Behavioral Health Lecture 5- Personality Disorders and Substance Abuse .

Milieu or Group Therapy-

-Appropriate for clients with antisocial personality disorder who respond more adaptively to support and feedback from peers. -Group feedback is more effective than 1:1 with a therapist. -May be helpful in overcoming social anxiety and developing interpersonal trust and rapport in Avoidant personality disorder.

Cognitive/Behavioral Therapy-

-Behavioral strategies offer reinforcement for positive change. -Social skills training and assertiveness training teach alternative ways to deal with frustration. -Cognitive strategies help the client recognize and correct inaccurate internal mental schemata. -Useful for Obsessive-Compulsive, Antisocial, and Avoidant personality disorders.

Drug history and assessment:

-Growing up, did anyone in your family drink alcohol or take other kinds of drugs? • If so, how did the substance use affect the family situation? -When did you have your first drink/drugs? -How long have you been drinking/taking drugs on a regular basis? -What is your pattern of substance use? • When do you use substances? • What do you use? • How much do you use? • Where are you and with whom when you use substances? -When did you have your last drink/drug? What was it and how much did you consume? -Does using the substance(s) cause problems for you? Describe. Include family, friends, job, school, other. -Have you ever experienced injury as a result of substance use? -Have you ever been arrested or incarcerated for drinking/using drugs? -Have you ever tried to stop drinking/using drugs? If so, what was the result? Did you experience any physical symptoms, such as tremors, headache, insomnia, sweating, or seizures? -Have you ever experienced loss of memory for times when you have been drinking/using drugs? -Describe a typical day in your life. -Are there any changes you would like to make in your life? If so, what? -What plans, or ideas do you have for seeing that these changes occur?

Nursing Interventions:

-Maintain a patent airway and monitor VS and intervene in hemorrhage/cardiac arrest/ seizures; maintain safety. -Observe for additional S/S of substance overdose, withdrawal, drug-drug interactions. -Assess physiologic and psychologic symptoms of withdrawal and the effects of the medications prescribed during the withdrawal process. -Initiate therapeutic interventions to treat withdrawal symptoms. -Provide emotional support, and support for nutritional and metabolic needs. -Establish a trusting, caring and empathetic yet firm therapeutic relationship. -Encourage support from others and building relationships. -Encourage Pt in maintaining active involvement with 12-step or alternative support groups. -Introduce Pt to community organizations.

Interpersonal Psychotherapy-

-May be appropriate because personality disorders reflect problems in interpersonal style. -Attempts to understand and modify the maladjusted behaviors, cognition, and effect of personality disorders. -Establishment of an empathic relationship based on collaboration in which the therapist functions as a role model. -Suggested for Paranoid, Schizoid, Schizotypal, Borderline, Dependent, Narcissistic, and Obsessive-Compulsive personality disorders.

The CAGE Questionnaire:

-Primarily used for brief screening for alcohol abuse but has been adapted to include drugs.

Psychopharmacology-

-SSRIs- Borderline personality disorder. -MAOIs. -Lithium- Antisocial personality disorder. -Propranolol (Inderal). -Anxiolytics- Avoidant personality disorder.

Michigan Alcoholism Screening Test (MAST):

-The oldest and most accurate alcohol screening tests available, effective in identifying dependent drinkers with up to 98 percent accuracy. -Questions relate to self-appraisal of social, vocational, and family problems frequently associated with heavy drinking.

Dialectical Behavior therapy (DBT)-

-Treatment for chronic self-injurious and parasuicidal behavior in Pts with Borderline personality disorder. • Group Skills- Learns skills such as mindfulness, interpersonal skills, emotion modulation skills, distress tolerance skills. • Individual Psychotherapy- Weekly sessions with therapist addressing behavior/motivation. • Telephone Sessions- Pt is able to call therapist 24hours/ day (with limits) to avoid self-injury and to help adjust between 1:1 therapy sessions. • Team Meetings-Therapists need to stay motivated, provide support for each other.

Psychoanalytical Psychotherapy-

-Treatment of choice for clients with Histrionic personality disorder. -Focuses on the unconscious motivation for seeking total satisfaction from others and for being unable to commit oneself to a stable, meaningful relationship.

The Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar):

-Used by many hospitals to assess risk and severity of withdrawal from alcohol. -It may be used for initial assessment as well as ongoing monitoring of alcohol withdrawal symptoms.

Define Alcohol Withdrawal Syndrome (AWS)

AWS is a set of symptoms that can occur when an individual reduces or stops alcoholic consumption after long periods of use. o Prolonged and excessive use of alcohol leads to tolerance and physical dependence. o The withdrawal syndrome is largely a hyper-excitable response of the CNS to lack of alcohol. o Symptoms typical of withdrawal include: Agitation; Seizures; and Delirium tremens. o This dependence is due to alcohol-induced neuro-adaptation. o Withdrawal is characterized by neuropsychiatric excitability and autonomic disturbances. o Dependence on other sedative-hypnotics can increase the severity of the withdrawal syndrome.

Identify S/S of Overdose or Withdrawal of specific substances:

Alcohol- Withdrawal: -Tremors; Nausea and Vomiting; Malaise; Weakness; Sweating; Tachycardia; Elevated BP; Anxiety; Depressed mood; Irritability; Transient hallucinations or illusions; Headache; Insomnia; Seizures. Overdose: -Nausea and Vomiting; Shallow respirations; Cold clammy skin; Weak rapid pulse; Coma; Death. Barbiturates and Non-Barbiturates- Overdose: -Anxiety; Fever; Agitation; Hallucinations; Disorientation; Tremors; Delirium; Convulsions; Possible death. Amphetamines and Related Substances- Withdrawal: -Anxiety; Depressed mood; Irritability; Craving for substance; Nightmares; Insomnia or Hypersomnia; Psychotic symptoms; Increased appetite; Sweating; Fatigue; Psychomotor agitation; Muscle cramping; Paranoid and Suicidal ideation. Overdose: -Cardiac arrhythmias; Headache; Convulsions; HTN; Rapid HR; Coma; Possible death. Caffeine- Withdrawal: -Headache. Cannabis- Withdrawal: -Restlessness; Irritability; Anger; Aggression; Nervousness or Anxiety; Abdominal pain; Sweating; Tremors; Fever; Chills; Headache; Insomnia; Loss of appetite. Overdose: -Fatigue; Paranoia; Delusions; Hallucinations; Possible psychosis. Cocaine- Withdrawal: -Depression; Anxiety; Irritability; Fatigue; Insomnia or Hypersomnia; Psychomotor agitation; Paranoid or Suicidal ideation; Apathy; Social Withdrawal. Overdose: -Hallucinations; Convulsions; Pulmonary edema; Coma; Cardiac arrest; Respiratory failure; Possible Death. Synthetic Stimulants- Overdose: -Depression; Paranoia; Delusions; Suicidal thoughts; Seizures; Panic attack; Nausea and Vomiting; Heart attack; Stroke; Hallucinations; Aggressive behavior. Nicotine- Withdrawal: -Craving for the drug; Irritability; Anger; Frustration; Anxiety; Difficulty concentrating; Restlessness; Decreased HR; Increased appetite; Weight gain; Tremor; Headache; Insomnia. Opioids- Withdrawal: -Craving for the drug; Nausea and Vomiting; Muscle aches; Lacrimation or Rhinorrhea; Pupil dilation; Piloerection or Sweating; Diarrhea; Yawning; Fever; Insomnia. Overdose: -Shallow breathing; Slowed pulse; Clammy skin; Pulmonary edema; Respiratory arrest; Convulsions; Coma; Possible death. Phencyclidine and Related Substances- Sedatives, Hypnotics, and Anxiolytics- Withdrawal: -Nausea and Vomiting; Malaise; Weakness; Tachycardia; Sweating; Anxiety; Irritability; Orthostatic hypotension; Tremor; Insomnia Seizures; Transient hallucinations. Hallucinogens- Withdrawal: -Craving for the drug; Fatigue; Irritability; Reduced ability to experience pleasure. Overdose: -Agitation; Extreme hyperactivity; Violence; Hallucinations; Psychosis; Convulsions; Possible death.

Delineate between the three clusters of Personality Disorders as defined by the DSM-V-

All personality disorders are experienced in an ego-syntonic way. Cluster A- Behaviors are odd and eccentric. -Paranoid Personality Disorder. -Schizoid Personality Disorder. -Schizotypal Personality Disorder. Cluster B- (most common) Behaviors are dramatic, emotional, or erratic. -Antisocial Personality Disorder. -Borderline Personality Disorder. -Histrionic Personality Disorder. -Narcissistic Personality Disorder. Cluster C- Behaviors are anxious or fearful. -Avoidant Personality Disorder. -Dependent Personality Disorder. -Obsessive-Compulsive Personality Disorder.

CNS Stimulants:

Amphetamines: -Meth, Speed, or Crank (Methamphetamine); Ecstasy (MDMA); Speed or Uppers (Adderall). Synthetic Stimulants: -Bath salts (Methylone); Flakka (Alpha-PVP). Non-amphetamine Stimulants: -Diet Pills (Benzenediamine); Speed or Uppers (Ritalin). Cocaine: -Coke, Blow, or Crack (Cocaine hydrochloride). Caffeine: -Coffee; Tea; Cola; Chocolate. Nicotine: -Cigarettes; Cigars; Pipes; Snuff.

Define Personality Trait-

Behaviors and those patterns of perceiving, relating to others and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. They way relate to the world around us.

Cannabinols:

Cannabis: -Weed, Pot, Maryjane (Marijuana); Hash (Hashish).

Cannabis effects (physiological and psychological)-

Cardiovascular Effects- Ingestion induces tachycardia and orthostatic hypotension. • With the decrease in blood pressure, myocardial oxygen supply is decreased. • Tachycardia in turn increases oxygen demand. Reproductive Effects- Some studies have shown that, with heavy marijuana use, men may have a decrease in sperm count, motility, and structure. • In women, heavy marijuana use may result in a suppression of ovulation, disruption in menstrual cycles, and alteration of hormone levels. CNS Effects- Acute CNS effects of marijuana are dose related. • Many people report a feeling of being "high"—the equivalent of being "drunk" on alcohol. • Symptoms include feelings of euphoria, relaxed inhibitions, disorientation, depersonalization, and relaxation. • At higher doses, sensory alterations may occur, including impairment in judgment of time and distance, recent memory, and learning ability. • Physiological symptoms may include tremors, muscle rigidity, and conjunctival redness. • Toxic effects are generally characterized by panic reactions. Sexual Functioning- Marijuana is reported to enhance the sexual experience in both men and women. • The intensified sensory awareness and the subjective slowness of time perception are thought to increase sexual satisfaction. • Marijuana also enhances the sexual functioning by releasing inhibitions for certain activities that would normally be restrained.

Dependent Personality Disorder-

Characterized by a lack of self-confidence and extreme reliance on others to take responsibility for them. -Allows others to make decisions; Feels helps when alone. -Submissive and subordinate to others; Tolerates mistreatment by others. -Demeans one-self to gain acceptance. -Overly generous, thoughtful and underplay their own attractiveness and achievements. -Pessimistic; Discouraged; Dejected; Suffer in silence.

Borderline Personality Disorder-

Characterized by a pattern of intense and chaotic relationships, with affective instability and fluctuation attitudes towards others. -Impulsive; Directly or indirectly self-destructive and lack a clear sense of identity.

Schizoid Personality Disorder-

Characterized by a profound deficit in the ability to form meaningful relationships or respond to others in an emotionally meaningful way; Poor social skills; Often seen as eccentric, isolated, or lonely. -Appear cold, or aloof; Little emotion is shown. -Detachment and restriction of affect; No desire for friends. -Prefer solidarity and prefer animals to humans. -Can appear to be shy, anxious, or uneasy. -Inappropriately serious and have difficulty with lightheartedness. -No spontaneity in conversation or behavior. -Commonly unable to exhibit pleasure; Affect is bland and constricted. -May use intellectualization as a defense mechanism. • Childhood described as cold and lacking in nurturance and empathy.

Histrionic Personality Disorder-

Characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people. -Have difficulty maintaining long-lasting relationships. -Require constant affirmation and approval from others; Use seductive, flirtatious behaviors to reassure themselves of their attractiveness and to gain approval. -Self-dramatizing; Attention seeking; Overly gregarious; Seductive. -Use manipulative and exhibitionistic behaviors to be center of attention. -Failure to evoke attention and approval leads to feelings of dejection and anxiety. -Highly distractible and flighty; Highly suggestable, impressionable, and easily influenced by others. -Strongly dependent; Interpersonal relationships are fleeting and superficial.

Discuss the physiological effects of long term Alcohol use

Chronic alcohol abuse can result in multisystem impairments including, but not limited to: o Peripheral Neuropathy- Characterized by peripheral nerve damage, results in pain, burning, tingling, or prickly sensations of the extremities. Believed to be the direct result of deficiencies in the B vitamins, particularly thiamine. The process is reversible with abstinence from alcohol and restoration of nutrition. Otherwise permanent muscle wasting, and paralysis can occur. o Alcoholic Myopathy- Acute- the individual experiences a sudden onset of muscle pain, swelling, and weakness; a reddish tinge in the urine caused by myoglobin, a breakdown product of muscle excreted in the urine; and a rapid rise in muscle enzymes in the blood. Chronic- symptoms include a gradual wasting and weakness in skeletal muscles; the pain and tenderness nor the elevated muscle enzymes seen in acute myopathy are event in the chronic condition. o Wernicke's Encephalopathy- Represents the most serious form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. If thiamine replacement therapy does not undertake quickly, death will ensue. o Korsakoff's Psychosis- Identified by a syndrome of confusion, loss of recent memory, and confabulation in alcoholics. It is frequently encountered in clients recovering from Wernicke's encephalopathy; In the United States, the two disorders are usually considered together and are called Wernicke-Korsakoff syndrome. Treatment is with parenteral or oral thiamine replacement. o Alcoholic Cardiomyopathy- The effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. Clinical findings relate to congestive heart failure or arrhythmia. Symptoms include decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, and nonproductive cough. Labs may show rise in enzymes CPK, AST, ALT, and LDH. Treatment is total permanent abstinence from alcohol. o Esophagitis- Inflammation and pain in the esophagus. Occurs because of the toxic effects of alcohol on the esophageal mucosa. It also occurs because of frequent vomiting associated with alcohol abuse. o Gastritis- Alcohol breaks down the stomach's protective mucosal barrier, allowing hydrochloric acid to erode the stomach wall. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. Damage to blood vessels may result in hemorrhage. o Pancreatitis- May be categorized as acute or chronic. Acute- usually occurs 1 or 2 days after a binge of excessive alcohol consumption. • Symptoms include constant, severe epigastric pain, nausea and vomiting, and abdominal distention. Chronic- leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus. o Alcoholic Hepatitis- Inflammation of the liver caused by long-term heavy alcohol use. Clinical manifestations include an enlarged and tender liver, nausea and vomiting, lethargy, anorexia, elevated white blood cell count, fever, and jaundice. o Cirrhosis of the Liver- It is the end-stage of alcoholic liver disease and results from long-term chronic alcohol abuse. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. Clinical manifestations include nausea and vomiting, anorexia, weight loss, abdominal pain, jaundice, edema, anemia, and blood coagulation abnormalities. Complications of cirrhosis include: Portal hypertension, Ascites, Esophageal Varices, and Hepatic Encephalopathy. o Leukopenia- The production, function, and movement of the white blood cells are impaired in chronic alcoholics. This condition places the individual at high risk for contracting infectious diseases as well as for complicated recovery. o Thrombocytopenia- Platelet production and survival are impaired as a result of the toxic effects of alcohol. This places the alcoholic at risk for hemorrhage. Abstinence from alcohol rapidly reverses this deficiency. o Sexual Dysfunction- Alcohol interferes with the normal production and maintenance of female and male hormones. For women, this can mean changes in the menstrual cycles and a decreased or loss of ability to become pregnant. For men, the decreased hormone levels result in a diminished libido, decreased sexual performance, and impaired fertility.

Paranoid Personality Disorder-

Defined as a pattern of pervasive mistrust and suspiciousness of others beginning in early childhood; Misinterpretation of motives as malicious. -Trust no one; Constantly on guard, hypervigilant and ready for any real or imagined threat. -Appear tense and irritable; Argumentative, hostile, and stubborn. -Develop a hard exterior and are insensitive to the feelings of others and avoid contact. -Believe others are out to get them; Intolerant of authority figures. -Extremely over-sensitive and misinterpret even the simplest cues within the environment, distorting them into thoughts of trickery or deception. -Do not accept responsibility of their own behaviors and feelings and use projection as a defense mechanism. -Highly jealous of anyone else's' success. • May have been subjected to parental harassment and neglect; May have been a target of parental aggression and gave up on approval or affection. • They learned to perceive the world as unkind and harsh. • Have learned to anticipate humiliation and betrayal, and attack 1st. • More common in men than woman.

Schizotypal Personality Disorder-

Described as latent schizophrenics; Individuals are peculiar in thought, behavior, and appearance. -Aloof and isolated; Behave in a bland and apathetic manner. -Magical thinking, ideas of reference, illusions, and depersonalization are their everyday world. • Superstitiousness; Belief in clairvoyance, telepathy, 6th sense, or that others can "feel my feelings'. • May exhibit psychotic symptoms when stressed, such as delusions, hallucinations, or bizarre behaviors. • Often talk or gesture to themselves.

Discuss treatment approaches that are available for Substance Abuse and Dependency-

Detox- Nurse gives enough of drug to relieve withdrawal symptoms. -The substance is decreased gradually every day. -Ativan manages alcohol withdrawal. Rehab- Vital for treatment. Psychotherapy- -Individual- Here and now; Learn to relate to others and adjust to life. -Group- Pts with similar problems help nurse facilitate participation. -Family- Therapy helps the whole family. -Behavior- Relaxation or biofeedback to teach how to deal with stress. -Aversive Conditioning- For nicotine and alcohol (Antabuse). -Contingency Management- Rewarded for abstinence. - Medication- Acamprosate can calm withdrawal of alcohol, methadone, and heroin; Naloxone blocks the effect of heroin and opiates (carry med-card). Relapse Prevention- Practices what to do if there is a relapse. Harm Production- Help individual change patterns to reduce harm and adapt healthier lifestyle. 12 step programs- AA; NA; Al-Anon (spouse, friends of alcoholic); Al-A teen (10yrs of age and older); Adult Children of Alcoholics. Independent Care- Structured treatment program, 2-4 weeks. Outpatient Care- Teach Pt to change and adjust to life while living in real life situations. Halfway House- Sober living environment; Shelter; Support, group; Direct access to AA meeting. Day/Night hospital- Support for those at risk for chemical use. Community Organizations; Faith & Spiritual Communications- After school; Sports; Education; Spiritual.

What is the nursing role in the spectrum of Substance Abuse and Dependency care-

Detoxification: -Provide a safe and supportive environment for the detox process. -Administer substitution therapy as ordered. Intermediate Care: -Provide explanations of physical symptoms. -Promote understanding and identify the causes of substance addiction. -Provide education and assistance in course of treatment to client and family. Rehabilitation: -Encourage continued participation in long-term treatment. -Promote participation in outpatient support system (AA).

Pharmacological-

Disulfiram (Antabuse)- This is a drug that can be administered as a deterrent to drinking in individuals who abuse alcohol. Ingesting alcohol while taking disulfiram results in a syndrome of symptoms that can produce a great deal of discomfort for the individual. It can even result in death if the blood alcohol level is high. Reactions vary, depending on the sensitivity of the individual and how much alcohol has been ingested. • Disulfiram works by inhibiting the enzyme aldehyde dehydrogenase, thereby blocking the oxidation of alcohol at the stage when acetaldehyde is converted to acetate. • Disulfiram-Alcohol reactions can occur within 5-10min of alcohol ingestion, and mild reactions can occur with a BAC of 5-10mg/dL. • Fully developed symptoms can happen with a BAC of 50mg/dL and include: -Flushed skin; Throbbing in head and neck; Respiratory difficulties; Dizziness; Nausea and Vomiting; Sweating; Hyperventilation; Tachycardia; Hypotension; Weakness; Blurred vision, and Confusion. • Severe reactions occur with a BAC of 125-150mg/dL and include: -Respiratory depression; Cardiovascular collapse; Arrythmias; Myocardial infarction; Acute CHF; Unconsciousness; Convulsions; and Death. • Disulfiram should not be administered unless it is certain that the individual has abstained from ingesting alcohol for at least 12hrs. Naltrexone (ReVia)- A narcotic antagonist , was approved by the FDA in 1994 for the treatment of alcohol addiction (was approved in 1984 for the treatment of heroin abuse). • Works on the same receptors in the brain that produce the feelings of pleasure when heroin or other opiates bind to them, but it does not produce the "narcotic high" and is not habit forming. • Although alcohol does not bind to these same receptors, studies have shown that naltrexone works just as well for this addiction. Nalmefene (Revex)- Works the same as Naltrexone. Selective serotonin reuptake inhibitors (SSRIs)- Decreases cravings of alcohol; • Greater success rates were observed in moderated drinkers opposed to heavy drinkers. Campral (Acamprosate)- Indicated for the maintenance of abstinence from alcohol in patients with alcohol addiction who are abstinent at treatment initiation. • The mechanism of action is not completely understood. • It is hypothesized to restore the normal balance between neuronal excitation and inhibition by interacting with glutamate and gamma-aminobutyric acid (GABA) neurotransmitter systems. • This medication is ineffective in individuals who have not gone through detox and not achieved alcohol abstinence prior to treatment. • Used concomitant with psychosocial therapy.

Avoidant Personality Disorder-

Extremely sensitive to rejection and may lead a very socially withdrawn life. (individual is not antisocial); May have an extreme desire for companionship; Shyness and fear of rejection create the need for strong assurances of unconditional acceptance. -Awkward and uncomfortable in social situations. -May be perceived as timid, withdrawn, or cold and strange. -Have sensitive, touchy, evasive, and mistrustful qualities. -Speech is slow and constrained with frequent hesitations; Fragmented thoughts. -Often lonely and express feelings of being unwanted. -View others as critical, betraying, and humiliating. -Commonly experience depression, anxiety, and anger at self.

Review Personality development theories that may have influence on the etiology of Personality Disorders-

Freud- The personality is composed of three elements; The id; The ego; and The superego. Mahler-

Narcissist Personality Disorder-

Have an exaggerated sense of self-worth; Lack empathy and are hypersensitive to the evaluation of others; Believe they have the right of special considerations. -Lack humility; Overly self-centered; Exploit others to fulfill their own desires. -View themselves as superior and are entitles to special rights and privileges. -Grandiose distortions of reality; Mood is optimistic, relaxed, cheerful, and carefree; Can easily change due to low self-esteem. -May respond to criticism with rage, shame, humiliation, or dejection.

Nursing diagnoses could include:

Ineffective Denial: -Makes statements such as, "I don't have a problem; I can quit any time I want to." Delays seeking assistance; does not perceive problems related to use of substances; minimizes use of substances; unable to admit impact of disease on life pattern. Ineffective Coping: -Abuse of chemical agents; destructive behavior toward others and self; inability to meet basic needs; inability to meet role expectations; risk taking. Imbalanced Nutrition: -Loss of weight, pale conjunctiva, and mucous membranes decreased skin turgor, electrolyte imbalance, anemia, drinks alcohol instead of eating. Risk for Infection: -Risk factors: Malnutrition, altered immune condition, failing to avoid exposure to pathogens. Chronic Low Self-Esteem: -Criticizes self and others, self-destructive behavior (abuse of substances as a coping mechanism), dysfunctional family background. Deficient Knowledge: -Denies that substance is harmful; continues to use substance in light of obvious consequences. Risk for Injury: For the client withdrawing from CNS depressants: -Risk factors: CNS agitation (tremors, elevated blood pressure, nausea and vomiting, hallucinations, illusions, tachycardia, anxiety, seizures) Risk for Suicide: For the client withdrawing from CNS stimulants: -Risk factors: Intense feelings of lassitude and depression; "crashing," suicidal ideation

Hallucinogens:

Natural Hallucinogens: -Peyote (Mescaline); Shrooms (Psilocybin); Salvia (Salvia divinorum). Synthetic Hallucinogens: -Acid (Lysergic acid diethylamide/LSD); Angel dust (Phencyclidine/PCP).

Opioids:

Opioids of Natural Origin: -Opium (in various anti-diarrheal); Codeine (cough suppressants). Opioids Derivatives: -Heroin; Hydromorphone (Dilaudid); Hydrocodone (Vicodin). Synthetic Opioids: -Meperidine (Demerol); Dollies (Methadone); Fentanyl.

Identify biological factors that contribute to Personality Disorder-

Paranoid Personality Disorder- Possible hereditary link; Higher incidence of paranoid personality disorder among relatives of Pts with schizophrenia. Schizoid Personality Disorder- Introversion trait highly inheritable characteristic. Schizotypal Personality Disorder- May be more common amongst those with 1st degree relatives who have schizophrenia; Considered part of the schizophrenic genetic spectrum. Antisocial Personality Disorder- Hereditary (nurture/nature); Arise from chaotic family situations. Borderline Personality Disorder- Mahler says that during the time of separation (16-24mths) the caregiver is insecure and feels threaten by the child's increasing independence and as a result the child develops a fear of abandonment. The caregiver rewards clinging behaviors and ignores independent behaviors; Causing and unresolved fear of abandonment that remains with the child throughout their life. Histrionic Personality Disorder- Possible hereditary, common among 1st degree relatives with the same disorder and biological links; Child learns positive reinforcement only comes when they perform behaviors approved and admired by their parents. Narcissist Personality Disorder- Childhood fears, failure, and dependency needs met with distain, criticism, or neglect; Causing the child to develop contempt for these behaviors within themselves and others; Parents of these children are usually demanding, perfectionistic, and critical, placing unrealistic expectations on the child; Child may have been subjected to physical or emotional abuse, and neglect; Can be environmental, parent trying to live vicariously through child. Dependent Personality Disorder- May be result of parents' extreme affection, attachment, and over protection; Child never learns skills needed for independent behaviors. Avoidant Personality Disorder- Infants who exhibit hyperirritabilities, crankiness, tension, and withdrawal behaviors may have a temperamental disposition. Repeated rejection throughout life. Trauma, neglect, and fear of abandonment. Obsessive- Compulsive Personality Disorder- May have had an overly controlling parent; Praise for positive behaviors is infrequent; But quick to be punished for negative behaviors.

Antisocial Personality Disorder-

Pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others; These individuals manipulate and exploit others for personal gain, and unconcerned with obey the law. -Have difficulty keeping consistent employment and developing stable relationships. -Substance abuse is common comorbid disorder.

Distinguish between a Personality Trait and a Personality Disorder-

Personality Trait- Characteristics with which an individual is born or develops early in life. These influence how the individual perceives and relates to their environment. Personality Disorder- Occur when traits become inflexible and maladaptive, causing either significant functional impairment or subjective distress.

Discuss other treatment modalities used with Personality Disorders:

Personality disorders are especially difficult to treat because "Pts with personality disorders do not recognize their maladaptive personality treats as undesirable or in need of change".

Hallucinogens are highly unpredictable-

Physiological Effects: • Nausea and vomiting; Chills; Pupil dilation; Increased pulse, blood pressure, and temperature; Mild dizziness; Trembling; Loss of appetite; Insomnia; Sweating; A slowing of respirations; Elevation in blood sugar. Psychological Effects: • Heightened response to color, texture, and sounds; Heightened body awareness; Distortion of vision; Sense of slowing of time. • All feelings magnified: Love, Lust, Hate, Joy, Anger, Pain, Terror, Despair. • Fear of losing control; Paranoia, panic; Euphoria, bliss; Projection of self into dreamlike images; Serenity, peace; Increased libido • Depersonalization; Derealization.

Non-Pharmacological-

Psychotherapy‡. Individual therapy. Group therapy. Family therapy. Behavioral therapy. Relapse prevention and Harm reduction- techniques to help an individual to change patterns of use to decrease the risk of harm and to adapt a healthier lifestyle. 12-step support groups (Alcoholics Anonymous), Inpatient care, Outpatient care, Halfway houses- sober living environments that provide shelter as well as support, in the forms of group therapy and direct access to AA meetings, day, or night (partial) hospitalization, community-based organizations and faith and spiritual communities.

Discuss nursing approaches to various Personality Disorders-

Risk for self-mutilation; Risk for self-directed violence; Risk for suicide. Risk for other directed violence. Complicated grieving; Impaired social interaction. Disturbed personal identity; Anxiety (severe to panic); Chronic low self-esteem. -Assist to achieve a reduction of extreme or self-defeating behaviors. -Assist Pt in stating and practicing healthy strategies for coping with inner experiences of discomfort or omnipotence and impulses to manipulate others to meet own needs. -Use firm but kind constructive confrontation to effect behavior change. -Praise efforts to practice learned strategies.

CNS Depressants:

Sedatives; Hypnotics; Anxiolytic-related drugs. Alcohol: -Beer; Rum; Vodka; Wine. Barbiturates: -Phenobarbital; Butobarbital (Butisol). Non-barbiturates: -Zolpidem (Ambien);Eszopiclone (Lunesta). Antianxiety agents: -Alprazolam (Xanax); Clonazepam (Klonopin); Diazepam(Valium). Club drugs: -Date Rape or Roofies (Rohypnol); Liquid X or Easy lay (GHB).

Inhalants:

Solvents: -Glues; Aerosols; Paint thinners. Nitrites: -Whippets.

Identify the following terms:

Splitting- A primitive ego defense mechanism in which the individual is unable to integrate and accept both positive and negative feelings. From these individuals point of view, with regards to people (including themselves), life situations are either all good or all bad. Common of those diagnosed with Borderline Personality Disorder. Idealization- Psychological or mental process of attributing overly positive qualities to another person or thing. It's a way of coping with anxiety in which an object or person of ambivalence is viewed as perfect, or as having exaggerated positive qualities. Devaluation- Defense mechanism that is used when a person attributes themselves, an object, or another person as completely flawed, worthless, or as having exaggerated negative qualities. Object Constancy- The phase in the separation/individuation process when the child learns to relate to objects in an effective, constant manner; A sense of separation is established, and the child is able to internalize a sustained image of the loved object or person when out of sight. Projective Identification- The unconscious act of attributing something inside ourselves to someone else; Usually, but not always, the "thing" we are projecting is an unwanted emotion or attribute.

Describe S/S of AWS

Symptoms of AWS may appear anywhere from six hours to a few days after your last drink and can last for up to one week. o To be classified as alcohol withdrawal syndrome, Pts must exhibit at least two of the following symptoms: Increased hand tremor; Insomnia; Increased HR; Sweating; Confusion; Nightmares; Headache; Nausea or Vomiting; Transient hallucinations (auditory, visual, or tactile); Psychomotor agitation; Anxiety; Tonic-clonic seizures: Autonomic instability. o The most severe type of withdrawal syndrome is known as Delirium Tremens; symptoms include: Extreme Confusion and Agitation; Fever; Seizures; Hallucinations (auditory, visual, or tactile); Severe AWS symptoms are a medical emergency and the individual should seek immediate help.

Identify the use of Disulfiram (Antabuse) and the nursing implications-

This is a drug that can be administered as a deterrent to drinking in individuals who abuse alcohol. Ingesting alcohol while taking disulfiram results in a syndrome of symptoms that can produce a great deal of discomfort for the individual. It can even result in death if the blood alcohol level is high. Reactions vary, depending on the sensitivity of the individual and how much alcohol has been ingested. -Disulfiram works by inhibiting the enzyme aldehyde dehydrogenase, thereby blocking the oxidation of alcohol at the stage when acetaldehyde is converted to acetate. -Disulfiram-Alcohol reactions can occur within 5-10min of alcohol ingestion, and mild reactions can occur with a BAC of 5-10mg/dL. -Fully developed symptoms can happen with a BAC of 50mg/dL and include: • Flushed skin; Throbbing in head and neck; Respiratory difficulties; Dizziness; Nausea and Vomiting; Sweating; Hyperventilation; Tachycardia; Hypotension; Weakness; Blurred vision, and Confusion. -Severe reactions occur with a BAC of 125-150mg/dL and include: • Respiratory depression; Cardiovascular collapse; Arrythmias; Myocardial infarction; Acute CHF; Unconsciousness; Convulsions; and Death. -Disulfiram should not be administered unless it is certain that the individual has abstained from ingesting alcohol for at least 12hrs. -Pts must be warned to avoid all forms of alcohol, including alcohol found in sauces and cough syrups & alcohol applied to the skin in aftershaves, cologne, and liniments. -Effects of Disulfiram will persist about 2 weeks after the last dose and continued abstinence is necessary. -Individuals using Disulfiram should be encouraged to carry ID indicating their status.

Obsessive- Compulsive Personality Disorder-

Very serious, formal individuals who have difficulty expressing emotions; They are overly disciplined, perfectionistic, and preoccupied with the rules. -Inflexible and lack spontaneity; Intense fear of making a mistake leads to difficulty with decision making. -Meticulous and work diligently. -Organized, efficient, and tend to be rigid and unbending about the rules. -See themselves as conscientious, loyal, dependable, and responsible. -Contemptuous of people they see as frivolous and impulsive. -Emotional behavior is considered immature and irresponsible. -Appear clam and controlled; Actually ambivalent, conflicted, and hostile. • Use reaction formation as a defense mechanism.

Explain possible physiological reasons behind the appearance of AWS

o Alcohol initially enhances the effect of GABA. o Chronic alcohol consumption eventually suppresses GABA activity. o Suppresses the activity of Glutamate, a neurotransmitter which produces feelings of excitability; To maintain equilibrium, the glutamate system responds by functioning at a far higher level than it does in moderate drinkers and nondrinkers. o When an individual suddenly stop or significantly reduces their alcohol consumption, the suppressed neurotransmitters rebound, resulting in brain hyperexcitability. o Effects associated with alcohol withdrawal: Anxiety; Irritability; Agitation; Tremors; Seizures; and DTs.

Discuss casual theories of development of Substance-related Disorders

o Biological Factors: Genetics- Children of alcoholics are four times more likely than other children to become alcoholics. Biochemical- Alcohol may produce morphine like substances (tetrahydro papaveroline and salsolinol) in the brain that are responsible for alcohol addiction. o Psychological Factors: Developmental Influences- The psychodynamic approach focuses on a punitive superego and fixation at the oral stage of psychosexual development; Individuals with punitive superegos turn to alcohol to diminish unconscious anxiety and increase feelings of power and self-worth. Personality Factors- Some clinicians believe a low self-esteem, frequent depression, passivity, the inability to relax or to defer gratification, and the inability to communicate effectively are common in individuals who abuse substances. Substance abuse has also been associated with antisocial personality and depressive response styles. o Sociocultural Factors: Social Learning- The effects of modeling, imitation, and identification on behavior can be observed from early childhood onward. In relation to drug consumption, the family appears to be an important influence. Studies show that children are more likely to abuse substances if their parents abuse substances. Peers often exert a great deal of influence in the life of the child or adolescent who is being encouraged to use substances for the first time. Conditioning- Another important learning factor is the effect of the substance itself. Many substances create a pleasurable experience that encourages the user to repeat it. Thus, it is the intrinsically reinforcing properties of addictive drugs that "condition" the individual to seek out their use. The environment in which the substance is taken also contributes to the reinforcement. If the environment is pleasurable, substance use is usually increased. Cultural and Ethnic Influences- Factors within an individual's culture help to establish patterns of substance use by molding attitudes, influencing patterns of consumption based on cultural acceptance, and determining the availability of the substance.

Describe behaviors that occur with stages of Alcohol use/abuse

o Phase I: Prealcholoic- Alcohol used to relieve the everyday stress and tensions of life. As a child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects. The child learns that use of alcohol is an acceptable method of coping with stress. Tolerance can develop, and the amount required to achieve the desired effect increases steadily. o Phase II: Early Alcoholic- This phase begins with blackouts. Alcohol is no longer a source of pleasure or relief for the individual but rather a drug that is required by the individual. Common behaviors include sneaking drinks or secret drinking, preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further blackouts. The individual feels enormous guilt and becomes very defensive; Excessive use of denial and rationalization is evident. o Phase III: Crucial Phase- The individual has lost control and physiological addiction is clearly evident. This loss of control has been described as the inability to choose whether or not to drink. Binge drinking, lasting from a few hours to several weeks, is common; These episodes are characterized by sickness, loss of consciousness, squalor, and degradation. In this phase, the individual is extremely ill; Anger and aggression are common manifestations. Drinking is the total focus, the individual is willing to risk losing everything that was once important, in an effort to maintain the addiction. By this phase it is common for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-respect. o Phase IV: Chronic Phase- Characterized by emotional and physical disintegration. The individual is usually intoxicated more than sober. Emotional disintegration is evidenced by profound helplessness and self-pity. Impairment in reality testing may result in psychosis. Life-threatening physical manifestations may be evident in virtually every system of the body. Abstention from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic. Depression and ideas of suicide are common.

Identify DSM-V criteria for each of the above

o Substance Abuse- A: A maladaptive pattern of substance use leading to clinically significant impairment or distress is manifested by one or more of the following, occurring within a 12-month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. • Recurrent substance use in situations in which it is physically hazardous. • Recurrent substance-related legal problems. • Continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. B: Additionally, the symptoms for substance abuse have never met the criteria for substance dependence. o Dependency- A: A maladaptive pattern of substance use leading to clinically significant impairment or distress is manifested by three or more of the following, occurring at any time in the same 12-month period: • Tolerance, as defined by either of the following: -A need for markedly increased amounts of the substance to achieve intoxication or desired effect. -Markedly diminished effect with continued use of the same amount of the substance. • Withdrawal, as manifested by either of the following: -The characteristic withdrawal syndrome for the substance. -Taking the same (or a closely related) substance to relieve or avoid withdrawal symptoms. • Taking the substance often in larger amounts or over a longer period than was intended. • Having a persistent desire or unsuccessful efforts to cut down or control substance use. • A great deal of time is spent in activities necessary to obtain the substance (visiting multiple doctors), use the substance (chain smoking) or recover from its effects. • Important social, occupational, or recreational activities are given up or reduced because of substance use. • The substance use is continued despite knowledge of having persistent or recurrent physical or psychologic problem that is likely to have been caused or exacerbated by the substance. o Withdrawal- A: Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B: Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: • Autonomic hyperactivity. • Increased hand tremor. • Insomnia. • Nausea or Vomiting. • Transient visual, tactile, or auditory hallucinations or illusions. • Psychomotor agitation. • Anxiety. • Generalized tonic-clonic seizures. C: The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D: The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. o Intoxication- A: Recent ingestion of alcohol. B: Clinically significant problematic behavioral or psychological changes (inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion. C: One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: • Slurred speech. • Incoordination. • Unsteady gait. • Nystagmus. • Impairment in attention or memory. • Stupor or coma. D: The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Define Substance Abuse, Dependency, Withdrawal, and Intoxication

o Substance Abuse- Use of a psychoactive substance (drug or alcohol) that poses significant hazards to health and interferes with social, occupational, psychological, and physical functioning. o Addiction- A compulsive or chronic requirement. The need is so strong as to generate distress (either physical or psychological) if left unfulfilled. o Dependency- Maladaptive pattern of substance use, leading to clinically significant tolerance, impairment, or distress. o Withdrawal- Physiological and mental readjustment that accompanies the discontinuation of an addictive substance. o Intoxication- A physical and mental state of exhilaration and emotional frenzy or lethargy and stupor. o Dual Diagnosis- Pts who have a substance abuse problem and other mental disorders. One issue may precede the other, but relapse rate is lowered when they are treated together. Common co-morbidities- Antisocial personality disorder; Bipolar disorder; Schizophrenia.

Differentiate between Substance Dependency and Substance Abuse

o Substance Dependency- When the body has become physically and psychologically reliant to a substance. Both withdrawal symptoms and tolerance are experienced, more of the substance is required to achieve the same effect. Tolerance- the need to increase amounts of the substance in order to achieve intoxication or the desired effect. A sign of tolerance is a diminished effect with continued use of the same amount of substance. Withdrawal- is the development of a substance specific syndrome when substance use is stopped or decreased. The type and length of withdrawal symptoms vary depending upon the substance. A sign of withdrawal is the need to take the same or similar substance in order to avoid withdrawal symptoms. Those who are dependent upon substances may also: • Take substances in a larger amount or over a longer period of time. • Want to cut down or control substance use but may be unable to do so. • Spend a lot of time and effort doing whatever is necessary to obtain the substance or recovering from the negative effects of using the substance. • Give up or reduce social, occupation, or recreational activities because of substance use. • Continue to use the substance despite awareness of physical or psychological problems that are either caused or worsened by substance use. o Substance Abuse- Is the excessive use of a substance that continues despite negative consequences. Those who abuse substances may: • Fail to fulfill major role obligations. • Use substances in situations that are physically hazardous. • Experience substance-related legal problems. • Continue to use substances despite having persistent or recurrent social or interpersonal problems caused or worsened by the effects of substances.