Case Study #1
Psychoactive Drug Learning Module
Disorders associated with emotional, unusual, or bizarre feelings are among the leading causes of
mental health problems. Medical experts have become very adept at identifying symptoms that
separate normal from abnormal behavior and more medications are available to treat these conditions
than ever before. Three major disorders fall within a broad range of ages from childhood to old age.
These are behavioral/emotional disorders, mood disorders, and psychoses.
Attention-Deficit Disorder (ADD) And Attention-Deficit Hyperactivity Disorder (ADHD)
The most common behavioral/emotional disorders are attention-deficit disorder (ADD) and
attention-deficit hyperactivity disorder (ADHD). ADD and ADHD are common in children and typically
diagnosed in childhood. These disorders are four to eight times more likely to occur in boys. ADD and
ADHD are characterized by lack of attention, poor organization, and behavior-control issues and/or
hyperactivity. These symptoms may extend into adulthood. Symptoms of ADD/ADHD in adults are
similar to those of mood disorders and include anxiety, mania, restlessness, and depression. The
symptoms of attention-deficit and hyperactivity (ADD/ADHD) are:
• Difficulty following instructions
• Failure to receive instructions properly
• Inability to listen carefully
• Inability to focus on one task at a time
• Difficulty remembering
• Frequent loss or misplacement of personal items
The causes of ADD/ADHD are not clear, but several theories have been proposed in which recent
evidence suggests that hyperactivity may be related to dysfunction of a special group of
neurotransmitters in the brain, including dopamine, norepinephrine, and serotonin. The location of the
neurotransmitter dysfunction is associated with the reticular activating system in the brain.
Medications used to treat ADD/ADHD are central nervous system (CNS) stimulants. These drugs
activate specific areas of the brain and reverse many of the symptoms. CNS stimulant medications
enable the client to focus on information given to them by teachers or parents. Methylphenidate
(Ritalin) is the drug choice for most clients. Methylphenidate (Ritalin) works by increasing
norepinephrine release in the reticular activating system, which maintains alertness. Furthermore,
methylphenidate (Ritalin) directly stimulates dopamine release in the areas of the brain responsible for
Like most medications, those used to treat attention-deficit/hyperactivity disorder have side effects. If
Ritalin is given to a client not experiencing ADD/ADHD, it will cause nervousness and insomnia.
Adverse reactions of Ritalin are irregular heartbeat, high blood pressure, and liver toxicity. In addition,
some children may lose weight, have a smaller appetite, and temporarily grow more slowly. Others
may have trouble falling asleep. However, many doctors believe the benefits of medication outweigh
the possible side effects. Side effects that do occur can often be handled by reducing the dosage.
The two major types of mood disorders are clinical depression and bipolar disorder (formerly called
manic depression). Mood disorders are also called affective disorders.
Clients diagnosed with depression may have a range of symptoms. Clinical Depression is a common,
real and treatable illness. Some basic facts about clinical depression are:
• Clinical depression is one of the most common mental illnesses, affecting more than 19 million
Americans each year. This includes major depressive disorder, manic depression and
dysthymia, a milder, longer-lasting form of depression.
• Depression causes people to lose pleasure from daily life, can complicate other medical
conditions, and can even be serious enough to lead to suicide.
• Depression can occur to anyone, at any age, and to people of any race or ethnic group.
Depression is never a “normal” part of life, no matter what your age, gender or health
• Unfortunately, though treatment for depression is almost always successful, fewer than half of
those suffering from this illness seek treatment. Too many people resist treatment because
they believe depression is not serious, that they can treat it themselves or that it is a personal
weakness rather than a serious medical illness.
Many things can contribute to clinical depression. For some people, a number of factors seem to be
involved, while for others a single factor can cause the illness. Oftentimes, people become depressed
for no apparent reason. The causes of clinical depression include:
• Biological – People with depression typically have too little or too much of certain brain
chemicals, called “neurotransmitters.” Changes in these brain chemicals may cause or
contribute to clinical depression.
• Cognitive – People with negative thinking patterns and low self-esteem are more likely to
develop clinical depression.
• Gender – Women experience clinical depression at a rate that is nearly twice that of
men. While the reasons for this are still unclear, they may include the hormonal changes
women go through during menstruation, pregnancy, childbirth and menopause. Other reasons
may include the stress caused by the multiple responsibilities that women have.
• Co-occurrence – Clinical depression is more likely to occur along with certain illnesses, such
as heart disease, cancer, Parkinson’s disease, diabetes, Alzheimer’s disease and hormonal
• Medications – Side effects of some medications can bring about depression.
• Genetic – A family history of clinical depression increases the risk for developing the illness.
• Situational – Difficult life events, including divorce, financial problems or the death of a loved
one can contribute to clinical depression.
Clients diagnosed with major depression must show five or more of these symptoms for two weeks or
more. Symptoms of Clinical Depression include:
• Persistent sad, anxious or “empty” mood
• Sleeping too much or too little, middle of the night or early morning waking
• Reduced appetite and weight loss, or increased appetite and weight gain
• Loss of pleasure and interest in activities once enjoyed, including sex
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment (such as chronic pain or
• Difficulty concentrating, remembering or making decisions
• Fatigue or loss of energy
• Feeling guilty, hopeless or worthless
• Thoughts of suicide or death
Clinical depression is very treatable, with more than 80% of those who seek treatment showing
improvement. The most commonly used treatments are antidepressant medication or mood
enhancers, psychotherapy or a combination of the two. The choice of treatment depends on the
pattern, severity, persistence of depressive symptoms and the history of the illness. As with many
illnesses, early treatment is more effective and helps prevent the likelihood of serious recurrences.
Mood-enhancing drugs or antidepressants work by a variety of mechanisms. There are three major
classes of antidepressants:
• monoamine oxidase inhibitors(MAOI)
• tricyclic anti-depressants (TCA)
• selective serotonin reuptake inhibitors (SSRI)
Bipolar disorder, also known as manic depression, is an illness involving one or more episodes of
serious mania and depression. The illness causes a person’s mood to swing from excessively “high”
and/or irritable to sad and hopeless, with periods of a normal mood in between. More than 2 million
Americans suffer from bipolar disorder.
Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is
often not recognized as an illness and people who have it may suffer needlessly for years.
Bipolar disorder can be extremely distressing and disruptive for those who have this disease, their
spouses, family members, friends and employers. Although there is no known cure, bipolar disorder is
treatable, and recovery is possible. Individuals with bipolar disorder have successful relationships and
meaningful jobs. The combination of medications and psychotherapy helps the vast majority of people
return to productive, fulfilling lives.
Although a specific genetic link to bipolar disorder has not been found, studies show that 80 to 90
percent of those who suffer from bipolar disorder have relatives with some form of depression. It is
also possible that people may inherit a tendency to develop the illness, which can then be triggered by
environmental factors such as distressing life events. The presence of bipolar disorder indicates a
biochemical imbalance, which alters a person’s moods. This imbalance is thought to be caused by
irregular hormone production or to a problem with certain chemicals in the brain, called
neurotransmitters, that act as messengers to our nerve cells.
Bipolar disorder is often difficult to recognize and diagnose. It causes a person to have a high level of
energy, unrealistically expansive thoughts or ideas, and impulsive or reckless behavior. These
symptoms may feel good to a person, which may lead to denial that there is a problem.
Another reason bipolar disorder is difficult to diagnose is that its symptoms may appear to be part of
another illness or attributed to other problems such as substance abuse, poor school performance, or
trouble in the workplace.
The symptoms of mania, which can last up to three months if untreated, include:
• Excessive energy, activity, restlessness, racing thoughts and rapid talking
• Denial that anything is wrong
• Extreme “high” or euphoric feelings -- a person may feel “on top of the world” and nothing,
including bad news or tragic events, can change this “happiness.”
• Easily irritated or distracted.
• Decreased need for sleep – an individual may last for days with little or no sleep without
• Unrealistic beliefs in one’s ability and powers -- a person may experience feelings of
exaggerated confidence or unwarranted optimism. This can lead to over ambitious work plans
and the belief that nothing can stop him or her from accomplishing any task.
• Uncharacteristically poor judgment -- a person may make poor decisions, which may lead to
unrealistic involvement in activities, meetings and deadlines, reckless driving, spending sprees
and foolish business ventures.
• Sustained period of behavior that is different from usual-- a person may dress and/or act
differently than he or she usually does, become a collector of various items, become indifferent
to personal grooming, become obsessed with writing, or experience delusions.
• Unusual sexual drive
• Abuse of drugs, particularly cocaine, alcohol or sleeping medications
• Provocative, intrusive, or aggressive behavior -- a person may become enraged or paranoid if
his or her grand ideas are stopped or excessive social plans are refused.
Some people experience periods of normal mood and behavior following a manic phase, however, the
depressive phase will eventually appear. Symptoms of depression include:
• Persistent sad, anxious, or empty mood
• Sleeping too much or too little, middle-of-the-night or early morning waking
• Reduced appetite and weight loss or increased appetite and weight gain
• Loss of interest or pleasure in activities, including sex
• Irritability or restlessness
• Difficulty concentrating, remembering or making decisions.
• Fatigue or loss of energy
• Persistent physical symptoms that don’t respond to treatment (such as chronic pain or
• Thoughts of death or suicide, including suicide attempts
• Feeling guilty, hopeless or worthless
Treatment is critical for recovery. A combination of mood stabilizer medication, professional help and
support from family, friends and peers help individuals with bipolar disorder stabilize their emotions
Bipolar disorder may be effectively treated with lithium. Lithium is effective in controlling mania in 60%
of individuals with bipolar disorder. Olanzapine (Zyprexa), an antipsychotic, is a new treatment for
bipolar disorder, Carbomazepine (Tegratol) and divalproex sodium (Depakote), which are mood-
stabilizers and anticonvulsants, are some of the other medications used. In addition, benzodiazepines
are sometimes prescribed for insomnia and thyroid medication can also be helpful.
The most common type of psychosis is schizophrenia. Schizoaffective disorder is characterized by
psychosis and mood disorder. In addition, clients with mood disorders may experience psychotic
episodes. Clients diagnosed with psychosis are treated based on the expression of positive and
negative psychotic symptoms.
Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with
schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be
unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations.
Schizophrenia affects about 1% of the world population. In the United States one in a hundred people,
about 2.5 million, have this disease. It knows no racial, cultural or economic boundaries. Symptoms
usually appear between the ages of 13 and 25, but often appear earlier in males than females.
Contrary to public perception, schizophrenia is not split personality or multiple personality. The vast
majority of people with schizophrenia are not violent and do not pose a danger to others.
Schizophrenia is not caused by childhood experiences, poor parenting or lack of willpower, nor are
the symptoms identical for each person.
The cause of schizophrenia is still unclear. Some theories about the cause of this disease include:
genetics (heredity), biology (the imbalance in the brain’s chemistry); and/or possible viral infections
and immune disorders.
• Genetics (Heredity). Scientists recognize that the disorder tends to run in families and that a
person inherits a tendency to develop the disease. Schizophrenia may also be triggered by
environmental events, such as viral infections or highly stressful situations or a combination of
both. Similar to some other genetically-related illnesses, schizophrenia appears when the body
undergoes hormonal and physical changes, like those that occur during puberty in the teen
and young adult years.
• Chemistry. Genetics help to determine how the brain uses certain chemicals. People with
schizophrenia have a chemical imbalance of brain chemicals (serotonin and dopamine) which
are neurotransmitters. These neurotransmitters allow nerve cells in the brain to send
messages to each other. The imbalance of these chemicals affects the way a person’s brain
reacts to stimuli--which explains why a person with schizophrenia may be overwhelmed by
sensory information (loud music or bright lights) which other people can easily handle. This
problem in processing different sounds, sights, smells and tastes can also lead to
hallucinations or delusions.
The signs of schizophrenia are different for everyone. Symptoms may develop slowly over months or
years, or may appear very abruptly. The disease may come and go in cycles of relapse and
remission. Behaviors that are early warning signs of schizophrenia include:
• Hearing or seeing something that isn’t there
• A constant feeling of being watched
• Peculiar or nonsensical way of speaking or writing
• Strange body positioning
• Feeling indifferent to very important situations
• Deterioration of academic or work performance
• A change in personal hygiene and appearance
• A change in personality
• Increasing withdrawal from social situations
• Irrational, angry or fearful response to loved ones
• Inability to sleep or concentrate
• Inappropriate or bizarre behavior
• Extreme preoccupation with religion or the occult
The symptoms of schizophrenia are classified in two general types: positive symptoms and negative
symptoms. Positive symptoms are disturbances that “add on” to normal behavior or are “added” to the
person’s personality. Negative symptoms subtract from normal behavior or are capabilities that are
“lost” from the person’s personality.
Positive symptoms include:
• Delusions -- false ideas--individuals may believe that someone is spying on him or her, or that
they are someone famous.
• Hallucinations – seeing, feeling, tasting, hearing or smelling something that doesn’t really
exist. The most common experience is hearing imaginary voices that give commands or
comments to the individual.
• Disordered thinking and speech -- moving from one topic to another, in a nonsensical fashion.
Individuals may make up their own words or sounds.
Negative symptoms include:
• Social withdrawal
• Extreme apathy
• Lack of drive or initiative
• Emotional unresponsiveness
The different types of schizophrenia are:
• Paranoid schizophrenia -- a person feels extremely suspicious, persecuted, or grandiose, or
experiences a combination of these emotions.
• Disorganized schizophrenia -- a person is often incoherent in speech and thought, but may not
• Catatonic schizophrenia -- a person is withdrawn, mute, negative and often assumes very
unusual body positions.
• Residual schizophrenia -- a person is no longer experiencing delusions or hallucinations, but
has no motivation or interest in life.
• Schizoaffective disorder--a person has symptoms of both schizophrenia and a major mood
disorder such as depression.
While no cure for schizophrenia exists, many people with this illness can lead productive and fulfilling
lives with the proper treatment. Early treatment--even as early as the first episode--can mean a better
long-term outcome. Anti-psychotic medications are also called neuroleptics. These drugs attempt to
stabilize clients with psychoses. The antipsychotic medications help to reduce the biochemical
imbalances that cause schizophrenia and decrease the likelihood of relapse.
There are two major types of antipsychotic medication:
• Conventional anti-psychotic drugs (phenothiazines and phenothiazine-type medications)
effectively control the “positive” symptoms such as hallucinations, delusions, and confusion of
• Atypical psychotic drugs treat both the positive and negative symptoms of schizophrenia, often
with fewer side effects.
Side effects are common with antipsychotic drugs. They range from mild side effects such as dry
mouth, blurred vision, constipation, drowsiness and dizziness, which usually disappear after a few
weeks to more serious side effects such as trouble with muscle control, pacing, tremors and facial
ticks. The newer generation or atypical anti-psychotic drugs have fewer side effects. Special nursing
considerations include continually monitoring the effectiveness of drug therapy and observing for
extrapyramidal side effects.
Tardive dyskinesia is an extrapyramidal symptom caused by the long-term use of neuroleptic drugs or
anti-psychotic medications. Neuroleptic drugs are generally prescribed for psychiatric disorders, as
well as for some gastrointestinal and neurological disorders. The prevalence of tardive dyskinesia is
estimated to be 10 to 20 percent of individuals treated with anti-psychotic medications. The elderly are
more susceptible to persistent and irreversible tardive dyskinesia than younger people.
Repetitive and involuntary movements characterize tardive dyskinesia. Features of the disorder may
include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking.
Rapid movements of the arms, legs, and trunk may also occur. Approximately 60 to 70 percent of the
cases are mild, with about 3 percent being extremely severe. Severe cases may involve problems
such as difficulty swallowing, speech interference, cosmetic disfiguration, and respiratory trouble.
There is no standard treatment for tardive dyskinesia. In many cases the medication will be adjusted
to use the lowest possible dose, or discontinued if at all possible. Stopping the medication is a gradual
process, lowering the doses 10 to 25 percent every one to three months. Replacing the neuroleptic
drug with other medications may help some patients. Other drugs such as benzodiazepines,
adrenergic antagonists, and dopamine agonists may also be beneficial. Symptoms of tardive
dyskinesia may remain even after the medication is stopped. However, with careful management,
some symptoms may improve or disappear with time.
Please answer the following questions after reading the Psychoactive Drug Learning Module and
reviewing Chapter 18 of Pharmacological Aspects of Nursing Care.
1. What are the common symptoms of attention-deficit disorder (ADD) and attention-deficit
hyperactivity disorder (ADHD) observed in adults?
2. Which classification of drugs is most often used in the treatment of attention-deficit
disorder (ADD) and attention-deficit hyperactivity disorder (ADHD)?
3. What are the two major types of mood disorders or affective disorders?
4. What is clinical depression?
5. What are the three primary classes of antidepressants or mood enhancing drugs?
6. What is bipolar disorder?
7. What is the main mood stabilizer drug used to treat bipolar disorder?
8. What are two nursing considerations associated with the main mood stabilizer drug
used to treat bipolar disorder?
9. What are the differences between conventional anti-psychotic drugs and atypical psychotic
10. What is tardive dyskinesia?