Chapter 17: Drugs Used for Psychoses Copyright © 2017 Elsevier Inc. All Rights Reserved.

Objectives 1. Identify the signs and symptoms of psychotic behavior. 2. Describe the major indications for the use of antipsychotic agents. 3. Discuss the antipsychotic medications used to treat psychoses. 4. Identify the common adverse effects observed with the use of antipsychotic medications. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Psychosis No exact definition; term used as a clinical descriptor Characteristics Being out of touch with reality Perceptual deficits like hallucinations, delusions Deterioration in social functioning Psychotic symptoms Can be associated with illnesses like dementia Common in mood disorders Can be caused by many drugs Copyright © 2017 Elsevier Inc. All Rights Reserved.

Psychosis Schizophrenia is the most common psychotic disorder. Psychotic disorders are influenced by biologic, psychosocial, and environmental circumstances. May require several months of observation and testing before a final diagnosis is made.

Symptoms of Psychosis Delusions-false or irrational belief (ex, grandios persecutory, sexual) Hallucinations-false sensory perceptions that are experienced without an external stimuli and seem real to the patient Disorganized thinking- flight of ideas Disorganized behavior-decline in every day functioning not purposeful or non functional Changes in affect- expressiveness is diminished Copyright © 2017 Elsevier Inc. All Rights Reserved.

Treatment of Psychosis Focus on decreasing symptoms that most interfere with functioning Target symptoms are critical monitoring parameters used to assess clinical status and response to drug therapy Consider both drug and nondrug therapies Determine baseline level of functioning Define treatment goals in terms of decreasing the severity of target symptoms Long-term outcome is much better with combination treatment. Most patients have recurring symptoms for most of their lives. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Drug Therapy Antipsychotic (neuroleptic) agents classified as Phenothiazines and nonphenothiazines Low potency and high potency—refer to the milligram dose Typical or atypical—refers to first- and second- generation agents Copyright © 2017 Elsevier Inc. All Rights Reserved.

Antipsychotic Agents Actions Uses Typical agents—block action of dopamine in the brain Atypical agents—block serotonin receptors in addition to dopamine receptors Uses Treat psychoses associated with mental illnesses (schizophrenia, mania, psychotic depression, psychotic organic brain syndrome) Copyright © 2017 Elsevier Inc. All Rights Reserved.

Antipsychotic Agents (cont.) Typical (1st generation)— Phenothiazines (chlorpromazine) Atypical (2nd generation)- Risperidone (Risperdal) Atypical agents block dopamine and serotonin receptors; are more effective and have fewer adverse effects than typical agents. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Premedication Assessment Blood pressure in supine, sitting, and standing positions Electrolytes Hepatic function Renal function Cardiac function Thyroid function Baseline clinical evaluation rating scales and adverse effect scales Baseline clinical evaluation rating scales include BPRS, CGI, and PANSS. Adverse effect scales include GDS and TWSTRS (for dystonias), DISCUS (for type of tardive dyskinesia), and AIMS (for extrapyramidal symptoms). Copyright © 2017 Elsevier Inc. All Rights Reserved.

Common Adverse Effects of Antipsychotic Agents Chronic fatigue/drowsiness Orthostatic hypotension Blurred vision Constipation Urinary retention Dry mouth/throat/nose Sedative effects can be minimized by administering drugs at bedtime. Other adverse effects include weight gain, hyperglycemia, dyslipidemia, and dysrhythmias. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Serious Adverse Effects of Antipsychotic Agents Seizure activity Parkinsonian symptoms Tardive dyskinesia Hepatotoxicity Blood dyscrasias Hives, pruritus, rash Photosensitivity Dosage adjustments may be necessary. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Serious Adverse Effects of Antipsychotic Agents (cont.) Extrapyramidal symptoms—four types Dystonic reactions/acute dystonia Pseudoparkinsonism (tremor, muscular rigidity, masklike expression, shuffling gait, loss/weakness of motor function) Akathisia (pacing, rocking, subjective feelings of anxiety and restlessness) Tardive dyskinesia (hyperkinetic abnormal movements) Neuroleptic malignant syndrome-characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Can be fatal. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Drug Interactions with Antipsychotic Agents Increase toxic effects Antihistamines Alcohol Analgesics Tranquilizers St. John’s wart Decrease therapeutic effects Carbamazepine Cimetidine Phenytoin Insulin/oral hypoglycemic medications Venlafaxine Diabetic patients must be monitored for hyperglycemia. Beta blockers enhance hypotensive effects of antipsychotics. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Nursing Assessment for Antipsychotic Therapy History of behavior Basic mental status Interpersonal relationships Mood/affect Clarity of thoughts/perception Thoughts of death Psychomotor function Sleep pattern Dietary history Premedication assessment is used to rule out other causes of psychosis. Baseline assessment gathers information from the patient regarding onset, duration, and progression of symptoms. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Implementations Safe, structured environment Acceptance, encourage expression of feelings Encourage self-care activities Use kind, firm manner to handle inappropriate behaviors Be open and direct with suspicious patients High-protein, high-calorie foods for patients who are active, pace Copyright © 2017 Elsevier Inc. All Rights Reserved.

Audience Response Question 1 A patient states that voices are telling her she is evil and that she should leave the hospital. From which condition is the patient suffering? a) Delusions b) Hallucinations c) Disorganized thinking d) Change in affect Answer: b Rationale: Hallucinations are false sensory perceptions, without an external stimulus. It seems real to the patient. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Audience Response Question 2 A patient has been admitted for further treatment of a psychotic disorder. After 5 days, the patient reports fatigue, dizziness, dry mouth, and constipation. The nurse explains to the patient that these symptoms are due to which factor related to the prescribed antipsychotic medication? a) Toxicity b) Common adverse effect c) Serious adverse effects d) Allergic response Answer: b Rationale: These symptoms are common adverse effects of antipsychotic medications. The nurse should implement appropriate interventions for the patient’s safety and comfort. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Audience Response Question 3 A patient with a history of schizophrenia has been on antipsychotic medications for a prolonged time. The patient is exhibiting new symptoms of tremors, hypotension, and tardive dyskinesia. Laboratory results show an increase in liver enzymes. What does the nurse suspect? a) These are common adverse effects of the medications. b) These are serious adverse effects of the medications and the health care provider must be notified. c) The patient has been taking increased amounts of antipsychotic medication. d) The patient’s schizophrenia is progressing predictably. Answer: b Rationale: These findings are significant and require prompt reporting to the provider. Tardive dyskinesia typically appears after antipsychotic dosage reduction or discontinuation and improves when the antipsychotic dosage is increased. Early signs of tardive dyskinesia may be reversible but over time may become irreversible, even with discontinuation of the antipsychotic medication. Copyright © 2017 Elsevier Inc. All Rights Reserved.

Audience Response Question 4 A patient has been taking an antipsychotic agent for 2 days, when suddenly his eyes roll back and his jaw develops spasms. The nurse notifies the prescriber that the patient is experiencing: a) pseudoparkinsonian symptoms. b) akathisia. c) tardive dyskinesia. d) dystonia. Answer: d Rationale: Dystonia is characterized by jaw spasms, eyes rolled back, and neck torsion (torticollis). Copyright © 2017 Elsevier Inc. All Rights Reserved.

Audience Response Question 5 Which symptoms are most likely associated with neuroleptic malignant syndrome? (Select all that apply.) a) Bradycardia b) Lead-pipe rigidity c) Hypothermia d) Comatose state e) Hypertension Answer: b, d, e Rationale: The patient with NMS has tachycardia, lead-pipe rigidity, hyperthermia, comatose state, and hypertension. The mortality rate ranges from 4% to 30%. Copyright © 2017 Elsevier Inc. All Rights Reserved.