1
Q
Anxiety
A
- a state arising from stress or change and frequently emanates from fear
- differs from fear in that it is diffuse, internal, and an anticipatory reaction to danger that may be ambiguous or non-specific
- the state of anxiety may be disproportionate to the degree of perceived danger
- the continuum of anxiety ranges fro a mild form to severe
- spectrum disorder
2
Q
Normal Anxiety
A
Normal: protective response that the body uses to mobilize coping resources to maintain homeostasis
- everyone experiences fear in response to the threat of injury, and the production of adrenaline accompanies the “fight or flight” response.
- expected to accompany developmental changes and life span issues
- increases in adolescence: don’t have built in resources, peer & parental pressure
3
Q
Abnormal Anxiety
A
- maladaptive responses or failure to mobilize homeostatic processes often culminate and contribute to formation of anxiety disorders
- overwhelming and enduring anxiety often produce maladaptive responses that globally affect a person’s level of functioning (avoidant behaviors & phobias)
- DSM: anxiety disorders one of the most common psychiatric conditions
- anxiety–>adrenaline. tissues absorb this and establish a higher baseline for anxiety.
4
Q
Epidemiology of Anxiety Disorders
A
- affects approximately 15% of the general population at sometime during lifespan
- one of the most common reasons for seeking medical and psychiatric tx
- one in four persons has met criteria for at least one anxiety disorder
- women higher prevalence
- most prevalent mental disorder in older adults (presenting symptom in depression)
- cultural variable: increased panic & OCD in Mexican immigrants, more phobias in AA population
5
Q
Causative perspectives and theories: Anxiety
A
- psychodynamic theories: early years. conflict, pleasure principle. Separation from primary caregiver: child doesn’t have coping to deal.
- Existential: world without a God. Pervasive uneasiness. Hopeless/pessimistic
- Cognitive-Behavioral: judgement & reasoning can be maladaptive. “overgeneralization”, “catastrophizing”. Learned from neg. reinforcement.
- Developmental: attachment. anxiety & separation from PCG. usually work through it by 3.
- Biological
6
Q
Biological Theories: Anxiety
A
- Neurotransmitter & Neuroendocrine Theories: GABA the most important. Helps control ongoing firing in limbic system. Serotonin. Norepi: mediates fight or flight.
- Neuroendocrine: ANS. HPA axis @ level of limbic system. Cortisol- excitation–> increased anxiety.
- Neuroanatomical Theories
- Genetic Factors: generalized anxiety disorders, phobias, PTSD. Twin studies indicate strong familial basis
7
Q
Autonomic/Biological global manifestations of anxiety responses
A
- increased respirations
- SOB
- tachycardia
- diaphoresis
- dizziness
- parasthesias (tingling, creeping feeling from increased cortisol levels. rule out med rx)
8
Q
Motor global manifestations of anxiety responses
A
- tension
- pacing
- tremors
- stuttering
- restlessness (akathesia)
9
Q
behavioral global manifestations of anxiety responses
A
- rituals: alleviate anxiety
- avoidance
- increased dependence
- clinging
- following (infant)
- crying (infant or school-aged child)
10
Q
Cognitive/Psychological/Spiritual global manifestations of anxiety responses
A
- sense of doom
- powerlessness
- intense fear
- vigilance (hyper- watching everything/everybody)
- rumination
- helplessness
- dissociation: like daydreaming. esp. in trauma
- distortions: watch when giving instructions. give hand written instructions.
- confusion
- overgeneralization: feeling disconnected from other people. don’t feel like we’re special or unique to other people.
11
Q
Common childhood and adolescent anxiety disorders
A
- separation: intense fear. normal- should be addressed by 3 y/o.
- Social Phobia: formal & interpersonal situations. modeling a parent, childhood losses, abuse, chronic illness
- OCD: 2-3%. Unwanted recurrent & intrusive thoughts and/or images. Compulsions relieve anxiety. Tx is family therapy. autoimmune beta strep= residual condition that manifests as OCD.
- PTSD: treat as early as possible. children do not have adequate coping mech. avoid closeness, clinging, regression, nightmares.
12
Q
Adulthood Anxiety Disorders
A
- GAD: onset in 20s. Chronic free-floating anxiety
- Panic Disorder w/or w/o Agoraphobia: sudden fear. ANS response. educate pt symtoms limited to 10 min.
- Agoraphobia: fear of outside environment. increased drinking. globally incapacitated.
- social phobia: can’t work. QOL. SSRIs.
- specific phobia
- OCD: Axis I. impaired social. rigidity/perfectionist. helplessness & powerlessness. lot of depression, alcoholism, eating disorders.
- Acute Stress Disorder: exposure to traumatic event- goes away in a couple days.
- PTSD: medication, cognitive. Pre-morbid, maladaptive coping. Recent- s/s can manifest after 6 mo. emotional numbing. EMDR- eye movement desensitization. disconnects flashback mechanism.
patients have increased CO2 from holding breath when anxious.
13
Q
Treatment considerations: Anxiety
A
- Cognitive behavioral: new & adaptive ways of coping. reasoning power. intellect intervenes- effective for diffusing anxiety.
- systematic desensitization: gradually expose to things they’re anxious about. Wolpy: 3 steps. 1: relaxation. 2: gradual exposure. 3: desensitization.
- progressive relaxation: visualize, sequentially relax muscle groups
14
Q
medications used as anxiolytic agents
A
- benzodiazepines: GABA. insomnia, anxiety, withdrawal. do NOT mix with alcohol. Klonapin: long acting. Ativan: short.
- nonbenzos: Busbar. non-addictive. serotinergic/ anxiety component. has to be used on a regular basis.
- SSRIs: inhibit 5-HT.
- TCA’s: norepi. mediate fight or flight. drowsiness a concern.
- MAOIs: not used much due to food contraindications. HTN crisis.
- beta blockers: Inderal, Atenolol. block phys. manifestation of anxiety. use caution for blocking @ b2 receptors.
15
Q
alternative/complementary therapies for A.D.
A
- biofeedback: promote healthy restoration
- visualization/imagery: focusing
- stress mgmt: residential care
- meditation: calm trance
- yoga/t’ai chi: decreases anxiety by focusing.
- hypnosis: self. deep form of relaxation.
- exercise: endorphins. burn off anxiety.
- acupuncture: 12 meridians linked to organs. rebalances energy flow.
- massage: improves circulation.
16
Q
Definition of personality disorders
A
Kernberg: defined personality disorders as a spectrum of maladaptive traits that produce or influence considerable psychological and emotional disturbance and impaired relationships
- DSM: delinieates clinical features of PD as an enduring pattern of feeling (emotions), thinking (cognitive distortions), and behaving (maladaptive in nature) that become rigid and stable over time.
17
Q
behavioral features of personality disorders
A
- rigid & inflexible
- distress or maladaptive coping skills
- personal problems that induce extreme anxiety, distress & depression–>ability to perform at optimum level compromised.
- lifelong difficulty adapting to change, tolerating frustration and crises, forming healthy relationships.
- deny existing problems, lack insight (ego-syntonic: rest of the world has trouble with their behavior, not the other way around)
- extremely sensitive to outside opinions & feedback
- differ from other patients b/c they experience ego-dystonic state (uncomfortable and unacceptable)
18
Q
recognition of special needs in patients with PDs
A
- understand factors associated with personality development
- recognize the impact of early traumas on coping styles
- deal with intense reactions that occur when working with these patients
- work with other MH professionals to develop consistency and prevent splitting of staff
- recognize the need to maintain boundaries that are extremely clear.
19
Q
splitting
A
- behavior that involves setting up conflict b/t others
- not uncommon to create between staff
- such behaviors arouse intense feelings and negative reactions (countertransference)
- clear boundaries essential
20
Q
boundary
A
- rule defining and how members participate in a subsystem or a relationship
- important to stay in role/in charge.
21
Q
understanding the origins of PD
A
- understanding the origins of these behaviors can play a key role in minimizing negative reactions
- must be perceived as a challenge rather than a burden
- nurses are challenged to sharpen skills in patience, self-awareness, creativity and a nonjudgemental approach
- staff needs to develop treatment plans that do not allow for splitting staff. must confer frequently
22
Q
foundations of PD
A
- most theories emphasize the significance of primary caregivers in growth & development. if PCG hasn’t helped child to feel safe and flourish, they will think people can’t be trusted.
- child must master the initial demands for the socialization within family, where the foundation is laid for the future emergence of interpersonal relationships with all others
- early interactions mediate the infant’s perception of the world–>maladaptive.
- nurses must understand key concepts in personality formation such as ego development and organization, and must assess the meaning of their own.
23
Q
Psychodynamic Theories: PD
A
Object Relations Concept: internalized relationships recollected from early primary caregivers. considered the core of the person’s existence, “all other human behavior and experiences…are relational derivatives.”
Mahler: internalization of the PCG allows child to maintain an image of the caregiver when absent (object constancy)
Kernberg: the basis of severe PD was r/t inadequate or impaired object relations that are ingrained in the personality (sees & functions in the world).
24
Q
Neurobiological Theories: PD
A
- NT such as Serotonin and Dopamine have been implicated in impulsivity, aggression and suicidal gestures manifested in disordered personalities, especially Borderline & Antisocial types
- cutting- way to feel. person numbed by trauma.
- imbalance: might use SSRIs, atypicals, typicals under rare circumstances to get it under control
25
Cluster A Personality Disorders
```
- those in which patients are considered withdrawn, odd, or eccentric.
Include:
- paranoid
- schizoid
- schizoptypal
```
26
paranoid personality disorder
- not an axis I
- there are delusions
- on guard, hypervigilant
- doesn't affect global functioning
- think people want to harm them
- bear grudges
27
schizoid personality disorder
- pervasive pattern of detachment; lots of isolation
- unlikely to seek treatment
- could be hospitalized
- no social connectedness
- non-nurturing/empathetic parents
- mostly men
28
schizotypal personality disorder
- odd & eccentric
- limited capacity for interpersonal r/s
- lots of social anxiety
- hyper-sensitive
- genetic markers for schizophrenia- likely grew up with someone w/it
- odd ways of seeing the world
29
nursing interventions for paranoid personality disorder
- establish rapport
- minimize potential for aggressive behaviors
- support adaptive behaviors: talk about how pt. can communicate with people
- do not need the increased level of precision in speech like in a schizophrenic patient
30
nursing interventions for schizoid & schizotypal PD
- approach pt in calm manner
- maintain a comfortable distance based on the patient's verbal and nonverbal communication (assess everything)
- administer psychotropics and observe the patient's responses- both desired and adverse effects
- provide structured social interactions
31
Cluster B PD
```
- patients seek attention and engage in erratic behavior
Include:
- antisocial
- borderline
- histrionic
- narcissistic
```
32
Antisocial PD
- the "conman"
- regularly engage in risky behavior
- lack sense of fidelity
- repetitive legal problems
- dysfunctional family
- watch out for being manipulated
- ADHD hx
33
Borderline PD
- deep, painful base
- tremendous fear of abandonment
- regulating affect
- chronic feelings of emptiness
- love/hate manifests in splitting
- "affect dysregulation disorder"
34
Histrionic PD
- exaggerated, labile emotion
- flamboyant/dramatic
- think r/s more intimate than they are
- theatrical
- sexualization of relationships
35
Narcissistic PD
- grandiose sense of self
- require a lot of admiration
- arrogant
- etiology: child from cold/rejecting parents
- lack of positive self worth
- aloof, detached, hauty
- depression common later in life
- illness: "narcissistic injury"
36
Nursing Interventions: antisocial PD
- respond to patient's maladaptive behavior with firm and consistent limit setting
- approach patient in a sensitive and nonjudgemental manner to facilitate trust and rapport; they fear and mistrust intimacy and closeness
37
Nursing interventions: borderline PD
- form a nurse-patient relationship based on clearly stated, realistic expectations
- assist in reduction of self-destructive behavior and intent
- encourage verbalization of feelings about self
- tend to be out of themselves- don't want to talk about their pain
- goal: affect regulation
- dialectical behavior therapy: 5 part series. meditation, cognitive, behavioral
- meds: antipsychotics, mood stabilizers, antidepressants
38
Nursing interventions: histrionic PD
- treatment is similar to that of other PD and e.g. BPD
- consistency
- understanding
- managing countertransference issues
- providing an environment that minimizes maladaptive coping patterns
- psychopharmacologic approaches center on depression, anxiety, and psychosis (fixed delusions)
39
Nursing interventions: narcissistic PD
- hospitalization is usually precipitated by depression, suicidal behaviors, and mood swings that often follow failure and rejection
- group therapy may be avoided by the pt because it would require them to balance the desire for a special patient-therapist r/s and because they may fear confrontation by group members
- may be alcohol connected with this
- older--> symptoms get worse
- medical illness- lot of distress
40
Cluster C PDs
```
- conditions in which the symptoms are anxiety and fear
Include:
- avoidant
- dependent
- obsessive-compulsive
```
41
avoidant PD
- any kind of activity that can cause criticism
- avoid intimate r/s
- preoccupied with rejection
- don't engage in intimate r/s
- produces a lot of anxiety
- etiology: parental rejection/criticism
- self doubt
42
dependent PD
- very submissive
- child-like
- fearful of making own decisions
- like having someone tell them what to do
- mostly females
- etiology: fear of making decisions- controlling environment
43
obsessive-compulsive PD
- not Axis I
- pervasive rigidity and pre-occupation with control
- exaggerated feeling of losing control
- inflexible
- interferes with ability to establish r/s, get along with others
- etiology: overly controlling parents
- organized, efficient
44
Nursing interventions: avoidant, dependent, OCD
- establish trust to minimize anxiety
- once anxiety is minimized, the nurse-patient relationship focuses on exploration of old behaviors with consideration for individual change, improved insight, improved sense of self, and overall improved quality of life relationships
45
Bipolar according to the DSM
a recurrent mood disorder featuring one or more episodes of mania or mixed episodes of mania and depression.
Differs from major depression in that there is a history of manic or hypomanic (milder and not psychotic) episodes.
46
Bipolar I: types
- mania
- hypomania
- depression
- mixed episodes (mania & depression)
spectrum disorder: mild, moderate, severe.
severe- psychotic s/s
47
Mania
- a mood disturbance ranging from pure euphoria or elation to an irritable labile admixture that also includes dysphoria (unpleasant mood)
- "crazed, frenzied"
- irritability: very difficult symptom to differentiate.
48
DSM Manic Episode
A. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g. feels rested after only 3hrs of sleep)
3. More talkative than usual or pressure to keep talking
4. flight of ideas of subjective experience that thoughts are racing (rapid series of ideas- about one topic.)
5. distractibility (e.g. attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work, or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (gambling, shopping, sex)
49
effects of manic episode
- mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- increased rate of recidivism
- stages you might see when people decomensate
50
Hypomania
- subsyndromal counterpart of mania
- never psychotic
- not associated with marked impairments or judgements/performance
- some long for this productive energy & heightened creativity
- see in bipolar I or II
- beginning stages of full-blown episode in I
- fears the depressive end of things
- many don't want to come down/take meds
- key to issue is non-compliance
- road to mania starts with hypomania
51
Mixed episodes
- coexistence of depressive & manic symptoms
- can be expressed on a continuum ranging from psychotic features to milder and subclinical states
- frequently present with severe depression with agitated features and acceleration of thought suggestive of a depressive mixed state
- labile: mood shifting all the time
52
Bipolar II
- presence or history of one or more Major Depressive Episodes
- presence (or hx) of at least one hypomanic episode
- there has never been a manic episode
- the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
- always want to rule out alcohol use- very high co-morbidity (self-medicating)
53
Cyclothymic Disorder
- for at least 2 years
- presence of numerous periods w/hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode
- in children and adolescents duration must be at least 1 year
- sometimes known as bipolar III
- 1/3 develop into type I
- like dysthymia: baseline of a bipolar state
- never had a true manic episode
54
Bipolar Epidemiology
- Bipolar I affects 1-1.5% pop
- equal numbers men and women
- Bipolar II affects 0.5-0.6% of the population with females affected more than males
- males have more manic episodes, are likely to have comorbidity of substance abuse/dependence
- initial episodes of mania: males display more hyperactivity,grandiosity, and risky behavior. females: racing thoughts, distractibility
55
Bipolar: Neurochemical Factors
- Depression: imbalance of Norepi & serotonin
- Mania: less understood. Suggested inability to modulate neuronal excitation.
- Lithium acts on second messenger system inhibiting neurons to release, activate or respond to NTs. Restores daily rhythms. Highly effective.
- also suggested that Depakote increases GABA thereby dampening aberrant neuronal excitation
56
Bipolar: Pharm modalities
- mood stabilizers: LIthium, Depakote, Lamictal, Topamax, Tegretol
- antipsychotics
- benzodiazepines: Ativan, Klonapin
- anti-depressants: Wellbutrin, SSRIs
57
ECT
- effective and often lifesaving
- pts are anesthetized
- performed in a closely monitored medical setting by a psychiatrist
- 5-10 treatments bi or unilateral
- most common side effects: headaches, n/v, mild confusion, temp. memory loss.
- start with meds before considering this tx
58
Psychosocial & Behavioral Interventions: Bipolar
- SAFETY
- safety best address in context of patient, family, milieu mgmt
- patients and families need to be assisted in design of a crisis intervention plan, family focused psychoeducation.
- manic episodes: tend to neglect self care
- limit setting v. important
- healthy coping mechanisms
- managing emotions, helping w/interpersonal relationships
59
Lithium
It provides relief from acute MANIA or DEPRESSION. The direct action of Lithium is complicated physiological process but Lithium (a salt) has a direct effect on receptors that effect proteins that help to restore daily rhythms and cycles to mood. **** Lithium has a direct effect on KIDNEY FUNCTION as Lithium is excreted through the kidneys with an interplay between electrolytes, ie, With a decrease in sodium (sometimes caused by excessive water drinking ) you can see an increase in intracellular Lithium which can produce a TOXICITY of Lithium in the body. IMPORTANT TO MONITOR LITHIUM, BUN AND CREATININE LEVELS. Thyroid function is also effected by Lithium with 4% (approx) of all lithium patients developing thyroid issues. It is estimated that long term use of Lithium (15 to 20 years) can cause kidney damage and the prescriber needs to do a risk/benefit determination to see if continued Lithium treatment is indicated. THERAPEUTIC RANGE IS 0.5 to 1.5 mEq/L.
****TAKES 1 to 2 weeks for therapeutic response. Patients are usually given Antipsychotics and/or Benzo to help stabilize before Lithium full therapeutic response is evident.
60
Nursing interventions: Lithium
avoiding dehydration and diarrhea which can effect electrolyte levels. Especially important in hot weather.
61
Depakote
very effective to calm down the agitated manic patient. It is suggested that it works on the GABA network which means it has a calming effect as it inhibits excitation. Remember the process of KINDLING EFFECT to prevent full excitation/agitation of mood symptoms. Depakote is said to enhance seratonergic and dopaminergic functioning. This means you can see positive changes in the mood of the patient.
62
Nursing interventions: Depakote
monitoring of LIVER ENZYMES – baseline and every 3 months. One patient concern is HAIR LOSS that is actually not loss from the hair root but breakage of hair. Recommend use of Selinium (vitamin replacement) and Panthenol (pantene shampoo).
63
Lamictal
sed effectively for newer diagnosis of Bipolar Depression. Major concern is STEVEN JOHNSON RASH – a life threatening condition involving a rash in the oral and nasal mucosa that can obstruct breathing. This is an ICU condition. Problem can be avoided by slowly titrating dose of medication no more than 25 mg every 2 weeks.
64
Topamix
- Topirimate
- has a side effect of decreased appetite and is therefore used to prevent weight gain from other meds. At best it is a mild mood stabilizer.
65
Tegretol
(Carbamazepine) – used for agitated states; mostly in developmental disabled.
66
Wellbutrin
- antidepressant
| - can be added as it has less chance of inducing mania.
67
SSRIs and Bipolar
can be added slowly and in low doses after a person is stabilized and only if there are symptoms of social phobia, ocd, or other co-morbid problems
68
4 common myths about human trafficking
1. HT is an international problem. In fact, it is happening here with high numbers of illegal activity happening at Kennedy airport
2. Trafficking occurs only for sex trade. (could be forced labor)
3. Poverty and inequality are the causes of HT (it's big business including recruiters, traffickers, and criminals. Silent partners: travel agents, landlords, publications).
4. People who are traffickers have a common stereotypical profile
69
gender identity
the internal process of one's self concept of their gender. For some this matches their assigned gender and bodies and social perceptions and for others it does not.
70
sexual orientation
the direction of one's sexual attractions and for some this can be fluid
71
Ativan
- benzo
- short acting: 4-6 hrs
- short term use only- dependency an issue
- used for bipolar disorder, anxiety, ETOH withdrawal
72
Klonapin
- benzo
- long acting in system and used for long term anxiety disorders, flashbacks, panic symptoms.
- if tx discontinued, pt needs to be tapered off
- used in bipolar disorder, anxiety
73
Xanax
- benzo
| - mostly for short term use, high potential for dependence
74
Busbar
- principle drug in non-benzo family
- serotinergic/ anxiety component
- non addictive
- needs to be taken on a regular basis
- not effective as a PRN medication
75
SSRIs
work on neural inhibition and re-uptake of serotonin.
- used to treat anxiety and depression
- Prozac, Zoloft, Paxil, Lexapro, Celexa, Luvox
76
Tricyclic Antidepressants
- original meds used to treat anxiety and depression
- work on norepi NT and mediates fight or flight mechanism
Meds include:
- Nortriptyline, Trazadone, Elavil, Imipramine
Major side effect: anticholinergic, Dry mucous membranes, sedation, weight gain
77
MAO Inhibitors
- works effectively for anxiety but has a side effect potential that can be difficult for pt to follow
- newer forms are in patch form and do not have food contraindications
78
Beta blockers
- blocks physiological aspect of anxiety symptoms, esp. CV & pulmonary
- good for pts with somatic symptoms
- caution in pts with asthma
meds: Inderal, Attenelol
79
Inderal
- beta blocker
- used to cardiac conditions but can also slow down palpitations and rapid pulse in anxiety disorders
- good for stage fright
80
Atenolol
- used for HTN but has same effect of slowing down phys. manifestations of anxiety
81
pharmacotherapy for alcohol withdrawal
- benzos increase GABA to inhibit the excitation of the CNS
- may also use Librium or Phenobarbital
- antipsychotics used for hallucinations and severe agitation
- thiamine used for nutritional deficiencies that may cause encephalopathy
- LIbrium or Ativan giving in progressively decreasing doses
- selection of medication and dosing guided by pt's liver function
82
pharmacotherapy for sobriety
- ReVia and Campral: decrease cravings
| - Anabuse: allergic reaction when alcohol is consumed
83
disease concept of addiction
- substance dependence is a complex biogenetic psychological disorder that is chronic, progressive, and potentially fatal.
84
denial and relapse
- denial is an integral part of addiction and fuels the addictive behaviors
- patients minimize or disconnect from the negative impact of chemical use
- s.a. being understood as a chronic, relapsing disorder with similarities to other long-term chronic illnesses
- relapses are part of the course of the illness
- tx outcomes need to be viewed as effective based on the decrease in substance use and length of time person has been substance free (harm reduction)
85
addiction
- dependent pattern
- ability to moderate or stop is repeatedly unsuccessful
- sense of craving in absence of substance
- uncontrolled compulsion to use despite knowledge of negative consequences
- loss of control over frequency and amount is key indicator
86
tolerance
- pharmacologic property of some abused substances
- chronic uses produces changes in CNS
- more needed to produce desired effects
- withdrawal syndrome may occur
87
DSM Substance Abuse criteria
A. a maladaptive pattern of substance use leading to conically significant impairment or distress, as manifested by one (or more) of the following within a 12 month period:
1. recurrent substance use resulting in failure to fulfill major role obligations
2. recurrent use in situations in which it is physically hazardous
3. recurrent substance abuse-related legal problems
4. continued substance use despire having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
B. The symptoms have never met the criteria for Substance Dependence for this class of substance
88
DSM Substance Dependence
See criteria A for Abuse as manifested by three or more of the following occurring at the same time in the same 12 month period.
1. Tolerance:
a. need to markedly increased amts to achieve desired effect
b. markedly diminished effect with continued use of the same amt
2. Withdrawal:
a. characteristic withdrawal syndrome for the substance
b. same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
3. taken in larger amts or over a longer period of time than was intended
4. persistent desire or unsuccessful efforts to cut back
5. lot of time spent trying to obtain
6. important social, occupational, recreational activities given up b/c s.a.
7. continued despite knowledge of problem
89
substance intoxication
- changes can be produced in alertness, coordination, attention, judgment, and thinking
- pulse, respiration, blood pressure
- all classes of substances (except caffeine & nicotine) may cause delirium and psychosis during intoxication
- varying degrees of depression and anxiety with intoxication or during/after withdrawal
90
Epidemiology of substance abuse
- binge drinking= 5 + drinks on the same occasion in the past month
- heavy drinking: 5+ drinks on the same occasion on each of 5 days in the same month
- use before 18 more likely to be dependent
- stronger in males
- female use woven into context of intimate relationships
- women more susceptible to ETOH b/c absorb more through GI tract
- men have more ETOH dehydrogenase
- men find way to tx due to legal problems
- women seek tx in response to health concerns (gyn issues, heart and lung disorders)
91
Alcohol
- absorbed quickly
- stimulates release of body's own opiods and endorphins which turn on the central dopamine reward system (id)
- abuse and dependence underdiagnosed and undertreated in the primary care setting
- legal problems, car accidents, predisposition to variety of health problems
92
alcohol withdrawal
- associated with neuronal excitation in the face of abrupt cessation
- dose dependent- heavier drinkers more likely to develop withdrawal
- brain adapts to regular doses- can't fx without presence of alcohol
- the last time and amt of alcohol consumed is an important assessment question
93
ETOH withdrawal s/s
- tremors
- hyper-arousal: easily startled, anxious, irritable, tachycardic, elevated bp, n/v/d, flushing, diaphoresis
- hallucinations
- symptoms usually peak @ 4 days after last drink and gradually subside. Symptoms can persist for 1-2 wks
- can become a medical emergency, esp in presence of medical comorbidity such as CV or renal disease.
94
ETOH withdrawal: DTs
- seizures
- profound confusion and disorientation (stay with patient!)
- hallucinations
- autonomic nervous system arousal: hyperprexia, HTN, tachycardia, course tremor, agitation
* * without medical intervention Hyperthermia and/or CV collapse can occur
95
Wernicke's Encephalopathy
- reversible condition associated with thiamine deficiency
| - s/s: ataxia, delirium, palsy of 6th cranial nerve (abducens muscle of the eye)
96
Wernicke-Korsakoff Syndrome
- thiamine deficiency
- profound memory impairment
- inability to learn new material
- 50% cases have permanent impairment
- use confabulation: will make up a story. another kind of denial.
97
other CNS depressants
- sedatives-hypnotics & anxiolytics: abuse usually consists of obtaining rxs from multiple physicians
- alprazolam (Xanax) associated with immediate and severe withdrawal due to substances short half-life
- opioids: morphine & codeine, heroin
98
CNS stimulants
- caffeine
- nicotine
- amphetamines & cocaine
- hallucinogens
- cannabis
- inhalants
- club drugs
- PCP
99
Misc. definitions: substance-related disorders
- dual diagnosis: the presence of substance-related disorders and psychiatric disorders occurring at the same time
- codependency/enabling: the spouse or significant other may devote inordinate amounts of time and energy to control the addicted person's behavior and forestall or soften a variety of impending disruptions or crises. many times the partner has more psychological symptoms than the alcoholic
100
types of treatment
- inpatient detox: med mgmt of withdrawal
- inpatient/outpatient rehab: models. ongoing knowledge and awareness
- individual therapy, group therapy: slowly deal with underlying issues. don't want to uncover too quickly- pain can make the pt go back to use
- self help, support grps
101
CAGE
C: cut down on drinking?
A: annoyed by criticism or complaining by others about drinking?
G: guilty about drinking?
E: eye opener in the morning?
102
resilience factors
- insight
- independence
- relationships
- initiative
- creativity
- humor
- care-giving, personality, temperament
- support of family/community
- religious/spiritual beliefs
- faith & hope
- mental health prevention, intervention, promotion
103
agency
the power of the individual person to initiate action and sustain power on their own behalf
104
risk factors for mental illness
- immigrant status: difficulty in acculturation, culture shock, intergenerational conflict
- refugee status: entry into new culture not active choice, trauma by experiences in homeland, vulnerable to PTSD
- minority status: SE disadvantage, poverty, limited opportunities for education and jobs, residence in disadvantaged neighborhoods
- higher incidence of mental health problems in minority groups is related to poverty, not ethnicity
105
antipsychotics and bipolar
All the atypical antipsychotic medications mentioned for Schizophrenia also have an indication for the treatment of mania. They can be used in conjunction with a mood stabilizer or alone (mono therapy). Many times bipolar patients are maintained on antipsychotics alone because of the issues with Lithium and Depakote
106
antidepressants and bipolar
CONTROVERSIAL addition to medication regiment as it may induce MANIA.
107
nurse as a second self
- awareness of patient's vulnerability and fear in the illness state
- aware that HCP has a higher degree of power over patients
- second self: nurse is cognizant of the need to maintain the patient's rights for self-determination
- help the person get their agency back
108
importance of culturally relevant care
Culture
- groups with shared beliefs, values, and practices
- influences their thinking and behavior
Cultural Norms
- define what is normal or abnormal within a culture
Enculturation
- learning the rules of right and wrong
- preparing a child to live within his or her culture
109
Intoxication
height of the effect of a particular substance is different for each substance. While intoxicated, a patient can demonstrate psychosis and delirium. You can see changes in alertness, coordination, attention, judgement and thinking, as well as physical symptoms of increase in pulse, blood pressure and changes in respiration rate.
110
ACT nursing interventions
engaging the client in a trusting relationship, health assessments, monitor vital signs, administer meds and monitor for side effects, continuous education re illness and treatment, advocates for client by collaborating with psych and medical, works with in-patient discharge planning, facilitate the process of housing which the client may be resistant to. The ACT RN functions at a high level of decision making in the community.
111
Nursing diagnoses: schizophrenia
```
Social Isolation
Ineffective Coping
Disturbed Sensory Perception: Auditory/Visual
Disturbed Thought Process
Impaired Verbal Communication
Self Care Deficit
Insomnia
```
112
Nursing diagnoses: depression
```
Risk for Suicide
Low self esteem
Impaired social interaction/social isolation
Powerlessness
Disturbed Thought Process
Imbalanced Nutrition
Disturbed Sleep Pattern
```
113
Nursing diagnoses: bipolar disorder
```
Risk for injury
Risk for self directed or other violence
Imbalanced Nutrition
Disturbed thought Process
Disturbed Sensory Perception
Impaired Social Interaction
```
114
Nursing diagnoses: anxiety disorders
```
Anxiety (Panic)
Ineffective Coping
Powerlessness
Fear
Self Care Deficit
Social Isolation
```
115
Nursing diagnoses: personality disorders
```
Risk for self-mutilation/Risk for self-directed or other-directed violence
Anxiety (Severe to Panic)
Impaired Social Interaction
Low self esteem
Ineffective Coping
Defensive Coping
```
116
Nursing diagnoses: substance related disorders
```
Ineffective coping
Ineffective denial
Imbalanced Nutrition
Chronic Low Self Esteem
Deficient Knowledge (Effects of Substance Abuse on the Body)
Dysfunctional Family Processes
```
Acute Psych
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