Behavioral Health Exam 2: Neurobiologic Theories, Psychopharmacology, and Legal Issues

Neurobiologic Theories and Neurotransmitters

  • GABA (Gamma-Aminobutyric Acid):     * Function: Acts as an inhibitory neurotransmitter.     * Mechanism: Modulates other neurotransmitters rather than providing a direct stimulus.     * Clinical Application: Drugs that increase GABA levels, such as benzodiazepines, are utilized to treat anxiety and induce sleep.

  • Serotonin:     * Function: Inhibitory neurotransmitter.     * Regulation: Controls food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, and regulation of emotions.     * Clinical Significance: Plays a critical role in anxiety, mood disorders (depression), and schizophrenia.

  • Dopamine:     * Function: Excitatory neurotransmitter.     * Regulation: Controls complex movements, motivation, and cognition. It also regulates various emotional responses.     * Clinical Significance: Implicated in schizophrenia and other psychoses. It is also involved in movement disorders, such as Parkinson's disease.     * Treatment: Antipsychotic medications are administered to treat schizophrenia by targeting dopamine pathways.

Psychotropic Medication Teaching and Classifications

  • Antipsychotics:     * Primary Use: Treatment of symptoms of psychosis, including delusions and hallucinations associated with schizophrenia. Also used for the manic phase of bipolar disorder.     * Off-label Uses: Anxiety and insomnia.     * Nursing Teaching:         * Patients should drink and eat sugar-free fluids to ease dry mouth.         * Drowsiness/sleepiness must be monitored closely.         * Immediate reporting of muscle rigidity and fever (indicators of severe reactions) is required.

  • Selective Serotonin Reuptake Inhibitors (SSRIs):     * Indication: First-line choice for treating depression, PTSD, and OCD.     * Specific Drugs: Sertraline, Paroxetine, Fluoxetine.     * Teaching Points:         * Take medication first thing in the morning unless sedation is contraindicated.         * Always ask the patient when they normally take their medications to align with their routine.         * It takes approximately 44 weeks for full effect.         * Avoid St. Johns Wort due to interactions.         * Missed Doses: Can be taken up to 88 hours after the missed dose time.         * Discontinuation: Must taper the drug gradually.

  • Tricyclic Antidepressants (TCAs):     * Indication: Major depressive disorder, anxiety disorders, OCD, and insomnia.     * Specific Drug: Imipramine.     * Adverse Effects: Kardiotoxic properties make them unsafe for patients with heart problems. They are lethal in overdose.     * Mechanism Actions: Known for anticholinergic effects.     * Effectiveness: Takes 4−64-6 weeks for therapeutic effects.

  • Benzodiazepines and Anxiolytics:     * Specific Benzodiazepines: Alprazolam, Clonazepam, Lorazepam.     * Use: Anxiety, seizures, alcohol withdrawal, and PTSD/Panic attacks.     * Nursing Actions: Fast-acting but not for long-term use due to dependence risk. Monitor for respiratory depression, withdrawal seizures, decreased vitals, and sedation.     * Avoidance: Avoid alcohol and do not stop the medication abruptly.     * Buspirone (Non-Benzodiazepine): Used for generalized anxiety disorder. It takes 2−42-4 weeks (or up to 2−62-6 weeks) for effect. Avoid grapefruit juice. It lacks sedation or dependence risks.

  • Monoamine Oxidase Inhibitors (MAOIs):     * Indication: Atypical or treatment-resistant depression.     * Specific Drug: Phenelzine.     * Teaching Point: Avoid foods containing tyramine to prevent a hypertensive crisis.     * Prohibited Foods: Mature/aged cheese, meats (pepperoni, salami), yogurt, sour cream, peanuts, brewers yeast, banana peel/bananas, avocado, figs, smoked fish, beers, red wine, and fava beans.

  • Mood Stabilizers:     * Lithium:         * First-line for bipolar disorder.         * Therapeutic Range: 0.5−1.50.5-1.5.         * Side Effects: GI distress and tremors.         * Patient Education: Do NOT change salt intake; a low-sodium diet is strictly prohibited.         * Toxicity Signs: N/V, GI upset, confusion, and poor coordination.     * Valproic Acid:         * Mechanism: Increases inhibitory GABA; stabilizes mood via the kindling process (used for bipolar, seizures, migraines).         * Side Effects: Weight gain, alopecia (hair loss), and hand tremors.         * Nursing Actions: Require periodic monitoring of blood levels. Female patients must use 22 forms of birth control (BC) and take a pregnancy test before starting.

Adverse Clinical Syndromes and Metabolic Effects

  • Neuroleptic Malignant Syndrome (NMS):     * Symptoms: Muscle rigidity, high fever, autonomic instability (unstable BP, diaphoresis, pallor), and delirium.     * Patient Presentation: Confused, mute, fluctuating between agitation and stupor.     * Interventions: Immediate discontinuance of all antipsychotics. Provide supportive care (dehydration treatment/hyperthermia care with cooling blankets).     * Risk Factor: Dehydration increases the risk of NMS.

  • Metabolic Syndrome:     * Definition: A cluster of conditions increasing risk for heart disease, diabetes, and stroke. Linked often to atypical antipsychotics (Risperidone, Olanzapine).     * Components: Weight gain, hypertension, high blood sugar (diabetes), and high cholesterol.     * Monitoring: Regularly check weight, BMI, blood sugar, and lipid levels. Encourage healthy diet and exercise.

Extrapyramidal Side Effects (EPS) and Anticholinergic Crisis

  • EPS Symptomology:     * Aksthisia: Characterized by internal restlessness.     * Dystonia: Severe muscle spasms starting at the eyes and progressing down the body.     * Pseudoparkinsonism: Mask-like face, shuffling gait, cogwheel rigidity (ratchet-like joint movement), tremors, and drooling.     * Tardive Dyskinesia: Irreversible condition involving lip smacking, tongue rolling, pill rolling, truncal twisting, and pelvic rocking.     * Treatment for EPS: Anticholinergics like benztropine and diphenhydramine.

  • Anticholinergic Crisis vs. Side Effects:     * Side Effects (Mild): Dry mouth, blurred vision, constipation, urinary retention, tachycardia, photophobia, mild confusion.     * Crisis (Life-Threatening): Mnemonic: "Hot as a hare, blind as a bat, mad as a hatter, dry as a bone, red as a beet."     * Crisis Symptoms: Hyperthermia, delirium, mydriasis, flushed skin, anhidrosis, hallucinations, seizures, and arrhythmias.     * Treatment: Stop the drug, provide supportive care, and administer physostigmine (antidote).

Legal and Ethical Issues in Psychiatric Nursing

  • Patient Rights:     * Includes informed consent, receiving/refusing treatment, privacy, confidentiality, visitors, filing complaints, and communication.     * Refusal of Treatment: If a patient refuses, the nurse must ask "Tell me why you do not want to take the medication?" Patients can refuse medication UNLESS they are a danger to self/others or there is a doctor's court order.     * Privacy (Private Rooms): There is no general right to a private room, but conditions like mania, severe schizophrenia, psychosis, or being a danger to self/others may qualify a patient for one.     * Confidentiality: HIPAA applies; information is shared with the facility healthcare team.     * Communication: Access to phones, mail, and interpreters is a right and cannot be withheld as punishment.

  • Admission and Competence:     * Competent: Patient understands information, makes decisions, and communicates them.     * Incompetent: Court declared; a legal guardian or healthcare proxy makes decisions.     * Voluntary Admission: Patient admits themselves; retains all rights including discharge requests.     * Involuntary Admission:         * 1013: Lasts 7272 hours without the patient signing in.         * 1014: After 7272 hours, extends to 55 days still without signing.         * 1021: 5 days without signing; waits for court date (up to 22 weeks).         * Evaluation: Conducted by a chief officer and a second (2nd2nd) MD to determine competence.

  • Duty to Warn:     * Legal obligation for professionals to warn/protect if a patient makes a credible threat against an identifiable person. Involves notifying the victim and/or law enforcement.

  • Least Restrictive Interventions:     * Progressive Hierarchy: Verbal de-escalation/therapeutic communication -> Decrease stimuli/quiet environment -> Offer PRN meds (Oral first, then IM) -> Seclusion (locked room) -> Restraints (physical/mechanical as a last resort).     * Restraint Protocol: Requires 1:11:1 evaluation within 11 hour. Order must be renewed q4hq4h. Nurse documentation q1−2q1-2 hours. Constant supervision is required.     * False Imprisonment: Unjustifiable detention via inappropriate use of restraint or seclusion.

Anger, Hostility, and Aggression Management

  • Stages of Aggression and Interventions:     * Triggering: Event initiates response (restlessness, pacing, loud voice). Intervention: Calm communication, active listening, offer quiet environment.     * Escalation: Movement toward loss of control (yelling, clenched fists). Intervention: Firm voice, set clear limits, direct to time-out, offer options, get help from staff.     * Crisis: Loss of control (hitting, biting, throwing). Intervention: Seclusion/restraint (if immediate danger), maintain distance, medication administration (antipsychotics like Haldol).     * Recovery: Regains control (lowered voice). Intervention: Remove restraints/seclusion, talk about triggers, explore coping strategies.     * Post Crisis: Reconciliation and return to baseline (remorse, crying). Intervention: Debrief with patient and staff, document objectively, reinforce strengths.

  • Aggression Pharmacotherapy:     * Haloperidol (Typical): Effective for acute agitation.     * Olanzapine, Risperdone (Atypical): Options for aggression; risk of metabolic syndrome.     * Adverse Effects: EPS, NMS, and QT prolongation (especially ziprasidone and IV haloperidol).

Family Violence and Abuse

  • Intimate Partner Violence (IPV):     * Cycle: Tension-Building (verbal abuse) -> Acute/Explosion (severe physical abuse) -> Honeymoon (apologies, promises to change).     * Signs: Injuries at various healing stages, partner refuses to leave or answers questions, frequent ED visits.     * Types: Psychological (belittling), Physical (shoving to choking), and Sexual.

  • Child Abuse and Specific Syndromes:     * Types: Physical, Neglect (malnutrition/hygiene), Emotional (extreme behavior), Sexual (age-inappropriate knowledge).     * Shaken Baby Syndrome (TEST): Whiplash-like closed head injuries. Indicators include retinal bleeding, respiratory distress, bulging panels (fontanels), and increased head circumference.     * Factitious Disorder (Munchausen’s Syndrome): Caregiver induces illness in a child to meet their own need for reinforcement.

  • Elder Abuse:     * Includes physical abuse, neglect (pressure ulcers), financial exploitation, and emotional belittling. Interventions involve caregiver stress relief and resource provision (Ref Box 12.412.4).

  • Community and Nursing Planning:     * Abuse Myths: Consult Box 12.512.5.     * Lethality Assessment (TEST): Assess safety by asking: "Do you feel safe?", "Do you own guns?", "Has anyone forced you to have sex?"     * Safety Plan/Go Bag (TEST): Essentials include ID, meds, money, keys, clothing. Teach children to call 911911 and use code words.

Trauma and Stressor-Related Disorders

  • PTSD (Post-Traumatic Stress Disorder):     * Symptom Categories:         1. Reexperiencing: Dreams, flashbacks, intrusive thoughts, distress from cues.         2. Avoidance: Avoiding memories, feelings, and external reminders.         3. Negative Cognition: Inability to remember parts of trauma, negative emotional state, detachment.         4. Hyperarousal: Hypervigilance, irritability, exaggerated startle, reckless behavior.     * High Risk Group: Children.     * Interventions: CBT (Changing thinking vs behavior), Exposure therapy, SSRIs, SNRIs (Venlafaxine, Duloxetine), and Prazosin.

  • Severe Anxiety and Dissociative Disorders:     * Intervention for Severe Anxiety: Use primitive survival skills/defensive responses; cognitive skills decrease. Remain with the person; walk with them if they cannot sit still.     * Dissociative Amnesia: Inability to recall personal info. Reduce environmental stimulation.     * Dissociative Fugue: Sudden move to new location, assumption of new identity without memory of past.     * Dissociative Identity: Multiple distinct personalities. Document emergence and encourage identification of stressful transitions toward integration.

  • Secondary PTSD:     * Risks for Nurses: Condition from indirect trauma exposure. Signs include intrusive thoughts of patient trauma, avoidance, irritability, and compassion fatigue/decreased empathy. Nurses should use supervision and debriefing.