusive symptoms—flashbacks
5. Acute toxic levels of glutamate and cortisol—after a severe trauma marked increases in
the neurotransmitter glutamate, and the stress hormone cortisol may reach toxic levels
and damage parts of the brain associated with affect regulation
6. Kindling—repeated episodes of trauma change brain functioning