Introduction to Psychopharmacology

1. Introduction to Psychopharmacology September 14, 2004

2. 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.

3. 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.

4. 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.

5. 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.

6. 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

7. …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

8. 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)

9. 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.

10. 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.

11. 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

12. ACCOMMODATIONS FOR DEPRESSIVE DISORDER • Flexibility in work schedule • Time for treatment (medical/psychological) • Reduction of workload during active stage of disorder

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

14. 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)

15. 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.

16. 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?

17. Side Effects of Bipolar Medications • Headache • Fatigue • Drowsiness • Dizziness • Blurred vision • Joint aches

18. 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

19. Accommodations • Similar modifications for a person with depressive disorders

20. 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

21. 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

22. 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

23. “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

24. “Positive Symptoms” • Hallucinations (occurs for all senses) • Loosening of Associations- cognitive slippage and neologisms

25. “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

26. 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)

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

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

29. 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

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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)

36. 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

37. 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.