STUDY GUIDE 3 (NSG 150)

Schizophrenia & other psychotic conditions 3.1 EOs1.1 key terms1.2 theories of the etiology of schizophreniaGenetics60% inherited

6-17% chance if one parent or sibling has it

identical twin rises to 40-65%

non-identical twin 17%

Toxin (environmental)toxin exposure as a result of breathing (pollutants), eating, drinking, & smoking

pollution

infections

viral exposure

malnutrition

being born in winter

being born in a city

childhood brain injury

Neurotransmitter alterationsdopamine- regulates both movement and emotions

dopamine hypothesis- persons w/ schizophrenia have an increased level of dopamine in certain areas of the brain such as the nigrostriaganglia & some critical functions.

Excessive dopamine causes symptoms of psychosis (e.g., hallucinations, delusions) b/c it disrupts cognition & thought.

66% increase in the # of dopamine receptors in persons w/ schizophrenia.

Serotonin, acetylcholine, norepinephrine, cholecystokinin. Glutamate, & GABA

Neuro anatomicalenlargement of cerebral ventricles

3rd ventricle dilation

ventricle asymmetry

abnormal lobes some atrophy as seen in MRI & PET scans

changes in blood flow

Viral (immunological)Exposure to influenza during pregnancy is a risk factor for development of schizophrenia in later life.

Polio, measles, varicella-zoster, rubella, & herpes simplex virus type 2 during childhood.

Few immunologic studies of schizophrenia

Stress-traumasubstance abusenicotine common addiction in these p/ts

socio-economicPsychological & psychosocial theoriesPersons vulnerability interacts w/ stressful environmental influences to produce the symptoms of schizophrenia.

Psychosocial stressors include stressful life events such as interpersonal losses, sociocultural stresses (poverty or homelessness) or stressful emotion situation where the p/t lives.

Psychosocial rehabilitative interventions have been shown to improve the quality of life in p/ts w/ schizophrenia.

1.3 epidemiological factorsmales earlier onset (15-25), poorer outcome

females later onset (25-35), better outcome

new dx of schizophrenia occur in b/t 0.3 & 0.6 individuals per 1000 persons per year in the US

1% of the US population has schizophrenia

paranoid-type schizophrenia occurs earlier in males than in females

disorganized-type schizophrenia occurs earlier in females than in males

prevalence is equal for males & females

childhood onset is rare

oldest of age-of-onset group is after the age of 60

a female fetus who is exposed to influenza has a higher risk for shizophrenia than a male fetus

males show significantly more structural brain abnormalities from perinatal or early childhood trauma than females do

1.4 onset and course of diseaserare onset in children

persons who have later onset have better outcomes in all areas

approx 80% of people w/ schizophrenia had an early onset, whereas 20% have a late onset (after 40) or very late onset (after 60).

Course of illnesspremorbid: social, motor, cognitive changes

Prodromal: 1 month to 1 year before dx/S&S of this phase includemood symptoms (anxiety, irritability, dysphoria, anguish)

cognitive symptoms (distractibility, concentration, difficulties, disorganized thinking)

obsessive behaviors

social withdrawal & role functioning deterioration

sleep disturbances

attenuated (weaker) positive symptoms (illusions, ideas of reference, magical thinking, superstitiousness)

Psychotic: acute, recovery/maintenance, stable phasesacute- florid positive symptoms (delusions, hallucinations) negative symptoms (apathy, withdrawal, avolition). Unable to perform self-care activities, brief hospitalization required.

Recovery/maintenance- 6-18 mo. After acute treatment. Less severe symptoms. Able to take care of themselves w/ some supervision.

Stable- symptoms are in remission. Residual symptoms (milder forms of symptoms). May live independently in the community.

1.5 subtypes & related disorders of schizophreniaParanoidBetter prognosis/less cognitive & neurological impairments

respond better to meds

in acute phase more a danger to self or others

suspicious of others

touch & personal space should be considered

must meet 2 of the symptoms in criterion A: also listed on pg 270presence of delusions & hallucinations.

The other diagnostic criteria (I.e disorganized speech, behavior, & other negative symptoms) are not prominent.

Disorganized (formerly called hebephrenic)severe disorganization in speech, odd behaviors

socially withdrawn

poor grooming

prognosis is poor

word salad (communication that includes both real & imaginary words in no logical order)

Catatonicpsychomotor disturbances catalepsy (waxy flexibility)

catatonic stupor (psychomotor retardation) or excitement (psychomotor excitation)

require the most nursing care due to chronic vegetative state can see & hear physical care

to meet the criteria, p/t must show two of the following behaviors:motor immobility

excessive motor activity

extreme negativism (resistance to all instructions & attempts to be moved)

peculiar voluntary movements (grimacing. Sterotypic movements, posturing)

echopraxia (imitating the movement of others) OR echolalia (repeating what was said by another)

Undifferentiated prognosis poor & chronic

does not fit other types

extreme delusions & odd behavior

Residualfree of prominent symptoms but still some negative

may continue for years w/ or w/o exacerbation

dx criteria:absence of prominent delusions, hallucinations, disorganized speech, disorganized or catatonic behaviors.

Continuing evidence of the presence of negative symptoms or reduced positive symptoms

Related disordersSchizoaffective: a condition in which a person experiences a combination of schizophrenia symptoms such as hallucinations & delusions & of mood disorder symptoms such as mania & depressionlater onset

severe mood swings

some psychotic symptoms

better prognosis

treatment is based on presenting symptoms

depressed phase like major depression

manic phase like bipolar manic

psychotic more like schizophrenia

diagnosis: Bleuler's fundamental signsaffect (feeling)

associative looseness (speech)

autism (thinking)

ambivalence (behavior)

Schizophreniform Defining characteristics same as those of schizophrenia w/ 2 exceptions: duration (at least 1 mo. But less than 6 mo.) & impairment function.

Prognosis: functional capacity is high.

Delusionalfixed false belief is not bizarre, that it may seem plausible, & that it lasts more than a month w/ causing obvious impairment in functioning.

Stalking behaviors

jealousy w/ evidence

sadness, grief, irritability, legal problems

Brief psychotic lasts less than a month

may have delusions, hallucinations, incoherent speech, grossly disorganized & confusing dysfunctional behaviors.

Symptoms not r/t to substance abuse or meds

associated w/ stressors

young adults who are high risk for suicide

care must focus on saftey & attention to the basic needs of nutrition & hygiene.

Shared psychotic (Folie a Deux)a person may share the same delusions w/ another person.

If primary person is a parent, affect children may literally grow up w/ the delusions.

Psychotic D. due to a general medical conditionhigh fever caused by a kidney infection may induce hallucinations, confusion, disorganization, aggressive or bizarre behavior.

Strokes, fluid & electrolyte imbalances, SLE, hypoxia, encephalitis, hypoglycemia.

Best approach is to assume that psychosis is a manifestation of an underlying & undiagnosed medical problem until it is proven otherwise

Substance-induced Psychotic D.tactile hallucinations (insects crawling over the skin) are characteristic of alcohol & drug abuse.

Symptoms usually resolve within a month.

Persons of psychosis may use drugs & alcohol as a method of self-medicating.

Psychotic disorder not otherwise specifiedetiology of psychotic behaviors is unclear

1.6 positive & negative symptomsNegativeinterfere w/ the ability to initiate or maintain relationships, conversations, hold a job, make decisions, & maintain ADLs.

Not as obvious

more insidious onset

more debilitating

contributes to social/occupational functioning

blunted or flat affect

Anhedonia- lack of pleasure

anergia- lack of energy

avolition- lack of motivation

depression, hopeless (risk for suicide)

social isolation

decreased spontaneity

poor response to 1st generation antipsychotics (may actually worsen)

Positive delusions, persecutory or grandiose

delusions of being controlled

mind-reading or thought-insertion ideas

perceptual: hallucinations, auditory or other sensory modes

bizarre dress & behavior

thought disorganization & tangential (superficial) speech

aggressive & agitated behavior

pressured speech

presence of suicidal ideation

ideas of reference

respond well to treatement & reduced stressors

1.7 nursing processAssesswhat problems have you been having recently

do you now or have you ever used alcohol or drugs

have you heard (sounds, voices, or messages) seen (lights, figures) smelled (strange, bad, good odors) tasted (strange, bad, or good tastes) or felt (touching, warm , or cold sensations) anything that others who were present did not

what are the voices like that you hear

it sounds like you're very scared right now

I don't hear any other voices but yours & mine

what helps to make the voices go away or get quieter

let's see if doing something (walking , crafts, singing etc.) helps with the hallucinations.

Nursing dxbased on the assessment of positive or negative symptoms

risk for suicide, risk for self-directed & other directed violence

disturbed sensory perception & thought processes

self-care deficit

outcomessafety always priority

vary w/ phase of illness & c/t

measurable, behavioral & realistic

demonstrate an absence of suicidal behaviors or violent behaviors toward others

demonstrate an absence of self-mutilating behaviors

nursing interventionsspecific to the symptom

aimed at lowering anxiety

decreasing defensive patterns

encouraging participation

raising self-esteem

agitated c/tsSAFETY

reduce stimulation

brief , concise , not abstract statements

what are the stressors/triggers

redirect come walk w/ me, tell me what is going on

prevent aggression c/ts always give signs, just look

acute phasecrisis intervention

stabilization

safety

limit setting

maintenance/stable phaseteach symptoms management

small amounts of info, can't tolerate lots of detail, use pictures

prevent relapse

1.8 shift to community treatmentassertive community treatment teamsdesigned specifically for the individuals strengths & deficits.

Deliver care 24/7

help w/ ADLs & job seeking skills & placement & offering support

family interventions, supported employment, CBT, social skills training, early intervention programsgroup therapy, group homes.therapeutic methods to prevent violence psychopharmacology, somatic therapy, milieu therapy, behavior modification

1.9 psychopharmological managementtypical/conventional antipsychotic/1st generationwork by blocking the D2 dopamine receptors in the limbic region of the brain

Phenothiazines: Chlorpromazine (Thorazine) (first drug to treat psychosis in the 50s), Thioridazine (Mellaril), Trifluoperazine (stelazine) & Fluphenazine (Prolixin)most effective for treating positive psychotic symptoms only

has many side effects which causes clients to stop taking them

blocks dopamine in the motor centers (Extrapyramidal Nerve tract) causes movement disorders or EPSincluding Tardive dyskinesia (a neurologic syndrome that consists of abnormal, involuntary, irregular choreoathetoid movements of the muscles, the head, the limbs and trunk)

choreoathetosis is the occurrence of involuntary movements in a combination of chorea (irregular migrating contractions) & athetosis (twisting & writhing)-manifested by tongue protrusion, puffing of the cheeks, chewing or puckering of the mouth-occurs rarely, but may be irreversible

AIM scale (autonomic involuntary movement scale)- performed not less than every 6 months when a p/t is taking either typical or aytypical antipsychotics

then came Butyrophenons: Haloperidol (haldol)

others: Thiothixene (Navane)

Extrapyramidal symptoms: serious reactions that appear r/t to high dose of neuroleptic medsAkathisia- subjective feeling of muscular discomfort that causes the p/t to become agitated, pace, alternately sit & stand & feel a lack of control

Parkinsonian- muscle stiffness, cogwheel, rigidity, shuffling gate, perioral tremor, hypersalvation, & mask like expression

acute dystonias-spasmodic movements caused by slow, sustained, involuntary muscle contractions such as:torticollis (abnormal, asymmetrical head or neck position)

opisthotonos ( body is rigid & arches the back, w/ the head thrown backward)

oculogyric crisis ( prolonged involuntary upward deviation of the eyes)

EPS can involve the neck, jaw, tongue or entire body

Drugs of treatment:Antiparkinson drug Benztropine (cogentin), trihexyphenidyl (Artane)

Acute emergencies Acute dystonic reactions, NMS (neuroleptic malignant syndrome)

Tardive dyskinesia life-threatening irreversible sweating, fever, unstable bp, stupor, muscle rigidity, autonomic dysfunction, elevated CPK, excessive salvation, occurs in 1% but 10% die

other side effects of typicals:anticholinergic (dry mouth, blurred vision, urinary retention, nasal congestion, constipation, ejaculatory inhibition)

sedation (most common during early stage of treatment, need to avoid alcohol, antihistamines, & sleeping aids)

postural hypotension

arrhythmias, palpitations, & prolonged QT intervals

lowered seizure threshold

weight gain increased risk for type II diabetes

photosensitivity & skin changes

poikilothermia loss of ability to regulate internal body temp. watch older adults in hot weather

galactorrhea & gynecomastia breast enlargement or tenderness

cholestatic jaundice

Atypicals- Clozoril (clozapine) was the first in the 90s1st to effectively treat both + & - symptoms of schziophrenia

not used as a first resort due to risk for agranulocytosis ( bone marrow does not make enough of a certain type of mature white blood cells (neutrophils)- regular & frequent serum lab testing required

used for refractory schizophrenia

other atypicals:Seroquel (quetiapine)

Risperdal (risperidone)

Geodone (ziprasidone) problem prolonged QT interval

Zyprexa (olanzapine) similar to clozapine w/o the risks of agranulocytosis, does have high risk for seizures- common side effect is gain weight

both serotonin + dopamine antagonists

work on + & - symptoms

fewer EPS side effects, but there still may be

less risk for tardive dyskinesia

cost more

elderly w/ dementia r/t to psychosis increased risk for death when taking these medsblack box warning contraindicated

mostly death r/t to cardiac failure/sudden death or infection (pneumonia)

3.2 Substance abuse disorders1.1 key terns1.2 definitions of SUDaddiction- compulsive drug seeking or use.

Substance misuse- use of psychoactive substance (drug or alcohol) for a purpose other than that for which it was intended & that causes physical, social , & psychologic harm.

Polysubstance abuse-

dependency-

abuse

1.3 USDEA categoriesschedule 1 (high potential for abuse, no accepted medical use in treatment in the U.S ex. Heroin, mescaline)

schedule II (high potential for abuse but has currently accepted medical use w/ severe restrictions, may lead to psychologic or physical dependence ex. Morphine, cocaine, codeine)

schedule III (potential for abuse less than for schedules I & II , currently accepted in medical practice, moderate-low dependence ex. Anabolic steriods, ketamine, thiopental)

schedule IV (low potential for abuse, current medical use, abuse may lead to limited dependence ex benzodiazepines, ambien, sonata, meridia)

schedule V (only contains cough preparation w/ codeine up to 200 mg/100ml

so basically just know that the lower the number the higher the strictness/regulation of these substances/drugs and the higher the risk for dependency. 1.4 neurobiological basis of addictiondrugs of dependence are categorized as depressants, stimulants, opiatesm hallucinogens, inhalants, & nicotine.

All drugs of abuse evoke a rapid release of neurochemicals that is followed by a reduced-from-baseline level of neurotransmitter when the effect of the drug wears off creating a reward threshold & biologic need for craving for more drug.

Drug serves as a reinforcer that increases the probability of a repeat behavior & the use of that substance.

Two sides of addiction:light side (beginning use): the feel good neurotransmitters dopamine, serotonin, opiod peptides, & other neurochemicals predominate.

Dark side (end use/withdrawal): neurotransmitters norepinephrine & corticotropin-releasing factor (CRF) as well as the stress circuits are activated, which results in withdrawal symptoms. The individual then uses the substance not to feel good but to prevent the physical & psychologic stress & discomfort.

Individuals w/ genetically greater neuroplastic potential for glutamate & dopamine production & activation may be more prone to addiction

4 circuits:reward: involves nucleus accumbens & ventral palladium (dopamine I.e light side)

Memory & learning: involve the amygdala & hippocampus

cognitive control: located in the prefrontal cortex & dorsal anterior cingulated cortex

motivation, drive, salience: orbital frontal cortex

all of these contribute to the initiation & continuation of substance use.

1 way path from amygdala to the frontal cortex frontal cortex does not have reciprocally direct communication w/ the amygdala this frontal cortex (prioritization, organization, decision making) is unable to tell the amygdala to stop.

1.5 epidemiological issues50% for men whose father was an alcohol dependent

women are at higher risk than men for problems r/t to alcohol use, including organ damage & other problems.

Women begin problem drinking later in life than men develop physical & psychosocial problems in a faster, often during child bearing years telescoping

native Americans have a high rate of alcoholism; Asians have low rate

the liver metabolizes alcohol by converting alcohol into acetaldehyde then into acetate & finally into carbon & water. The enzyme responsible is ADH, alcohol dehydrogenaseJapanese, Chinese, & Koreans are missing this enzyme or have an inactive form. This is protective as acetaldehyde increases in the blood quickly resulting in flushing, nausea, dizziness, & rapid HR. REMEMBER this when we talk about Antabuse (disulfiram)

Co-morbidpeople w/ mental illness have a greater risk of addiction & abuse PTSD, bipolar, anxiety, depression

medical comorbidites associated w/ drug & route of choice

vehicular accidents due to DUI & associated medical complications due to substance ingested.

1.6 substance abuse among special populationswomen are more vulnerable to domestic violence & suicide

traditional programs do not address women's issues

binge drinking or frequent drinking problem in pregnant women

drinking in pregnancy is the leading known cause of preventable birth defects & learning difficulties

Fetal alcohol syndrome growth retardation, central nervous system involvement that results in mental retardation & other learning difficulties, facial & other abnormalities occurs in 1 to 3 per 1000 live births.

Health

care professionals10-20 % of nurses & 9% physicians are identified as having substance abuse problems

Older adultsat risk population for substance abuse

statistics do not reflect true extent of the population

70% of those 60 or older hospitalized for medical problems or accidents was r/t to alcohol

use to manage pain & loneliness

always look for it: falls, cognitive changes, assaults, & suicides may be correlated w/ alcohol abuse

Adolescentsp/t- family teaching guidelines: signs & preventionbloodshot, red eyes, droopy eyelids

wearing sunglasses at inappropriate times

changes in sleep patterns (napping, insomnia)

unexplained periods of moodiness, depression, anxiety, or irritability

decreased interaction & communication w/ family

loss of interest in previous hobbies, sports & so on

change in friends; will not introduce new friends

decline in academic performance, drop in grades

loss of motivation & interest in school activities

change in peer group

disappearance of money or items of value

use of eye drops & mouthwash

unfamiliar containers or locked boxes

money missing from the house

preventionensure positive role modeling by parents & adults

reinforce the dangers of SU & teach positive behaviors

reinforce positive coping

establish limits & structure

anticipate pressures

provide life skills training

monitor media use

1.7 dual dxConcurrent mental illness & drug abuse or dependence. Occur at the same time, or one follows the other, eventually it becomes difficult to know which came first.

Antisocial personality disorder, bipolar, & schizophrenia highest w/ substance abuse.

Depression + bipolar disorder also have increased rates of substance abuse

HIV, HBV, HCV, TB sharing/reusing needles, syringes exposes risk.

1.8 alcohol use on American populationmost widely used & abused substance

effects on the neurologic systemassess alcohol use in all cases of rapidly developing confusion.

Liver damage fatty liver

GI ulcers & inflammation

cardio high bp, LDL, triglycerides myocardial infarction & thrombosis wasting of heart muscle

immune system lowers white blood cells prone to infection

sleep fall asleep more quickly but depressed levels of REM & less stage 4 sleep glutamate increases causing inability to sleep hangover symptoms

hormonal changes menstrual irregularity, decreased sperm production & motility, decreased ejaculate volume, testosterone production & impotence.

Accidents DUI

1.9 intoxication, overdose , & withdrawal from:CNS depressants: Alcohol, prescription opiates, anxiolytic drugsAlcohol: significant psychologic/maladaptive changes that occur during or shortly after the ingestion of alcohol.Slurred speech, lack of coordination, unsteady gait, nystagmus, the breath smell of alcohol, impaired attention & memory, coma or stupor.

Withdrawal symptoms: irritability, anxiety, agitation, insomnia, tremors, diaphoresis, delirium alcohol DTs, seizures, possible death, begins 12-24 hrs after last ingestion

Prescription opiates: pain relievers, tranquilizers, stimulants, & sedativescognitive impairment + physical instability

Anxiolyticdrowsy, calming, & sedating effects to help w/ sleep disorders & symptoms of anxiety (common in all CNS depressants)

lethal in overdose situations

when used as drug abuse, people often take them to reduce subjective unpleasant anxiety or to manage withdrawal symptoms from other drugs (alcohol, cannabis, heroin, methadone, cocaine, amphetamines)

GHB illegal CNS depressant that relaxes/sedates the user often used in combination w/ alcohol involved in date rapes, poisonings, overdoses, deaths.

Overdose in GHB Nausea, vomiting, headache, loss of consciousness & reflexes

overdose in benzodiazepines chlordiazepoxide (librium), diazepam (valium), lorazepam (Ativan), clonazepam (klonopin), Alprazolam (xanax) disturb sleep patterns & cause changes in affect withdrawal is lengthy, rapid discontinuation after habitual use of large amounts often causes seizures.

Live support measures: Naloxone (Narcan), lavage or dialysis, control of withdrawal seizures phenobarbital tapering

Symptoms of CNS depressants withdrawal:begins 12-16hrs after last dose

cravings

Abdominal cramps

diarrhea

Nausea & vomiting

bone & muscle pain

muscle spasm

tremor, chills, diaphoresis

treatment of CNS withdrawal: opioid substitutionmethadone (dolophine) opioid agonist

buprenorphine (subutex) opioid agonist

naltrexone (re-via) blocks opioid receptors (antagonist) used for alcohol & opiate maintenancedecreases the craving & blocks the high or the effects of heroin & other opioids during rehabilitation or overdose

**P/t's need to be wear alert bracelet **

revia is the oral form

vivitrol depot is the injection (last 1 month)

naltrexone implant is good for 2 months

suboxone (buprenorphine) in combination w/ naltrexone used for maintenance

treatment of alcohol acute intoxication or overdose ABCs

Thiamine/high protein diet

nutrional support IV glucose

Clonidine (catapress) for tx of withdrawal symptoms

benzodiazepines such as ativan or librium (detox) (cross-tolerance)

Stimulants: cocaine, crack coaine, nicotine, caffeine, ephedrine, propanolamine, amphetamines, amphetamine-like substances. Substances similar in action but diff. Chemical structure (diet pills).Popular drugs of abuse b/c of their effects on brain

people get addicted to the sense of high energy, alertness, & well-being produced by them

effect the CNS mechanism HR & RESP.

raise bp & temp.

aggressive or violent behavior occurs w/ high dose use anxiety, paranoia, & psychotic episodes occur w/ the abuse of & dependence on stimulants

cocaine most potent inhibits the uptake of dopamine in the brain & increases the dopamine receptors in the brain reward system rapid dependency as it magnifies the pleasure sites of the brain increases norepinephrine which causes vasoconstriction & cardiovascular stimulation.

Intoxication: Euphoria, feelings of impending doom, agitation/combativeness, hallucinations paranoia confusion, seizures

withdrawal: headache, anxiety, restlessness, dreaming, cravings, depression (in cocaine high risk suicide), decreased Bp, psychomotor retardation

nicotine has same intoxication, tolerance, withdrawal symptoms as other CNS stimulants

Steroids: anabolic androgenic steroid (r/t to male sex hormones)anabolic (muscle building) androgenic (increased masculine characteristics)

higher risk for heart attacks, strokes, liver problems

physical changes: breast development, genital shrinking in men, increased risk for prostate cancer, infertility, reduced sperm count. Women masculinzation of their bodies growth of facial hair, male pattern baldness, changes in menstrual cycle, enlargement of the clitoris, deepened voice.

Drug abuse Extreme mood swings occur, violent behaviors, depression, paranoid jealousy, delusions, & impaired judgment

Hallucinogensalter perception, cognition & mood.

LSD famous derivative of peyote or mescaline (flashbacks)

clinical symptoms: delirium, psychosis, confusion, paranoia, hallucinations, & violent outbursts. Act as stimulants.

Emergencies hypertension, hyperexcitability, & hyperthermia

long-term use does not result in withdrawal symptoms

little tolerance or dependency

risk for suicide, may trigger psychiatric disorders

Cannabisranks 4th as most commonly used drug after caffeine, nicotine, & alcohol

active ingredient is THC (creates most of the effects that lead to continued use)

euphoria, grandiosity, distorted sensory perception, lethargy, distortions of time

dilated pupils, high HR, cravings, dry mouth & eyes, impaired ovulation & sperm count

long-term users performed poorly on memory, attention, & info testing

medical use: control nausea & vomiting from chemotherapy; stimulate appetite in c/ts w/ aids

Inhalantscheap/ readily accessible in home

solvents (paint thinners, gasoline, glue)

gases (spray paints, hair, deodorant sprays)

Nitrites

slight stimulation, decreased inhibition, loss of consciousness sniffing high amounts causes heart failure, suffocation, death

irreversible effects hearing loss, peripheral neuropathies/limb spasms, CNS damage, bone marrow damage.

Reversible effects liver, kidney impairment, blood oxygen depletion

OTC

Club drugs/designer drugsMDMA, GHB, Rohypnol, Ketamine, methamphetamine, LSD

potential lethal effects or produce long lasting or permanent brain or other physical damage.

Uncertainties about drug sources, chemicals used, possible contaminants make it difficult if not impossible to determine the symptoms, toxicity, & consequences of the use of these club drugs.

1.10 assessmentawareness of what the p/t does not say as well as what the p/t says

nurse makes decisions about when to ask, what questions to ask, when to seek more info from those who know p/t.

Under-estimate vs over-estimate

age of first use

patterns of use

binges, blackouts, DTs, seizures

treatment successes or failures

MSE

DAST 28 self-reported items

CAGE 2 out of 4 positive responses potential problem w/ alcoholismhave you ever felt that you out to Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or t o get rid of a hangover (an Eye-opener)?

Blood tests useful for determining light or heavy alcohol or drug use quantitative measures. Elevated liver enzymes & macrocytic anemia, carbohydrate-deficient transferrin (CDT). Urine drug screens within a specified time frame qualitative.

1.11 plan of care nursing dx, goals & outcome, interventionsnursing dx address orientation, level of anxiety, limitations in function (mental or physical) as a result of substance use, social limitations, & dx r/t to altered family relationships.

The at risk for nursing dx relate to withdrawal, trauma, & relapse.

Be aware of difficulties w/ the 4 Ls love, livelihood, liver (health), & legal (problems)

outcome & goalsdirect outcomes toward short or long-term changes in behaviors & lifestyles.

Maintain: safety & health, sobriety, his/her vital signs within normal range, normal fluid hydration.

Interventionsnurse focuses on treating & supporting the p/t through the drug withdrawal process detoxification. Focus on education during stages of recovery.

FYI : cross-tolerance used to prevent withdrawal effects of drugs or alcohol. Ex. Ativan has a cross-tolerance w/ alcohol b/c both affect the GABA receptors in the brain. It is used & gradually decreased to manage withdrawal symptoms.

1.12 pharmacological agents used for withdrawal, detox, & maintenancebenzodiazepines used for alcohol withdrawal, detox & maintenance: oxazepam (Serax), Lorazepam (ativan) for p/ts w/ severe liver failure

chlordizepoxide (Librium) long-acting for severe withdrawal symptoms

Acamprosate (campral) treats cravings that occur during early sobriety

Naltrexone (ReVia) used in conjunction w/ antidepressants it is an opioid antagonist

disulfiram (Antabuse) deterrent to alcohol use & abuse

thiamine (vitamin B1) for p/t's w/ severe alcohol withdrawal symptoms b/c of inadequate dietary intake & malabsorption

OpioidsMethadone morphine & heroin addicts long acting used to treat withdrawal symptoms

L- -acetylmethadol (LAAM) longer acting opioid withdrawal

all these are used to suppress withdrawal symptoms.

Naltrexone opioid antagonist blocks opioids from reaching receptors in the brain.

Buprenorphine/naloxone (suboxone) naloxone (opioid antagonist) helps prevent abuse. Buprenorphine helps w/ withdrawal symptoms & cravings

Buprenorphine (subutex) partial opioid agonist

Nicotinevarenicline (Chantix), bupropion (Zyban or Wellbutrin) reduce cravings

1.13 other treatment modalitiespsychotherapy active involvement in a recovery program in addition to participating in individual or group therapies.

Addresses p/t's addiction as well as any comorbid disorders or life threatining behaviors.

Relapse prevention help p/ts avoud or take control of situations in which relapse is possible.

Practices what to do if relapse occurs & develops a comphrenisive plan to follow.

Harm reductiontechniques that help a person to change patterns of use to decrease the risk of harm & to adapt to a healthier life-style.

Opiate replacements, needle-exchange programs

residential, half way houseprovide living situations for c/ts who will need to totally reshape their lives, friends, social network, reconnect w/ family & friends.

Outpatient careteach the p/t to change & adjust to life w/o drugs while living in a real-life situation.

Community & faith based organizationsafter-school programs, mentoring activities, sports

spirituality important to recovery for many individuals

Personality disorders 3.3 EOs1.1 define key terms1.2 distinguish what makes personality traits adaptive or maladaptivePersonality traits- behaviors & patterns of perceiving, relating to others, & thinking about the environment & oneself that are exhibited in a wide range of social & personal contexts.

Adaptive or maladaptive depending on whether the trait is inflexible or cause significant functional impairment or subjective distress.

When a person demonstrates inflexible & maladaptive methods of problem solving & relating to others that cause difficulty w/ functioning, this individual can be described as having a personality disorder.

Long story short: if your behaviors & patterns cause problems to your ability to function then that is considered maladaptive. If they do not not cause problems to your ability to function then they are considered adaptive.

1.3 Examine the DSMIV-TR criteria for the dx of a personality disordersan enduring pattern of inner experience & behavior that deviates markedly from the expectations of the individuals culture. This pattern is manifested in 2 (or more) of the following areas:cognition (i.e., ways of perceiving & interpreting self, other people, & events)

affectivity (i.e., the range, intensity, lability & appropriateness of emotional response)

interpersonal functioning

impulse control

The enduring pattern is inflexible & pervasive across a broad range of personal & social situations.

The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The pattern is stable & of long duration, & its onset can be traced back at least to adolescence or early adulthood.

The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

The enduring pattern is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

1.4 discuss theoretical perspectives of the development of personality disordersPsychoanalytic Mr. Freudoral stage: met is to try to relate to others w/o excessive dependency or jealously. You build trust, self-reliance. Not met leads one to have lack of trust, become self-centered, dependent, & jealous. Paranoid, borderline or a histrionic PD.

Anal stage: met Manage uncertainty by making decisions w/o shame or self-doubt. Sense of self-autonomy & independence. Not met unable to make decisions, withholds friendships or cannot share w/ others, is full of rage, stubborn, may have sadomasochistic tendencies (desire to hurt others or be hurt by others). Antisocial, borderline, histrionic, dependent PD.

Phallic stage: met to master ones internal processes & impulses & gain beginning sense of relating to other people. Not met issues managing internal impulses, relating to others, & sexual identity. Antisocial, borderline, histrionic, Narcissistic PD. (risk for psychotic disorders).

Latency stage: met inner control over instinctive drives & emotions, learning & industry, exploration of the environment & play. Not met lack inner control, difficulty relating to others, interactions & problem-solving abilities disturbed. OCD, borderline PD.

Genital stage: met work & learn, establish goals & values within the context of ones own unique personal identities. Not met compromised sense of self & ones ability to relate to others. Unable to attain identified goals or to form values. Difficulty identifying ones strengths & weaknesses, likes & dislikes, other skills. All PDs.

Object relations theory: studied ability of individuals to relate to each other

observed development of personality structure & relatedness.

Mahler theorized about the relationship of the separation-individuation phase, of development to PDs ( b/t 3-25 months)

Separation- child's developing self, distinct, & separate from the mother.

Individuation- infants attempts to form a distinct identity.

4 stages of separation-individuation: differentiation (3-8 mo.)- differentiates own image from significant nurturer.

Practicing (8-15 mo.)- explores world on his/her own (walking)

rapprochement (15-22 mo.)- conflict b/t dependence & independence (terrible twos)

object constancy (25 mo.)- ability to maintain a relationship regardless of frustration & changes in the relationship (can comfort self even w/o mother present-use of representation-blanket).

Kernbergtasks for ego development- distinguish b/t self & others. Integration of good & bad (self images, objects- other person 's image)

Splitting: inability to synthesize + & - aspects of self & others.

Idealization: idealizes person when needs are met.

Devaluation: devalues person when needs are unmet.

Lack of object constancy: inability to maintain the object (memory of good/bad characteristics) in one's memory- leads to feelings of abandonment.

Projective identification-primitive type of projection person projects an impulse on to another person (e.g., anger projected on to mother)

person continues to experience the impulse that they have projected to another (e.g, anger)

person fears the other person b/c they believe they have an impulse (e.g., anger)

person needs to control the other person

Borderline PD exhibit these issues.

1.5 biological factors r/t to the etiology of personality disordersgenetic twin studies- strong biological relationship b/t genetics & personality organization.

Focus on biological similarities b/t schizotypal PD & people w/ schizophrenia (similar symptoms/not as severe)inability to correctly interpret environmental information- eye tracking behavior & backward masking-suggests neurointegrative functioning deficits in the frontal lobes-associated w/ deficit traits of schizophrenia-social integrative functioning, isolation, detachment & inability to r/t to others.

Some biomarkers of neurochemical measures are evident w/ schizotypal borderline & antisocial PD

1.6 identify characteristics of p/ts in each of the 3 personality clusters A, B, C & unspecified personality disorders & 1.7

Cluster AParanoid, schizoid & Schizotypal make up the odd or eccentric cluster. These diagnosis are more likely to co-occur in an individual w/ a psychotic disorder.

Clinical symptoms:interpret all experiences from the perspective that they have done damage by others.

Avoid relationships

reluctant to share info, guarded, suspicious, odd, detached

hypervigilant

Paranoid PDdistrustful & suspicious

difficulty adjusting to change

overly sensitive & argumentative

feelings of irreversible injury by others often w/ evidence

anxiety w/ difficulty relaxing

short temper

difficulty w/ problem-solving

unwilling to forgive even minor events

jealousy of significant other, often w/ evidence

Epidemiology: males more often than females; family members diagnosed w/ paranoid PD are at increased risk; SUD common.

Schizoid PDbrief psychotic episodes in response to stress

lack of desire to socialize, enjoys solitude

lack of strong emotions

detached & self-absorbed affect

lack of trust in others

difficulty expressing anger

passive reactions to crisis

Epidemiology: males slightly more than females; increased prevalence w/ family members who have schizophrenia or shizotypal PD.

Schizotypal PDincorrect interpretation of external events/believes all things refer to self

superstitious w/ preoccupation w/ paranormal phenomena

belief in possession of magical control over others

constricted or inappropriate affect

anxiety in social situations

Epidemiology: generally seek treatment for anxiety or depression-not generally for PD;1st degree relatives of persons w/ schizophrenia at increased risk; males slightly more than females.

Cluster BAntisocial, borderline, Histrionic, & narcissistic PD constitute the dramatic & emotional cluster. Great deal of co-morbidity w/ axis 1 disorders: substance abuse, mood & anxiety disorders.

Clinical symptomsthese disorders share dramatic, erratic, or flamboyant behavior

they share a high degree of overlap of symptoms

Co-morbidiysubstance abuse, mood disorders, depression, eating disorders, & anxiety disorders.

Antisocial PDirresponsible

failure to honor financial obligations, plan ahead or provide children w/ basic needs.

Involvement in illegal activities

lack of guilt

difficulty learning from mistakes

initial charm dissolves in coldness, manipulation, & blaming others

lack of empathy

irritability

abuse of substance

Epidemiology: APD usually diagnosed before 18 yrs, Hx, conduct disorder before 15 years; males (characteristics in early childhood) more than females (characteristics evident by puberty); Many in SUD programs or prison; incidence higher among lower socioeconomic populations; impulsive behavior common; approx. 1% of U.S population 18 yrs or older.

Borderline PDrecurrent suicidal &/or self-mutilating behaviors

poor impulse control & engage in impulsive acts (gambling, binging, spending money, reckless driving, unsafe sex).

Negative or angry affect

feeling emptiness or boredom

difficulty being alone or feelings of abandonment

difficulty identifying self

perception of people all good or bad

intense & stormy relationship

Epidemiology: condition diagnosed in 1.6% of population 18+ yrs; often hx of physical or sexual abuse, neglect, hostile or conflictual experiences, & early parental loss or separation; more females than males.

Histrionic PDuse of suicidal gestures & threats when feeling abandoned

fluctuation in emotion

attention-seeking & self-centered attitude

sexual seduction & flamboyance

attentiveness to own physiologic appearance

dramatic & impressionistic speech style

vague logic; a lack of conviction in arguments, often switching sides

shallow emotional expression

craving for immediate satisfaction

complaints of physical illness; somatization

Epidemiology: females more than males

Narcissistic PDgrandiose view of self

lack of empathy towards others

need for admiration

preoccupation w/ fantasies of success, brilliance, beauty & ideal love

Epidemiology: males more often than females

Cluster CAvoidant, dependent, & Obessive-Compulsive PD compose the anxious & fearful cluster. These dx are often associated w/ anxiety disorders.

Clinical symptoms:experiences high levels of anxiety & outward signs of fear

exhibits social inhibitions like shyness & awkwardness esp. w/ opposite sex

usually afraid to express irritation or anger even when its justified

tend to internalize blame for frustrations in their lives

Avoidant PDfearful of criticism, disapproval, or rejection

avoidance of social interactions

tendency to withhold thoughts or feelings

negative sense of self-esteem & low self-esteem

Epidemiology: 5.2% of population 18+ yrs in US; males 2x as often as females.

Dependent PDsubmissiveness & tendency to cling

inability to make decisions independently

inability to express negative emotions

difficulty following through on tasks

Epidemiology: more females than males; symptoms are demonstrated early in life; children or adolescents w/ chronic physical illness or separation anxiety disorder may be predisposed to this condition.

Obsessive-compulsive PDpreoccupation w/ perfection, organization, structure & control

procrastination

abandonment of projects due to dissatisfaction

excessive devotion to work

difficulty relaxing

rule-conscious behavior

self-critisim & ability to forgive own errors

reluctant to delegate

inability to discard anything

insistence on others conforming to own methods

rejection of praise

reflectance to spend money

background of stiff & formal relationships

preoccupation w/ logic & intellect.

Epidemiology: males 2x females

unspecified PDindividuals whose personality patterns meets the general criteria for a PD but not the criteria for any specific PD.

Also for individuals whose personality pattern meets the general criteria for a PD; however, the person has a PD that is not in the current classification, such as passive-aggressive PD.

1.8 examine the prognosis & expectations for improvement for persons w/ dx of a PDprognosis is guarded as a result of ingrained & prevasive nature of these disorders

relaistic outcomes person will commit to explore & evaluate their thoughts & behaviors, esp. when under stress.

1.9 Discuss the assessment of a p/t w/ a personality disorderplace needs to be comfortable, quiet, private, & safe.

No interruptions during the assessment

do not be judgmental or confrontational during the interview.

There is a physical, emotional, cognitive, social & spirtual domain to the assessment

Look at nursing assessment box on page 307

1.10 nursing dxCluster A (schizoid, schizotypal, paranoid)anxiety social isolation ineffective coping disturbed thought processes

Cluster B (borderline, histrionic, narcissistic) risk for suicide risk for self-mutilation risk for self & other directed violence ineffective coping chronic low self-esteem impaired social interactions disturbed personal identity complicated grieving

Cluster C (Avoidant, dependent, obsessive compulsive PD) anxiety ineffective coping chronic low self-esteem impaired social interaction

1.11 measurable outcomesdemonstrate absence of active suicide ideation

stop having thoughts of harming others

refrain from self-mutilation

1.12 nursing interventionsHistrionic PDrealize seduction is a response to stress

keep interactions & communications professional

never respond to p/t in a flirtatious or misleading manner

teach assertive behaviors in lieu of seductive ones

Narcissistic PDalways remain neutral despite behaviors

avoid power struggles over control

avoid becoming defensive

show unassuming self confidence when providing care

Obsessive Compulsive PDdo not engage in power struggles, the person's need for control is very high

treatment is geared towards psychotherapy. Supportive or insight orientated therapy, cognitive-behavioral therapy & group therapy.

1.13 specific modes for treatmentDialectic Behavioral therapy (DBT)useful for people w/ borderline PD, eating disorders, & chronically depressed older adults

helps the individual build skills that involve mindfulness, mediation, to reduce emotional dysregulation, & to increase validating & dialectic strategies (balance change w/ acceptance).

DBT is combined w/ individual & group therapy & telephone support

Goal of treatment increase tolerance, regulate their emotions, & learn to adopt more effective behavioral responses

first therapy that has been experimentally demonstrated to be generally effective in treating borderline PD.

Uses journaling to recognize emotions; dialogue to rework destructive ways to deal w/ crisis; teaches there are choices to decrease suicidal thoughts & emotionally reactive patterns; clients learn new patterns of thinking & behaving.

Milieu therapya planned treatment environment in which everyday events & interactions are therapeutically designed for the purpose of enhancing social skills & building confidence.

Valuable in treating PD & behavioral problems

encourages person to take responsibility for themselves

allows interactions w/ other c/ts & problem solving

1.14 dischargeinpatient dependent on safety & risk factors (e.g., suicidal thinking/behaviors)

P/t's w/ PD often have multiple dx & complex issues follow-up w/ outpatient care & medication (when appropriate) is important