THE AUTONOMIC NERVOUS SYSTEM CONTROLS ORGANS IN THE VISCERA, HEAD AND SKIN HAS TWO SUBDIVISIONS: 1. Sympathetic: a. Usually important for arousal/stress responses b. Exits from middle 2/3rds of the spinal column c. Uses (mostly) norepinephrine as a neurotransmitter 2. Parasympathetic: a. Usually important for calming, digestion, etc b. Exits from top and base of spinal column c. Uses (mostly) acetylcholine as a neurotransmitter IMPORTANT BECAUSE MANY PSYCHOTROPIC DRUGS ALSO AFFECT THE AUTONOMIC SYSTEM THERAPEUTIC EFFECTS AND SIDE EFFECTS NEUROTRANSMITTERS AND THEIR RECEPTORS ARE FOUND IN NUMEROUS BRAIN REGIONS HENCE DRUGS AFFECTING A SINGLE NT SYSTEM WILL HAVE MULTIPLE EFFECTS! Which is the therapeutic effect and which the side- effect depends entirely upon the therapeutic goal Although toxicity is always an undesired side effect FACTORS WHICH INFLUENCE DRUG EFFICACY DRUG POTENCY AND EFFICACY POTENCY: The AMOUNT of drug required for a given effect EFFICACY: The maximal therapeutic effect achievable, independent of dose considerations: thus morphine has greater Analgesic efficacy than aspirin CHANGES WITH REPEATED EXPOSURE: Sensitization and tolerance: Tolerance: attributable to receptor down-regulation, self-induction of metabolic enzymes, etc Sensitization: Common with psychoactive compounds, poorly understood, involves a form of learning CHANGES IN THE DISEASE STATE: Few diseases are static - psychiatric disorders in particular can change over time ALL THE ABOVE NECESSITATE "TITRATION" OF DRUG DOSAGE NEGOTIATING THE JUNGLE OF DRUG NAMES DRUGS HAVE MANY NAMES. Four common sources of names are described here: THE CHEMICAL NAME: A mind-numbing jaw breaker, seldom used in practice THE DRUG-DEVELOPMENT NAME: While undergoing testing, drugs are often given initials of the drug company, followed by a serial number: RU 486, SKF1362. These sometimes are carried over into common parlance THE GENERIC NAME: Often used for whole families of compounds: Thus barbiturates often end in -al; secobarbital Benzodiazepines end in -am: diazepam THE TRADE NAME: All drug companies give their products "sexy" proprietary names: Prozac for the generic fluoxetine, for example Once the proprietary license expires, there can be hundreds of such names THE PHYSICIANS' DESK REFERENCE (PDR): The most common guide to the jungle, not necessarily the best PUTTING THE PSYCHO IN PSYCHOPHARMACOLOGY HISTORY OF THE TREATMENT OF MENTAL DISORDERS 1780-1850: THE LIBERATION OF THE MAD In the 18th century Bedlam was typical of the very few "mad houses" Beginning in revolutionary France, chains were struck off the mad, conditions in asylums greatly improved, and private asylums for the wealthy were established 1850-1950: THE WAREHOUSING OF THE MAD The very success of the sanitorium reform movement created a vast number of institutionalized patients, overwhelming the public's willingness to pay And creating huge warehouses with as many as 10,000 patients During most of this period NO treatment helped most of the institutionalized. The 19th and early 20th century was dominated by the belief that mental abnormalities had a neurological cause - but nobody could find that cause! Treatments developed in the 30s were often harsh, including: ECT: Electro-Convulsive Therapy Induced Convulsions, including insulin shock and metrazol-induced convulsions Coma, often for weeks, induced by bromides Psychosurgery: prefrontal lobotomy Under these circumstances, it is hardly surprising that in the US, Freudian psychotherapy swept the psychiatric establishment 1950s - PRESENT: THE PSYCHOPHARMACOLOGICAL REVOLUTION One of the greatest of 20th century medical advances Providing real hope for sufferers of previously hideous, crippling mental disorders The Entry of the Drug Companies: The sheer magnitude of such problems: Drugs such as Valium, Prozac become multi-billion dollar "Most Prescribed" compounds Consequently, big business dominates psychopharmacology NOSOLOGY: DIAGNOSTIC CATEGORIES OF MENTAL DISORDERS THE SITUATION IN 1850: Asylums growing and filling With an incredible assortment of: Neurological disorders, including syphilitic paresis, MS, Alzheimers Mental retardation Inconvenient behaviors, including alcoholism, embarrasing sexual behavior, etc "True" psychiatric disorders 1850 - 1950: PROGRESS IN DIAGNOSIS By 1950, most currently-recognized diagnostic categories established, mostly by German psychiatry This was no small advance, considering the situation in 1850! THE CONTINUING CONTROVERSY: What is a "real" psychiatric disorder? "Organicity": Something WRONG in the brain! "Acting Out" disorders excluded - these probably include: i. Multiple personality disorder ii. PMS iii. Anorexia Nervosa iv. Post-traumatic stress disorder, at least the longer-term varieties A problem: once organicity is established, the disorder becomes a neurological not a psychiatric disorder! The alternative to brain disease: ANY "dysfunctional" behavior having consistent characteristics is a psychiatric disorder, regardless of etiology DSM IV: The current state of the diagnostic controversy Splitting rather than lumping into over 300 diagnostic categories Often for political or financial reasons!