NCMB317 LECTURE: Prelim Week

01
Psychiatric Mental Health Nursing
Bachelor of Science in Nursing 3YB
Professor: Donato Mirador MAN, RN
PSYCHIATRIC MENTAL HEALTH NURSING • Loss of emotional control
Mental Health and Mental Illness 3) Social cultural factors
- WHO a state of complete physical, mental and social • Lack of resources
wellness and not merely the absence of disease or infirmity. • Violence
- Mental health a state of emotional, psychological, and • Homelessness
social wellness evidenced by satisfying interpersonal • Poverty
relationships, effective behavior and coping, positive self • Unwanted negative view of the world discrimination
concept, and emotional stability.
Components of mental health Diagnostic and Statistical Manual of Mental Disorders
1) Individual or personal factors 1) Provide a standardized nomenclature and language for all
• Biologic make up mental health professionals.
• Autonomy and independence 2) To present defining characteristics or symptoms that
• Self esteem differentiate specific diagnosis.
• Capacity for growth 3) To assist in identifying the underlying cause of disorders.
• Vitality
• Ability to find meaning in life Multi Axial Classification System
• Emotional resilience or hardness • AXIS I for identifying all major psychiatric disorders except
• Sense of belonging mental retardation and personality disorders.
• Reality orientation • AXIS II for reporting mental retardation and personality
• Coping or stress management abilities disorders as well as prominent maladaptive personality
2) Interpersonal or relationship factors features and defense mechanism.
• Effective communication • AXIS III for reporting current medical conditions that are
• Ability to help others potentially relevant to understanding or managing person’s
• Intimacy mental disorder as well as medical conditions that may
• Balance of separateness and connectedness contribute to understanding the person.
• Social cultural and environmental factors • AXIS IV for reporting psychosocial and environmental
• Sense of community problems that may affect the diagnosis treatment and
• Access to adequate resources prognosis of mental disorders. Ex problems with primary
support grp, social environment, education, occupation,
• Intolerance of violence
housing, economic access to health care and legal system.
• Support of diversity among people
• AXIS V this represents the clinicians assessment of the
• Mastery of environment
persons current level of functioning. Ex the Global
• Positive yet realistic view of one’s world
Assessment of Functioning
Mental illness
Historical Perspectives
- Mental disorder a clinically significant behavior or
Ancient times
psychological syndrome, or pattern that occurs in an
- The illness indicate the displeasure of the gods and
individual and is associated with present distress.
punishment for sins and wrong doings.
Factors contributing to mental illness
- Aristotle (382-322 BC) attempt to relate mental disorders
1) Individual factors
to physical disorders and developed the theory that the
• Biologic make up
amount of blood water and yellow and black bile in the
• Intolerable or unrealistic worries or fear body control the emotions. Imbalance of the four humors
• Inability to distinguish reality from fantasy were believed to cause mental disorders.
• Intolerance of life uncertainties - Early Christian times (1-1000 AD) all diseases were blamed
• A sense of disharmony in life on demons and the mentally ill were possessed
• A loss of meaning in one’s life - Renaissance (1300-1600) mental illness were
2) Interpersonal factors distinguished from criminals, harmless are allowed to
• Ineffective communication wander to country side and lived in rural communities, the
• Excessive dependency dangerous were thrown into prison chained and starved.
• Withdrawal from relationships - 1547 St Mary of Bethlehem Hospital was officially declared
• No sense of belonging a hospital for insane.
• Inadequate support

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- 1775 visitors at the institution were charged of fees for the - Medulla contains the vital centers for respiration and
privilege of viewing and ridiculing the insane viewed as cardio vascular functions.
animals less than human. - Pons bridges the gaps both structurally and functionally,
- 1790 Phillippe Pinel, Wlliam Tukes formulate the concelts serving as a primary motor pathway
of assylum as safe refuge or haven for the mentally ill in the - Midbrain connects the pons and cerebellum with the
institution from being whipped beaten and starved. cerebrum (0.8 inches) 2cm long includes mostly the RAS
- Dorothea Dix ( 1802-1887) began a crusade to reform the and the EPS.
treatment of mental illness after a visit to Tuke’s institution. - Extra pyramidal system (EPS) relays information about
Sigmund Freud and Emil Kraeplin movement and coordination from brain to the spinal nerve
• Freud (1856-1939) - Locus Ceruleus nor epinephrine producing neuron in the
• Kraeplin (1856-1926) brain stem, associated with stress, anxiety and impulsive
• Eugin Bleuler (1857-1939) behavior.
Psychopharmacology Limbic System
- 1950 development of psychotropic drugs, drugs used to - Located above the brain stem, includes the thalamus,
treat mental illness. hypothalamus, hippocampus, and amygdala.
• Chlorpromazine (thorazine) anti-psychotic drug - Thalamus regulates activity, sensation and emotion.
• Haldol anti-psychotic - Hypothalamus temp regulation, appetite control,
• Lithium anti manic agent endocrine function, sexual drive, and impulsive behavior,
• MAO inhibitor anti-depressant such as anger, rage and excitement.
- Hippocampus and Amygdala involve in emotional arousal
• Tricyclic antidepressant
and memory.
• Benzodiazepines anti-anxiety agents
- Disturbances in the limbic system have been implicated in
a variety of mental illness memory loss, poorly controlled
Neurobiological Theories and Psychopharmacology
emotions, impulses seen in psychotic and manic behavior.
Neurotransmitter
- Neurotransmission the process of sending electrochemical
messages from neuron to neuron.
- Neurotransmitter chemical substances manufactured in
the neuron that aid in the transmission of information
throughout the body
A.) Synapses and neurotransmitters
• Information in the nervous system is transferred
across the synaptic cleft (i.e., the space between the
axon terminal of the presynaptic neuron and the
dendrite of the postsynaptic neuron).
• When the presynaptic neuron is stimulated, a
neurotransmitter is released, travels across the
Cerebrum synaptic cleft, and acts on receptors on the
- Divided into two lobes, all lobes and structures are found postsynaptic neuron. Neurotransmitters are
in both halves except for the pineal body, or gland which is excitatory if they increase the chances that a neuron
located between the hemispheres. will fire and inhibitory if they decrease these
- Pineal body is an endocrine gland which affects the activity chances.
of the pituitary, islets of Langerhans, parathyroid, adrenal B.) Presynaptic and postsynaptic receptors are proteins
and gonads. present in the membrane of the neuron that can
- The frontal lobe controls the organization of thoughts, body recognize specific neurotransmitters.
movement, memories, emotions, and moral behavior. The
• The changeability of number or affinity of receptors
integration of all the information regulates arousal, focuses
for specific neurotransmitters (neuronal plasticity)
attention, enables problem solving and decision making.
can regulate the responsiveness of neurons.
- Abnormalities is associated with schizophrenia ADHD and
• Second messengers. When stimulated by
dementia
neurotransmitters, postsynaptic receptors may alter
Cerebellum
the metabolism of neurons by the use of second
- CENTER FOR COORDINATION MOVEMENT AND
messengers, which include cyclic adenosine
POSTURAL JUDGEMENTS.
monophosphate (cAMP), lipids (e.g., diacylglycerol),
- Inhibited transmission of dopamine in this area is
Ca2+, and nitric oxides.
associated with the lack of smooth coordinated
C.) Classification of neurotransmitters. Biogenic
movements such in Parkinson’s disease and Dementia.
amines (monoamines), amino acids, and peptides
Brain stem
are the three major classes of neurotransmitters.
- Includes the midbrain, pons, medulla oblongata and the
D.) Regulation of neurotransmitter activity
nuclei for cranial nerve III and XII

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• The concentration of neurotransmitters in the the nigrostriatal tract, can result in Parkinson-like
synaptic cleft is closely related to mood and symptoms.
behavior. A number of mechanisms affect this 2) Dopamine acts on the tuberoinfundibular tract to inhibit
concentration. the secretion of prolactin from the anterior pituitary.
• After release by the presynaptic neuron, a) Blockade of dopamine receptors by antipsychotic drugs
neurotransmitters are removed from the synaptic prevents the inhibition of prolactin release and results
cleft by mechanisms including: in elevated prolactin levels.
o Reuptake by the presynaptic neuron. b) This elevation in turn results in symptoms such as
o Degradation by enzymes such as monoamine breast enlargement, galactor- rhea, and sexual
oxidase (MAO). dysfunction.
- Depression Norepinephrine (↓), serotonin (↓), dopamine (↓) 3) The mesolimbic–mesocortical tract is associated with
- Mania Dopamine (↑), g-aminobutyric acid (GABA) (↓) psychotic disorders.
- Schizophrenia Dopamine (↑), serotonin (↑), glutamate (↑or a) This tract may have a role in the expression of emotions
↓) since it projects into the limbic system and prefrontal
- Anxiety GABA (↓), serotonin (↓), norepinephrine (↑) cortex.
- Alzheimer disease Acetylcholine (↓), glutamate (↑) b) Hyperactivity of the mesolimbic tract is associated with
• Availability of specific neurotransmitters is associated the positive symptoms (e.g., hallucinations) of
with common psychiatric conditions (Table 4.4). schizophrenia; hypoactivity of the mesocortical tract is
Normalization of neurotransmitter availability by associated with the negative symptoms (e.g., apathy) of
pharmacological agents is associated with symptom schizophrenia
improvement in some of these disorders Norepinephrine, a catecholamine, plays a role in mood,
anxiety, arousal, learning, and memory.
Biogenic Amine 1) Synthesis
Overview a) Like dopaminergic neurons, noradrenergic neurons
- The biogenic amines, or monoamines, include synthesize dopamine.
catecholamines, indolamines, ethyl amines, and b) Dopamine b-hydroxylase, present in noradrenergic
quaternary amines. neurons, converts this dopamine to norepinephrine.
- The monoamine theory of mood disorder hypothesizes that 2) Localization. Most noradrenergic neurons (approximately
lowered monoamine activity results in depression and 10,000 per hemisphere in the brain) are located in the
elevated levels in mania. locus ceruleus
- Metabolites of the monoamines are often measured in Serotonin, an indolamine, plays a role in mood, sleep,
psychiatric research and diagnosis because they are more sexuality, and impulse control. Elevation of serotonin is
easily measured in body fluids than the actual associated with improved mood and sleep but decreased
monoamines sexual function (particularly delayed orgasm). Very high
- Distribution of dopaminergic, noradrenergic and levels are associated with psychotic symptoms
serotonergic tracts in the CNS Decreased serotonin is associated with poor impulse control,
Dopamine depression, and poor sleep.
- Dopamine, a catecholamine, is involved in the 1) Synthesis. The amino acid tryptophan is converted to
pathophysiology of schizophrenia and other psychotic serotonin (also known as 5-hydroxy- tryptamine [5-HT]) by
disorders, Parkinson disease, mood disorders, the the enzyme tryptophan hydroxylase as well as by an amino
conditioned fear response and the “rewarding” nature of acid decarboxylase.
drugs of abuse 2) Localization. Most serotonergic cell bodies in the brain are
- Synthesis. The amino acid tyrosine is converted to the contained in the dorsal raphe nucleus in the upper pons
precursor for dopamine by the enzyme tyrosine and lower midbrain
hydroxylase. 3) Antidepressants and serotonin. Heterocyclic
- Receptor subtypes. At least five dopamine receptor antidepressants (HCAs), selective serotonin reuptake
subtypes (D1–D5) have been identified; the major site of inhibitors (SSRIs), and monoamine oxidase inhibitors
action is D2 for traditional antipsychotic agents and D1 and (MAOIs) ultimately increase the presence of serotonin and
D4 as well as D2 for the newer “atypical” antipsychotic norepinephrine in the synaptic cleft
agents a) HCAs block reuptake of serotonin and norepinephrine,
and SSRIs such as fluoxetine (Prozac) selectively block
Dopaminergic tract reuptake of serotonin by the presynaptic neuron.
1) The nigrostriatal tract is involved in the regulation of b) MAOIs prevent the degradation of serotonin and
muscle tone and movement. norepinephrine by MAO.
a) This tract degenerates in Parkinson disease. Histamine
b) Treatment with antipsychotic drugs, which block 1) Histamine, an ethylamine, is affected by psychoactive
postsynaptic dopamine receptors receiving input from drugs.
2) Histamine receptor blockade with drugs such as
antipsychotics and tricyclic antidepressants is associated
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with common side effects of these drugs such as sedation and ultimately decreasing anxiety. Anticonvulsants also
and increased appetite leading to weight gain. potentiate the activity of GABA.
Acetylcholine (Ach), a quaternary amine, is the transmitter Glycine
used by nerve–skeleton–muscle junctions. - an inhibitory neurotransmitter found primarily in the spinal
1) Degeneration of cholinergic neurons is associated with cord. Glycine works on its own and as a regulator of
Alzheimer disease, Down’s syndrome, and movement and glutamate activity.
sleep disorders (e.g., decreased REM sleep.
2) Cholinergic neurons synthesize Ach from acetyl coenzyme Neuropeptides
A and choline using the enzyme choline acetyltransferase. - Endogenous opioids such as enkephalins, endorphins,
3) The nucleus basalis of Meynert is a brain area involved in dynorphins, and endomorphins are produced by the brain
production of Ach. itself. They act to decrease pain and anxiety and have a
4) Acetylcholinesterase (AchE) breaks Ach down into choline role in addiction and mood.
and acetate. - Placebo effects may be mediated by the endogenous
5) Blocking the action of AchE with drugs such as donepezil opioid system. For example, prior treatment with an opioid
(Aricept), rivastigmine (Exelon), and galantamine (Reminyl) receptor blocker such as naloxone can block placebo
may delay the progression of Alzheimer disease but cannot effects
reverse the function already lost. - Types of neurotransmitter:
6) Blockade of muscarinic Ach receptors with drugs such as 1) Excitatory excites or stimulates an action in the cell
antipsychotics and tricyclic antidepressants results in the • Dopamine
classic “anticholinergic” adverse effects seen with the use • Nor epinephrine
othese drugs, including dry mouth, blurred vision, urinary • Epinephrine
hesitancy, and constipation. Use of these agents can also • Acetylcholine
result in central anticholinergic effects such as confusion • Glutamate
and memory problems. 2) Inhibitory inhibit or stop an action in the cell
7) Anticholinergic agents are commonly used to treat the • Serotonin
Parkinson-like symptoms caused by antipsychotic agents • Acetylcholine
(see section IV.B.4.a. above).
• GABA
Amino Acid Neurotransmitter
Synapse
These neurotransmitters are involved in most synapses in the
brain and include glutamate, g-aminobutyric acid (GABA), and
glycine.
Glutamate
- Glutamate is an excitatory neurotransmitter that
contributes to the pathophysiology of neurodegenerative
illnesses such as Alzheimer disease and schizophrenia.
• The mechanism of this association involves activation
of the glutamate receptor N-methyl-d-aspartate
(NMDA) by sustained elevation of glutamate.
• Such activation results in calcium ions entering
neurons leading to nerve cell degen- eration and death
through excitotoxicity.
• Memantine (Namenda), an NMDA receptor antagonist,
ultimately blocks this influx of calcium and is indicated
Neuromodulators enhances both the excitatory or inhibitory
for patients with moderate to severe Alzheimer disease.
function of a neurotransmitter
GABA
• Histamine
- GABA is the principal inhibitory neurotransmitter in the
CNS. It is synthesized from glutamate by the enzyme • Neuropeptide
glutamic acid decarboxylase, which needs vitamin B6 Dopamine
(pyridoxine) as a cofactor. - Located primarily in the brainstem found to involve in the
- GABA is closely involved in the action of antianxiety agents control of complex movement, motivation, cognition, and
such as benzodiazepines (e.g., diazepam [ Valium]) and regulation of emotional response, it is synthesize from
barbiturates (e.g., secobarbital [Seconal]). tyrosine. Implicated in schizophrenia as well as psychoses
Benzodiazepines and barbiturates increase the affinity of and other movement disorders.
GABA for its GABAA-binding site, allowing more chloride to Nor epinephrine and epinephrine
enter the neuron. The chloride-laden neurons become - Nor epinephrine located primarily in the brain stem play a
hyperpolarized and inhibited, decreasing neuronal firing role in changes in attention, learning and memory, sleep
and wakefulness and mood regulation.
- Excess is implicated in several anxiety disorders
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- Deficit contribute to memory loss, social withdrawal and

depression.
- Antidepressant block the reuptake of norepinephrine
- MAO inhibit the metabolism or NE
- Epinephrine has limited distribution in the brain but control
the fight or flight response in the PNS
Serotonin
- Found only in the brain derived from tryptophan
- Involved in the control of food intake, sleep and
wakefulness, temp regulation, pain control, sexual
behavior, and regulation of emotion.
- Plays important role in anxiety, mood disorders and
schizophrenia.
- Some Antidepressant block serotonin reuptake, leaving it
available longer in the synapse thus improving the mood.
Histamine
- Involves in peripheral allergic responses, control of gastric
secretions, cardiac stimulation and alertness.
- Some psychotropic drugs block histamine, resulting in
weight gain, sedation and hypotension.
Acetylcholine
- Found in the brain spinal cord and peripheral nervous
system at the neuromuscular jucntion of skeletal muscle.
Synthesize from dietary choline found in red meat and
vegetables and found to affect the sleep and wake cycle
and to signal muscle to become active
- Study shows people with alzheimer’s disease have
decrease acetylcholine secreting neurons, and people with
myasthenia gravis (impulses fail to pass myoneural
junctio )
Glutamate
- At high level can have major neurotoxic effect, implicate in
brain damage caused by stroke, hypoglycemia, sustained
hypoxia, ischemia and some degenerative diseases such
as huntington’s and alzheimer’s
GABA
- Major inhibitory neurotransmitter in the brain, found to
modulate other neurotransmitter system than to provide a
direct stimulus.

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