Antipsychotics and Anxiolytics

Chapter 22: Antipsychotics and Anxiolytics

Psychosis

• Definition: Loss of contact with reality.

• Theory: Psychosis results from an imbalance in the neurotransmitter dopamine in the brain.

• Characteristics:

  • Difficulty in processing information.

  • Disorganized thoughts and incoherence.

  • Distortion of reality, including delusions and hallucinations.

  • Possible symptoms of catatonia.

  • Aggressive or violent behavior.

Schizophrenia

• Definition: A chronic psychotic disorder.

• Onset: Usually occurs in adolescence or early adulthood.

• Major Categories of Symptoms:

  • Cognitive Symptoms:

  • Disorganized thinking.

  • Memory difficulty.

  • Decreased ability to focus attention.

  • Positive Symptoms:

  • Exaggerations of normal functions.

  • Symptoms such as agitation, delusions, hallucinations, incoherent speech, and paranoia.

  • Negative Symptoms:

  • Decrease or loss in function and motivation.

  • Symptoms include poverty of speech, blunted affect, inertia, poor self-care, and social withdrawal.

Antipsychotics

• Purpose: Treatment of mental illness to improve thought processes and behavior.

• Mechanism of Action: Primarily block dopamine receptors in the brain.

• Major Categories:

  • Typical (Traditional) Antipsychotics:

  • Phenothiazines: Block norepinephrine, leading to sedative and hypotensive effects early in treatment.

  • Nonphenothiazines: Block only the neurotransmitter dopamine.

  • Atypical Antipsychotics: Treat schizophrenia and other psychotic disorders in patients who do not respond to or cannot tolerate typical antipsychotics, offering decreased side effects.

Adverse Reactions of Antipsychotics

• Extrapyramidal Syndrome (EPS):

  • Symptoms include stooped posture, masklike facies, rigidity, tremors at rest, shuffling gait, pill-rolling motion of hands, bradykinesia.

• Other Reactions:

  • Acute dystonia, akathisia, tardive dyskinesia.

  • Neuroleptic Malignant Syndrome (NMS):

  • Symptoms include excess agitation, altered mental status, exhaustion, dehydration, muscle rigidity, hyperthermia, profuse diaphoresis, blood pressure fluctuations, tachycardia, dysrhythmias, seizures, rhabdomyolysis, respiratory and renal failure, coma.

Typical Antipsychotics

• Phenothiazine Groups:

  • Aliphatic (Example: chlorpromazine):

  • Side effects: Strong sedation, orthostatic hypotension, moderate EPS.

  • Piperazine (Examples: fluphenazine, perphenazine):

  • Side effects: Dry mouth, urinary retention, agranulocytosis, severe EPS.

  • Piperidines (Example: thioridazine):

  • Side effects: Strong sedation, low to moderate effect on blood pressure, few EPS.

• Individual Drugs:

  • Fluphenazine:

  • Action: Blocks dopamine receptors in the brain.

  • Use: Manages symptoms of schizophrenia and psychosis.

  • Interactions: Increased depression when taken with alcohol or other CNS depressants; kava kava may increase EPS. Increased effects with magnesium sulfate, lithium, beta blockers.

  • Side effects: Sedation, dizziness, headache, seizures, dry mouth, nasal congestion, blurred vision, photosensitivity, urinary retention, GI distress, peripheral edema, tachycardia, EPS.

  • Haloperidol (Nonphenothiazines):

  • Action: Blocks dopamine receptors.

  • Use: Treats psychoses, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), Tourette’s syndrome.

  • Contraindications: Narrow-angle glaucoma, CNS depression, severe liver, kidney, and cardiovascular disease, blood dyscrasias.

  • Side effects: Drowsiness, headache, insomnia, dry mouth, blurred vision, photosensitivity, tachycardia, orthostatic hypotension, dysrhythmias, seizures, weight gain, urinary retention, sexual dysfunction, blood dyscrasias, EPS, NMS.

  • Interactions: Increased sedation with alcohol, CNS depressants; increased toxicity with anticholinergics; decreased effects with phenobarbital, carbamazepine, caffeine.

Atypical Antipsychotics

• Advantages: Effective in treating both positive and negative symptoms of schizophrenia; less likely to cause EPS or tardive dyskinesia.

• Mechanism of Action: Block serotonin and dopaminergic D4 receptors.

• Individual Drugs:

  • Clozapine:

  • Use: Severe schizophrenic patients unresponsive to traditional antipsychotics.

  • Side effects: Dizziness, sedation, constipation, tachycardia, orthostatic hypotension, tremors, occasional rigidity, seizures, agranulocytosis. Low possibility of EPS.

  • Risperidone:

  • Use: Manage symptoms of psychosis, treats both positive and negative symptoms of schizophrenia.

  • Side effects: Sedation, headaches, photosensitivity, EPS, seizures, dry mouth, weight gain, tachycardia, orthostatic hypotension, urinary retention, sexual dysfunction. Low possibility of EPS and tardive dyskinesia.

  • Aripiprazole:

  • Use: Manage symptoms of schizophrenia, bipolar disorder, autism, depression, Tourette syndrome.

  • Side effects: Drowsiness, dizziness, headache, insomnia, anxiety, agitation, memory impairment, blurred vision, photosensitivity, GI distress, weight gain/loss, tachycardia, orthostatic hypotension, dysrhythmias, seizures, sexual dysfunction, suicidal ideation, NMS. Low possibility of EPS and tardive dyskinesia.

Nursing Process: Phenothiazines and Nonphenothiazines

• Assessment: Assess baseline vital signs and obtain health history including present drugs.

• Nursing Diagnosis:

  • Ineffective relationship related to social withdrawal.

  • Disturbed sleep pattern related to medication adverse effects.

• Planning: The patient’s psychotic behavior will improve with medication, psychotherapy, and adjunct therapies.

• Nursing Interventions:

  • Monitor vital signs.

  • Remain with the patient while the medication is taken and swallowed.

  • Observe for EPS and assess for symptoms of NMS.

  • Inform patients that medication may take 6 weeks or longer to achieve full clinical effect.

  • Caution patients against consuming alcohol or other CNS depressants.

Anxiety

• Types of Anxiety:

  • Primary Anxiety: Not caused by a medical condition or drug use; managed with short-term anxiolytics.

  • Secondary Anxiety: Related to selected drug use, medical, or psychiatric conditions; medications are not usually given for secondary anxiety.

Anxiolytics

• Lorazepam:

  • Action: Inhibits GABA neurotransmission by binding to specific benzodiazepine receptors.

  • Use: Anxiolytic, antiseizure, sedative-hypnotic, preoperative drug, and for substance abuse withdrawal.

  • Side effects: Drowsiness, dizziness, ataxia, restlessness, weakness, headache, confusion, amnesia, blurred vision, GI distress, sleep disturbance, hallucinations, bradycardia, hypotension/hypertension, seizures, suicidal ideation, NMS, respiratory depression.

• Discontinuation: Gradually decrease dose over several days to avoid withdrawal symptoms, which may develop slowly in 2 to 10 days, lasting several weeks, and include tremors, agitation, nervousness, sweating, insomnia, anorexia, muscle cramps.

Nursing Process: Benzodiazepines

• Assessment: Assess for suicidal ideation and obtain a history of the patient’s anxiety reaction, as well as their support system.

• Nursing Diagnosis:

  • Anxiety related to situational crisis.

  • Noncompliance related to adverse effects of medications.

• Planning: Patient’s anxiety and stress will be reduced.

• Nursing Interventions:

  • Observe patient for side effects of anxiolytics.

  • Monitor vital signs.

  • Encourage family support for the patient.

  • Advise the patient against driving a motor vehicle or operating dangerous equipment due to sedation.

  • Warn against consuming alcohol or CNS depressants while taking an anxiolytic.

Miscellaneous Anxiolytics: Buspirone

• Action: Binds to serotonin and dopamine receptors.

• Efficacy: May not be effective until 1 to 2 weeks after continuous use; fewer side effects involving sedation and physical and psychological dependency compared to many benzodiazepines.

• Common Side Effects: Drowsiness, dizziness, headache, excitement, nausea, nervousness.

• Interactions: Grapefruit juice interaction can lead to toxicity.

Practice Questions

• Question 1: Medication teaching necessary if patient states, "I can stop this drug after 3 weeks if I feel better."

• Question 2: Signs indicating need to add an anticholinergic to medication regimen for patient on fluphenazine include facial grimacing and tongue spasms.

• Question 3: Increased injury risk for patient on risperidone due to falls from orthostatic hypotension.

• Question 4: Assessment findings for neuroleptic malignant syndrome (NMS) include rhabdomyolysis.

• Question 5: Report to health care provider if a patient taking lorazepam smells of alcohol due to fatal interaction risk.

• Question 6: Anticipate administration of Dantrolene to treat a patient with neuroleptic malignant syndrome.