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Counseling: Communicatio n Guidelines

The brain stem (midbrain, pons, medulla oblongata) REVIEW don't memorize

refer to book, pages 212-213 and slides..too much to write.

-midbrain; controls capillary reflex, eye movement, -brain stem-ponds: processing station & auditory pathways. -medulla obligate: reflex centers, balance, HR, BP, respirations, coughing, swallowing, sneezing, involving regulation area.

cerebellum
cerebrum (frontal, parietal, occipital, temporal lobes, the basial ganglia, amygdala and hippocampus)

skeletal muscle, coordination, contraction, and maintains equilibrium

- frontal: thinking, planning, central executive functions and motor execution. -parietal lobe: senitol sensory perception, integration of visual, and information centers. -Temporal: language function & auditory perception, long term memory & emotion. -occipital: visual perception & processing, vasoganglion, regulation of movement. -amygdala and hippocampus, emotions, learning, memory, & basic drives.

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dopamine Gaba
MRI & CT shows in schizophrenia

neurotransmitter involved in a wide variety of behaviors & emotions including pleasure. -excessive transmission in schizophrenia.

- a largely inhibitory neurotransmitter. -Distributed widely throughout the CNS -implicated in sleep and eating disorders -Low levels has also been linked to extreme anxiety

Through MRI or CT it is possible to ID gross anatomical changes in the brain: increased posterior ventricles=loss of brain tissue -In schizophrenia, cortical atrophy is detected, so there is an enlargement of the posterior ventricles.

PET shows in schizophrenia

-injected radioactive tracer travels to the brain and concentrates in area of high activity -shows dif f ering bain activity is and shows intensity of the activity & dif f ering areas f rom the normal brain

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Standard (FirstGeneration) Antipsychotic Drugs -Traditional Antipsychotics

Act as antagonists to these receptors: --->Acetylcholine (muscarinic receptors) ---> Norepinephrine (a1 receptors) ---> Histamine (H1 receptors) **also a dopamine antagonists**

-Traditional Antipsychotics Action for schizo -Traditional Antipsychotics Advantage -Traditional Antipsychotics Disadvantage

targets positive symptoms of schizophrenia b/c they dopamine antagonists-blocks dopamine (remember excess for schizo) No effect on negative symptoms, so used less often

Less expensive
-Do not treat negative symptoms. (w/drawn, lack of feeling, pleasure, interest. not motivated in ADLs) -block of dopamine receptors in motor area cause extrapyramidal side effects (EPSs) as well anticholinergic effects, retarded Indonesian,

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extrapyramidal side effects (EPSs) (EPS) Type of dystonia's mentioned

what can help lessen extrapyramidal side effects (EPSs)

Three of the most common EPS s/e are: -acute dystonia=acute sustained contraction of muscles usually head & neck -akathisia=psychomotor restlessness evident as pacing or fidgeting, pronounced & distressing to pt -pseudoparkinsonism= parkinsons symp: tremors, reduced accessory movements, shuffling gait, stiff, drooling, masked expression, "pin rolling"

-Occulogyric-eyes are locked upward, painful -Torticollis neck muscles contracting involuntarily side to side (recording says head to side? )

-reduce dose amount -adding anti-Parkinson meds, esp centrally acting meds like: trihexyphenidyl (artane) & benztrophine & amantadine hydrochloride (Benadryl) -Most pt will develop tolerance after a few months

Serious EPS that sows up later

T ardive dyskinesia (T D): shows up mont hsyrs af t er -Face: prot ruding and rolling t ounge, spast ic f acial dist ort ion, smacking movement s. grimincing -Limbs: Choreic (rapid, purposeless), At het oid (slow, complex) -T runk:neck & shoulder movement s, dramat ic hip jerks, rocking

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Tardive dyskinesia how common treatment

Neuroleptic malignant syndrome (NMS) -TX

20% >2 yrs -D/C of drug rarely relieves symptoms -best to catch early, will worsen w/ time -changes in appearance, provide support

Severe EPS, rare, can be f atal (renal f ailure, cardiac) -can occur 1st week but of ten occurs later, rapid progress over 2-3 days. -early detection is the key. d/c med tx symptoms

Neuroleptic malignant syndrome (NMS) S/S

-Hyperpyrexia: cardinal featuretemp over 103 - Autonomic dysfunction; htn, tachycardia, diaphoresis, incontinence, elevated vitals, UR -delirium, stupor, coma -Severe extrapyramidal symptoms

Other negative side effect of block of dopamine receptors

increase pituitary secretion of prolactin causing amenorrhea (no period), Galactorrhea (milk flow) gynecomastia in men (man boobies)

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Anticholinerg ic Symptom

many tradiontional Antipsycs also block mucus secretentic receptors in internal organs, causing -Dry Mouth - blurred vision (usually abates in 1-2 weeks -Urinary retention -constipation -photo-sensitivity -sexual dysfunction

Anticholine rgic toxicity

-Traditional: Other common Side Effects
-Traditional Antipsychotics Low Potency examples

-non reactive puplis -dry mucus membranes -reduced or absent peristalsis (smooth muscle move) -unstable vitals -seizures -urinary retention LIFE THREATENING- EMERGANCY

constipation, hypotension, ortho-hypon, increased appetite insomnia, sedation, UR, weight gain

-high sedation + high ACH + low EPSs -high acetylcholine (acts as neurotransmitter) af f ect -low risk f or extrapyamidal symptoms -*Chlopromazine (Thorazine), Thioridazine (Mellarill)*

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There are medium potency

-Traditional Antipsychotics High potency = Examples

*loxapine (Loxitane), perphenazine (Trilafon)* Molindone (Trilafon)

low sedation + low ACH + high EPSs -low acetylcholine (acts as a neurotransmitter) affect -high risk for extrapyamidal symptoms -*Haldol (haloperidol)*, *fluphenazine (Prolixin)*, Pimozide (Orap), triflupoperazine

-Traditional Antipsychotics Long acting -A-typical, or a newer antipsychotic

Haldol Decanoate and Prolixin Decanoate: these "decanoates" are long acting dont have to take the medications every day, it helps with med adherence

-Serotonin-dopamine antagonists (5HT2A) -bind to dopamine receptors in the alembic system, therefore we do see motor side effects such as Tardive dyskinesia which is irreversible -target negative and positive symptoms

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-A-typical, or a newer antipsychotic Advantages

-fewer to no EPS, and other motor side effects -target negative symptoms of psychosis as well as positive symptoms -tx mood disorders: bipolar, depression and anxiety -decreases suicidal behavior.

-A-typical, or a newer antipsychotic disadvantages

-weight gain, can happen in all, but more so. -Metabolic abnormalities: need to monitor blood sugars & related metabolic changes -serious side effects depending on med -more expensive

A-Typcials Begin to work

1 Week but takes seceral months to reach max ef f ect Brief dose on benzodiazepine may be given to help pt maintain control during that time

Common A-typical

-Airpiprazole (Abilify) -Quetiapine (Seroquel) -Clozapine (Clozaril) -Ziprasidone (Geodone) -Paliperidone (invegal) -Asenapine (Saphris) -Risperidone (Risperdal) -Olanzapine (Zyprexa)

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-A-typical Clozaril
-A-typical Risperidone
Metabolic disturbances weight gain higher w/

-risk for agranulocytosis: monitoring the CBC closely -other s/e= connvulsions/sezier , myocarditis -anticonvulsive may be given as a preventative measure & cardiac status & labs monitored

May cause EPS at higher doses observing f or a side ef f ect known as neuromalignant syndrome convulsions, myocardit is, ot her side ef f ect s. Monit oring t he CBC, maybe based on t he risk, ant iconvulsive may be a prevent at ive measure and also looking at t he cardiac st at us and all t he labs relat ed t o t hat .

Olanzapine (Zyprexa) Clozapine (Clozaril)

Quetiapine (Seroquel) Clozapine (Clozaril) Asenapine (Saphris)

Sedation higher w/

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Differences in drug responses among ethnic groups

-Lithium: Greater toxicity in African Amer than whites -Haloperidol: Same dose, but plasma concentrations 50% higher in Asians than in whites -Clozapine: Life-threatening s/e agranulocytosis, more prevalent in Ashkenazi Jews than others