This slideshow explores the neurobiologcial structures under pinning clinical change. Overview of pharmacodynamics and pharmacokenetics, and neurotransmitters. Problem based learning exploration of difficult conversations with patients about psychopharmacology and medication management.

1. NEUROPHARM HAVING DIFFICULT
CONVERSATIONS ABOUT MEDICATIONS

2. INSIDE THE CELL
Biovisions Project Harvard
Research in the biological sciences often depends on the
development of new ways of visualizing important processes and
molecules. Indeed, the very act of observing and recording data
lies at the foundation of all the natural sciences. The same holds
true for the teaching and communication of scientific ideas; to see
is to begin to understand. The continuing quest for new and more
powerful ways to communicate ideas in biology is the focus of
BioVisions at Harvard University.
https://www.youtube.com/watch?v=tMKlPDBRJ1E
https://www.youtube.com/watch?v=FzcTgrxMzZk&t=357s

6. COLORING STRUCTURES Neurons to structure

7. The brain translates predictable signals
from the world into information

8. Each brain region has a kind of information it is
interested in you can speak their language

9. Temporoparietal
Junction
• Integrates Information From:
Thalamus, Limbic System, Visual
System, Auditory System and
Somatosensory System
• Theory of Mind: Self and other
reflection.
• Damages to TPJ appears to
impact moral reasoning.
• Damage or Stimulation can
cause out of body experiences.

14. PHARMACODYNAMICS &
PHARMACOKINETICS
Neurons to structure

15. PHARMACOKINETICS AND PHARMACODYNAMICS
Pharmacokinetics– What the body does to the
drug.
Pharmacodynamics – What the drug does to the
body.
https://www.youtube.com/watch?v=8-Qtd6RhfVA

17. PHARMACOKINETICS - ADME
Liberation (L) – Liberating the medication from the pill.
Absorption (A) – How the body takes in the drug (stomach,
lungs, patches, intestines).
Distribution (D) – How the body is transported through out the
body.
Metabolism (M) – How the body transforms the medication
and for many psychiatric medications this occurs in the liver.
Excretion (E) – How the body eliminates the medication.

24. PAXIL – PHARMACOKINETIC DATA
Bioavailability Completely absorbed from GI, but extensive first-pass
metabolism in the liver; T-max 4.9 (with meals) to 6.4 hours (fasting)
Protein binding: 93–95%
Metabolism: Extensive, hepatic (mostly CYP2D6-mediated)
Half-life: 24 hours (range 3–65 hours)
Excretion: 64% in urine, 36% in bile

25. VIGNETTE – GEORGE LADME
George is a 75 year old Mexican American came into the clinic with
slurred speech and staggering. He recently stepped down from
directing a family run business.
George had been treated for difficulty sleeping in the last two weeks.
He reported that the first time he took the medication he slept and was
“groggy” but felt less anxious.
Since that time he reports he was feeling better (no anxiety) but in the
last two days he became more and more disoriented and now does not
feel safe driving.

26. DISCUSSION: MEDICATION CONSULTS
WITH PATIENTS
Talking Medications

27. DISCUSSION: MEDICATION CONSULTS
WITH PATIENTS
Let’s talk about some
cases where we have
consulted about
anti-depression or
anxiety medication
and it went well…

28. THREE LEVELS OF PSYCHOLOGIST ROLE IN
PSYCHOPHARMACOLOGY
Level 1 Education – All psychologists are expected to participate at this live. It is
providing education to your patient about medications and side effects. It also
includes informing the health team about developments and patient diagnosis.
Level 2 Consultation – At this level psychologists participate in the decision making
about medications with a psychiatric or medical provider. The psychologists job is to
discuss core clinical information, collaborate on diagnosis and may participate in the
decision making about which medication is chosen.
Level 3 Prescribing Psychologists – California does not currently allow for
psychologists to prescribe medications. However, there is a shortage of psychiatrists
and child psychiatrists that may make it reasonable to consider advocating for this at
the level of state.

30. VIGNETTE
A 28 year old man of Japanese American dissent
(4th generation). Grew up in a family with significant
discord and a divorce occurring when he was 12
years old. His mother drank and he lived with her.
He was regularly bullied in the house by his older
cousin that lived with the family. He has significant
anxiety every time he walked out of his house. The
anxiety increases when he talks with people. He
finds himself exhausted and dysphoric. He has
feelings that he wishes that he were dead but would
never harm himself. He has read many self-help
books and they are not helping him change. He
reports it is difficult to work and he is more and
more needing to rest and recover from the stress. He
reports challenges with trusting people.

32. PASS THE STETHOSCOPE Problem focused learning…

33. “I tried an antidepressant in the past
and they did not work.”

34. “I won’t take drugs. I don’t want
to take mood-altering drugs.”

35. “My friend took antidepressants
and they made her crazy.”

36. ”I have heard that antidepressants make you suicidal.
I don’t want that!”

37. “My family will think I am crazy if I take these pills.”

38. “I am really more anxious then
depressed. Why would I need
an antidepressant?”

39. WHAT MOTIVATES CHANGE?

40. MOTIVATIONAL INTERVIEWING IS A COLLABORATIVE
PERSON CENTERED FOR OF GUIDING TO ELICIT AND
STRENGTHEN MOTIVATION FOR CHANGE.

41. Pulled from web on 11/20/17: http://slideplayer.com/slide/10590135/

42. MI SPIRIT GUIDES INTERVENTIONS
Collaboration
Confrontation
Autonomy
Authority
Evoking
Imposing
Compassion
Kindness/Judgement

44. WHY IS CHANGE SO HARD?

45. YOUR TASK…
Is to figure out how to elicit
change talk. Rather then
provoke resistance. It is to
move from wrestling to
dancing
Change Talk vs. Sustain Talk

46. We see people at
a moment on their
journey. How can
we help them
move forward?

47. Healing is a large
step on the road to
building a life of
meaning and
purpose…
Change talk can help
people committe to
their health.

51. TALKING WITH MEDICAL PROVIDERS Curbside Consults

52. VIGNETTE
A 42 year old man of African American man. Grew
up in a highly supportive family. He has become
increasingly depressed since he lost his job. He fell
from a building (4 floors up) during an electrical
installation. Since then he feels betrayed by the
medical system and his previous employer who he
feels are out to serve themselves not him. He has
been married for 18 years and he had his wife have
four children. He is concerned about being a good
father. He has chronic pain due to nerve compression
in spine, sciatica and centralized pain. He has been
feeling hopeless, helpless and overwhelmed for 2
years and is finally willing to seek help. His provider
does a curbside consult with you. What might you
ask? What might you recommend?

53. PASS THE STETHOSCOPE Problem focused learning…

54. A provider comes to you and has questions about a
patients anxiety symptoms. How could they impact
depression?

55. A provider is considering Wellbutrin for anxiety and
depression but you have read in the chart that the patient has
a seizure condition.

56. A provider has a patient with an addiction history (EtOH) and has a patient
who has challenges with depression and anxiety. They have started on Prozac
and now have increased to 40 mg. The depression is remitting. The patient
has more energy but their anxiety is making it hard to leave the home? The
want to consider augmenting the Prozac. Should they increase dose? Consider
another medication? Or add an adjunctive agent?

57. A provider has a patient who has refused medications for
depression but they feel it is the right choice. How can you
explore how they might enhance motivation in the patient for
this treatment?

58. INFORMATIONAL SLIDES Informational Slides

59. NEUROBIOLOGY OF AFFECT REGULATION
HPA-AXIS AND THALAMUS
Hypothalamus Pituitary Adrenal-axis (HPA--
axis): Is made up of the hypothalamus, pituitary gland, and adrenal cortex. I
ts main task is to mobilize a powerful energetic defense when a person is th
reatened and to return to rest when the threat is gone. The HPA--
axis triggers cortisol secretion.
Thalamus: Is a relay station for the brain.
It plays a role in modulating levels of arousal. A damaged thalamus can result
in a coma. The thalamus may be the seat of human consciousness.

61. THALAMUS AND HYPOTHALAMUS

62. HPA AXIS
HYPOTHALAMIC
PITUITARY ADRENAL
AXIS

63. NEUROBIOLOGY OF AFFECT REGULATION
HIPPOCAMPUS
The hippocampus Is found in the medial temporal lobe.
­The three major theories used to explain hippocampus functi
oning are that the hippocampus is involved in: behavioral
inhibition, declarative memory consolidation, and sense of pl
ace. In those with PTSD
hippocampus declines have been noted.
­Dissociative Identity Disorder (DID), one study found a 26%
decline compared with controls.

65. HIPPOCAMPUS

66. INSULAR CORTEX
1. “Though the insula plays a significant role in pain perception, social engagement, empathy, emotions,
and numerous other vital functions, it is far from the only brain region that contributes to
these functions. Moreover, it must work with other brain regions—and other parts of the body—to
properly function.”
2. “Brain lesions that damage the insular cortex interrupt addictive behaviors, suggesting that drug
addiction sensitizes the insula.”
3. “The insular cortex (IC) has been known for a while as a receiver of interoceptive signals, and a
necessary substrate for experiencing emotion and self-awareness”
4. “More recently its role in attention and decision-making has been gathering increased attention”
5. “The insula is often involved in Altzhimer’s, and some of the behavioral abnormalities in AD may
reflect insular pathology.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486609/
https://www.ncbi.nlm.nih.gov/pubmed/16215463

67. INSULAR CORTEX

69. CINGULATE CORTEX
The cingulate gyrus is the curved fold covering the corpus callosum. Often called the Limibic
cortex. It is a component of the limbic system, it is involved in processing emotions and
behavior regulation. It also helps to regulate autonomic motor function. It divides into two
sections:
1. The posterior cingulate cortex, or PCC, lies just behind the anterior cingulate. Although it is
believed the PCC has important roles in cognition and affect, there is some debate as to
what exactly those roles are. Neuroimaging studies indicate the PCC is active during the
recall of autobiographical memories.
2. The anterior cingulate cortex, or ACC, is found at the front of the cingulate cortex and
wraps around the head of the corpus callosum. The ACC has connections with a variety of
other brain regions, and thus the functions associated with it are diverse. There are, for
example, areas of the ACC that are densely interconnected with limbic system structures
like the amygdala and hypothalamus.
Pulled from: https://www.neuroscientificallychallenged.com/blog//know-your-brain-cingulate-cortex

70. NEUROBIOLOGY OF AFFECT REGULATION
CINGULATE GYRUS
The cingulate gyrus is often referred to as the limbic cortex.
­ At three to nine months of development, the infant grows the ability to modulate social engagement
through immobility and withdrawing (noradrenalin) and active protection through fight/flight
(dopamine), monitors internal and external behavior, attends to mistakes, and modulates behavior for
more successful outcomes.
­ The anterior is discussed here and is related to autonomic homeostasis, reward anticipation; heart rate,
decision-making, emotions, and modeling the emotions of others.
­ It plays a central role in integration of bottom up and top down neural processes.

72. CINGULATE CORTEX

73. NEUROBIOLOGY OF AFFECT
REGULATION: THE AMYGDALA
1. The Amygdala is often known as the fear center of the brain.
2. Although it could be better conceptualized as a smoke detector. It notices
changes in the insula, and other limbic structures.
3. The amygdala is involved in classical conditioning and emotional memory. Likely
involved in “flash bulb” memories.

74. AMYGDALA

75. NEUROBIOLOGY OF AFFECT REGULATION
BASAL GANGLIA… SEPTAL NUCLEUS
Basal Ganglia (BG): Is central to the modulation of
movement, emotional set, anticipation of movement, eye
movement, motivation, and reward.
Septal Nucleus: Plays a role in pleasure, relaxation and
rest. It has an inhibitory effect of cortisol. In rat pups, a
damaged septal nucleus leads to increased aggression
and loss of maternal behaviors.

77. BASAL GANGLIA

78. BASAL GANGLIA

79. NEUROBIOLOGY OF AFFECT REGULATION
ORBITAL FRONTAL CORTEX
Orbital Frontal Cortex:
“emotion and reward” area of the prefrontal cortex.
­This is likely the most abstract area of emotional pr
ocessing.
­It is also the last to mature.
­It reaches full maturity in the early twenties.
­It is involved in decision making and expectation.

81. FRONTAL CORTEX

82. EMOTION
REGULATION

83. BRAIN STRUCTURES
AND MENTAL HEALTH
Group Activity.
Divide up into groups.
Look at the brain structures and their functions.
Identify as a group possible mental health conditions that maybe associated with the
brain areas and why.

84. AUTONOMIC NERVIOUS SYSTEM

85. AUTONOMIC RESPONSES

86. STRESS REACTIONS

87. TRACKING THE
STRESS
RESPONSE

88. RECEPTOR ACTIONS

89. MAJOR AREAS TO ASSESS
Axis – II
Substance Abuse/Drug Seeking
Medical Conditions
Primary and secondary gain.

90. MEDICAL ILLNESSES CHECKLIST
Sudden onset “out of the blue”
Older then 55 yrs
PT Taking multiple medications
No family hx of similar MH dx.
Hallucinations or illusions (visual)
Looks ill, poor vitals, fever or weekness

91. ROLE PLAYS
Form groups of two.
One person is the clinician, one the client.
You have a 10 min session.
5 minuet debriefing

92. CLOSING QUESTIONS
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