Mental Health Exam 3

Substance abuse disorders

involves repeated use of chemical substances, leading to clinically significant impairment during a 12-month period; (can be physiological and psychological)

Non-Substance-Related Disorders

behavioral/process addictions; primarily psychological
- gambling
- sexual activity
- shopping
- social media
- internet gaming

Substance and Addictive Disorders are characterized by

- loss of control due to the substance use of behavior
- participation that continues despite continuing associated problems
- tendency to relapse

Denial

commonly used by clients who have problems with substance use or addictive behaviors

- EX: "I can quit whenever I want to, but smoking really doesn't cause me any problems"
- prevents a client from obtaining help with substance use or an addictive behavior

Risk Factors for Substance Use and Addictive Disorders

- genetics: possibility to developing a substance use disorder due to family history

- chronic stress: socioeconomic factors(peer pressure)

- history of trauma: abuse, combat experience (war)

- lowered self-esteem

- adolescents at higher risk

- risk-taking tendencies

Sociocultural Risk Factors for Substance Use and Addictive Disorders

Alaska natives and Native American groups have a high percentage of members who have alcohol use disorder

- Asian groups and African Americans have a low rate of alcohol use disorder

- peer pressure can increase the likelihood of substance use

- older adult clients can develop a pattern of alcohol/substance use later in life due to life stressors (losing a partner or a friend, retirement, or social isolation)

Protective Factors

- Positive Family Support

- Social Relationships

- Positive self-esteem

- Caregiver involvement in activities

- Availability of community resources and programs

- Employment

The rate at which a person becomes addicted depends on

- the substance
- frequency of use
- route taken
- intensity of the high
- the person's genetics
- psychological susceptibility

Chronic Disease

condition lasting longer than 6 months and often a lifetime and requires ongoing treatment/life changes
ADDICTION IS A CHRONIC DISEASE
- dopamine is the neurotransmitter that regulates pleasure and is often involved

CNS Depressants

substances that slow down normal brain function; can produce physiological and psychological dependence and can have cross-tolerance, cross-dependency, and an additive effect when taken concurrently
- Alcohol (ethanol), Sedatives/Hypnotics/Anxiolytics, Cannabis

CNS Stimulants

Drugs that stimulate specific areas of the brain or spinal cord
- Cocaine, Amphetamines, Inhalants, Hallucinogens, Caffeine

Population Specific Substance Use and Addictive Disorder Concerns

- the rate of substance use is highest in clients age 18 to 25

- the younger a person is at the time of initial substance use, the higher the risk of developing a substance use disorder

Population Specific Substance Use: ADOLESCENTS

decreased cocaine use, about half of adolescents report access to marijuana

Population Specific Substance Use: OLDER ADULTS

use of substances increase prone to falls and other injuries, memory loss, somatic reports (headaches), and changes in sleep patterns

Indications of alcohol use: a decrease in ability for self-care (functional status), urinary incontinence, and manifestations of dementia

- can show effects of alcohol use at lower doses than younger adults

Standardized Screening Tools for Substance Use and Addictive Disorders

- Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) >8 - give benzo; done frequently through the day to be able to intervene

- DAST: Drug Abuse Screening Test

- Michigan Alcohol Screening Test (MAST) - nurse's perception

- CAGE Questionnaire: Asks client questions to determine how THEY perceive their current alcohol use

Opioid Agonists

attach to CNS receptors altering the perception of response to pain. This response can lead to generalized CNS depression

- Prescribed opioid agonists: Schedule II under the Controlled Substances Act.

Opioids

HIGHLY ADDICTIVE; heroin, morphine, and hydromorphone can be injected, smoked, inhaled, and swallowed. Misuse of prescription opioids for non-medical use has increased in the past few years

Opioid: Intended Effects

a rush of euphoria, relief from pain

Opioids: Effects of Intoxication

slurred speech, impaired memory, pupillary changes, decreased respirations and LOC which can cause death, impaired judgement/social functioning

Opioid: Antidote

Naloxone available for IV use for toxicity

Opioid: Withdrawal Manifestations

- PAINFUL abstinence syndrome starts with sweating and rhinorrhea, progressing to gooseflesh, tremors, and irritability; then severe weakness, diarrhea, fever, N/V, muscle/bone pain, muscle spasms, pupil dilation, insomnia (typically lasts 7-10 days)

BAC for Legal Intoxication

0.08% (80 g/dL)
- cannot get behind wheel with this %

BAC for Acute Toxicity

death can occur in levels greater than 0.4% (400 g/dL)

3 Questions to Ask a Patient Going Through Alcohol Withdrawal

1. When was your last drink?
2. What was your last drink?
3. How much did you drink?

Alcohol (ethanol): Intended Effects

relaxation, decreased social anxiety, stress reduction

Alcohol (ethanol): Chronic Use

direct cardiovascular damage, liver damage (ranging from hepatomegaly to cirrhosis), erosive gastritis and GI bleeding, acute pancreatitis, sexual dysfunction

Alcohol (ethanol): Withdrawal

start 4-12 hours after last intake, and can last for 5-7 days

abdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased HR BP RR temp, transient hallucinations or illusions, tonic-clonic seizures

Delirium Tremens (alcohol withdrawal delirium)

MOST SEVERE FORM OF WITHDRAWAL SYNDROME; occurs within 2 to 3 days after cessation of alcohol

- medical emergency

- Manifestations: severe disorientation, hallucinations, severe hypertension, cardiac dysrhythmias, and delirium; can progress to death

- IMPLEMENT SEIZURE PRECAUTIONS

- DO NOT leave the patient alone

- CIWA is used to differentiate between common withdrawal and DT (score above 8 is an issue)

- Treatment: sedatives, anticonvulsants, antipsychotics, IV fluids & electrolytes, antipyretics

Seizure Precautions

- all side rails up and padded
- have suction and oxygen available

Withdrawal

decreased concentration of a substance in the client's bloodstream = physiological adverse effects

abstinence syndrome

occurs when a client abruptly withdraws from a substance on which they are physically dependent, withdrawal manifestations occur, can be life-threatening

What are non-pharmacological therapies for substance use disorders?

· Cognitive behavioral therapy
· Psychoeducation
· Group therapy
· Individual therapy
· Alcoholics Anonymous: first 12-step self-help program

What are the S/Sx of cannabis use?

· Euphoric feeling
· Relaxation
· Abnormal pupillary reaction
· Spatial misperception
· Food cravings
· Time misperception

What are the S/Sx of cannabis withdrawal?

· Restlessness
· Inability to sleep
· Irritable/aggressive
· Decreased appetite
· Abdominal pain
· Tremors
· Diaphoresis

What is cannabinoid hyperemesis syndrome?

Condition of repeated & severe bouts of vomiting typically seen in daily long-term marijuana users
- 3 phases

What is the prodromal (1st) phase of cannabinoid hyperemesis syndrome?

Early morning nausea & abdominal pain; normal eating patterns; use more marijuana to ease nausea; lasts months to years

What is the hyperemesis (2nd) phase of cannabinoid hyperemesis syndrome?

Persistent nausea & repeated episodes of vomiting; abdominal pain; decreased intake; weight loss; dehydration; self-soothe with hot showers; continues until person stops using marijuana

What is the recovery phase (3rd) of cannabinoid hyperemesis syndrome?

Symptoms subside; normal eating patterns resume; can last days or months; symptoms & cycle often begins again if the person uses marijuana again

Is there an antidote or helpful drug for cannabinoid hyperemesis syndrome?

No, have to wait for cannabis to get out of system & stop using

Tobacco (Nicotine): types

Includes inhaled cigarettes and cigars & snuffed/chewed smokeless tobacco; HIGHLY TOXIC

Tobacco (Nicotine): Intended Effects

relaxation and decreased anxiety

- acute toxicity seen only in children or when exposure is to nicotine in pesticides

Tobacco (Nicotine): Long-term effects

cardiovascular disease (HTN, stroke), respiratory disease (emphysema, lung cancer); irritation to oral mucous membranes/cancer with smokeless tobacco

Tobacco Nicotine: Withdrawal Manifestations

evidenced by irritability/anger, craving, anxiety/nervous, insomnia, depressed mood, increased appetite

Nursing Care for Substance Use and Addiction Disorders

- have an objective, non-judgmental nursing approach
- safety is the primary focus during acute intoxication or withdrawal
- maintain a safe environment (milieu therapy) to prevent falls; implement seizure precautions
- provide one-on-one supervision
- maintain adequate nutrition and fluid balance
- create a low-stimulation environment
- administer meds as prescribed
- monitor for covert substance use during the detoxification period
- educate

Individuals Psychotherapies

- CBT (relaxation techniques or cognitive reframing) can be used to decrease anxiety and change behavior
- Acceptance and Commitment Therapy (ACT) promotes acceptance of the client's experiences and promotes client commitment to positive behavior changes
- Relapse prevention therapy assists clients in identifying the potential for relapse and promotes behavioral self-control

What is the FIRST-LINE treatment for alcohol withdrawal?

BENZOS (diazepam, lorazepam, chlordiazepoxide)

- intend to maintain vital signs, decrease the risk of seizures, decrease intensity of WITHDRAWAL SYMPTOMS, and substitution therapy during withdrawal

- administer around the clock or PRN, provide seizure precautions

Adjunct Medications for Alcohol Withdrawal

Carbamazepine: decrease in seizures

Clonidine, Propranolol, Atenolol: decrease in BP & HR

Propranolol, Atenolol: decrease in craving

What are the alcohol abstinence maintenance medications?

· Naltrexone

· Acamprosate

· Disulfiram

“ need a drink don’t !!!”

Treatment for Alcohol Abstinence Maintenance: Disulfiram

Daily PO medication that is a type of aversion (behavioral) therapy

- NO ALCOHOL BC ACETALDEHYDE SYNDROME (N/V, weakness, sweating, palpitations, hypotension; can progress to respiratory depression/seizures/death)

- monitor liver to detect hepatotoxicity

- AVOID ALL ALCOHOL CONTAINING PRODUCTS (drinks, cough syrup, aftershave lotion, mouthwash, hand sanitizer)

- medication effects persist for 2 weeks following discontinuation of med

- wear med alert bracelet

Treatment for Alcohol Abstinence Maintenance: Naltrexone

opioid antagonist that suppresses craving and pleasurable effects of alcohol

- monthly IM injections for clients who struggle with med adherence

- take with meals to decrease GI distress

- wear ID in case of emergency as no opioids can be used: will block them·

Treatment for Alcohol Abstinence Maintenance: Acamprosate

taken orally 3x/day to reduce the unpleasant effects of abstinence (dysphoria, anxiety, restlessness)

- can cause diarrhea (maintain adequate fluid intake)

- avoid pregnancy

Treatments for Opioid Use Disorder: Methadone Substitution

Dependence is transferred from the illegal opioid to ___; prevents abstinence syndrome; used for withdrawal and long-term maintenance

- blocks euphoria

- must be slowly tapered to produce detoxification

- must be administered from an APPROVED TREATMENT CENTER DAILY

Treatments for Opioid Use Disorder: Clonidine

doesn't reduce the craving for opioids, but helps with diarrhea, N/V

- watch for dry mouth (chew sugarless gum or candy & sip small amounts of water)

- watch for drowsiness (Avoid driving)

Treatments for Opioid Use Disorder: Buprenorphine

used for BOTH withdrawal and maintenance; decreases feelings of craving; FDA approved; SAFER

- a PCP can prescribe and dispense it (don't have to go into treatment center daily)

- sublingual

Treatments for Nicotine Use Disorder: Bupropion

decreases of cravings & manifestations of nicotine withdrawal
- Chew sugarless gum/candy & sip on water
- Avoid caffeine & other stimulants to control insomnia

Treatments for Nicotine Use Disorder: Nicotine Replacement Therapy

- GUM: chew slowly/intermittently for 30 mins; avoid eating/drinking 15 mins prior, do not use longer than 6 mo

- PATCH: apply to clean, dry, skin each day; applied in morning and removed 16 hrs later @ bedtime; can cause nightmares; remove before MRI

- SPRAY: one spray in each nostril (delivers amount of nicotine in one cigarette)

- LOZENGES: slowly dissolve in mouth (20-30 mins), limit to 5 in a 6 hr period and max 20/day

Treatments for Nicotine Use Disorder: Varenicline

reduces cravings, severity of withdrawal manifestations, and incidence of relapse
- can cause neuropsychiatric effects (unpredictable behavior, mood changes, & suicidal ideation)
- BANNED in clients who are truck/bus drivers, air traffic controllers, or airplane pilots
- take after meals and monitor BP & BS
- discourage use of e-cigars

Obsessive Compulsive Disorder (OCD)

the client has intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors, such as repetitive cleaning or washing of hands. Obsessions or compulsions are time-consuming and result in impaired social and occupational functioning.
- DO NOT immediately stop the patient's compulsions as it is their only coping mechanism
- use thought stopping or cognitive restructuring

Mild Anxiety

occurs in the normal experience of everyday living

- increases one's ability to perceive reality

- characteristics: vague feeling of mild discomfort, restlessness, irritability, impatience, apprehension

- client exhibits mild tension-relieving behaviors such as finger/foot-tapping, fidgeting, or lip chewing

Moderate Anxiety

occurs when mild anxiety escalates

- ability to think clearly is hampered, but learning and problem-solving can still occur

- characteristics: concentration difficulties, PACING, change in voice pitch, shakiness, and increased HR & RR

- somatic manifestations: headaches, backache, urinary urgency & frequency, insomnia

- client usually benefits from the direction and specific instruction of others

Severe Anxiety

- learning and problem solving DO NOT occur: do not teach!

- do not leave the patient alone

- characteristics: confusion, feelings of impending doom, hyperventilation, tachycardia, withdrawal, loud and rapid speech

- not able to take direction from others

Panic- Level Anxiety

often described as feeling like they're having a "heart attack"
- characterized by markedly disturbed behavior
- client is not able to process what is occurring in the environment and may lose touch with reality
- extreme fright and horror
- characteristics: dysfunction in speech, dialted pupils, inability to sleep, delusions, and hallucinations

Nursing Interventions for MILD/MOD Anxiety

- active listening, open-ended questions, seeking clarification to develop trust and identify the source of anxiety

- provide a calm presence (adjust lighting)

- evaluate past coping mechanisms

- encourage exercise to relieve tension

- assess for suicidal ideation

Nursing Interventions for SEVERE/PANIC-LEVEL Anxiety

- Remain with client ALWAYS & stay calm

- Quiet environment with minimal stimulation

- Use medications & restraints after less restrictive have failed

- Encourage forms of exercise

- Set limits by using short but firm, simple statements (slowly and low pitched voice)

- Direct client to acknowledge reality & focus on what is present

Generalized Anxiety Disorder (GAD)

uncontrollable, excessive worry (persistent & unreasonable) for at least 6 months

- causes significant impairment in one or more areas of life (work/relationships)

- manifestations: restlessness, muscle tension, avoidance of stressful activities or events, increased time/effort to prepare for stressful activities/events, procrastination, sleep disturbances (#1 physical complaint)

- treated with SSRIs/SNRIs (#1 long term), buspirone (long-term)

- benzos (#1 short-term),

Separation Anxiety Disorder

the client experiences excessive fear or anxiety when separated from an individual that the client is emotionally attached too

- developmentally appropriate for TODDLERS (before school-age)

Social Anxiety Disorder (Social Phobia)

- the client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance
- the client might report physical manifestations (actual or factitious) to avoid the social situation
- treatment: CBT, SSRIs, anti-anxiety meds

Agoraphobia

Experiences extreme fear of certain places (outdoors or being on a bridge, subway, cruise); feel trapped, like there's no quick exit

Cognitive Behavioral Therapy (CBT)

uses cognitive reframing/restructuring to help the client identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas/positive thoughts that replace negative self-talk

Behavioral Therapies

teach clients ways to decrease anxiety or avoidant behavior and allow an opportunity to practice techniques
Includes: relaxation training, modeling, systematic desensitization, flooding, response prevention, thought stopping

Relaxation Training

used to control pain, tension, and anxiety
Includes: guided imagery, breathing exercises, progressive muscle relaxation, physical exercise

Modeling

allows a client to see a demonstration of appropriate behavior in a stressful situation. the goal of therapy is that the client will imitate the behavior

Systematic Desensitization

begins with mastering relaxation techniques; the client is gradually exposed to increasing levels of an anxiety-producing stimulus and uses relaxation to overcome the resulting anxiety
- especially effective for clients who have phobias

Flooding

immediately exposing the client to a great deal of undesirable stimuli in attempt to get it out of the system & turn off anxiety response

- useful for clients who have phobias

Response Prevention

focuses on preventing the client from performing a compulsive behavior with the intent that anxiety will diminish

Thought stopping

Teaches a client to say "stop" when a negative thought or compulsive behavior arises and substitute w positive thought.

- The goal is that the client with time will use command silently

EX: popping a rubber band/hair tie on wrist every time you get a bad thought

Meds for Anxiety & Trauma/Stressor-Related Disorders: Benzos

Includes: "-lams & -pams": FIRST-LINE SHORT-TERM TREATMENT

- habit-forming

- report if the paradoxical response occurs

- complications: CNS depression, anterograde amnesia, acute toxicity, withdrawal effects

- antidote: Flumazenil

- avoid abrupt discontinuation of treatment to prevent withdrawal manifestations

Meds for Anxiety & Trauma/Stressor-Related Disorders: Atypical Anxiolytic

: BUSPIRONE: used for long term treatment of General Anxiety Disorder

- non-habit-forming and doesn't cause sedation

- needs to be taken on a scheduled basis because it takes up to 4 weeks for full effects

- not recommended for breastfeeding clients

- avoid erythromycin, ketoconazole, St. John's Wort, and grapefruit juice

- take at the same time every day with meals

Meds for Anxiety & Trauma/Stressor-Related Disorders: SSRIs

Includes: Paroxetine, Escitalopram, Fluoxetine; FIRST-LINE LONG-TERM TREATMENT for anxiety, panic disorder, PTSD & OCD

- used before other antidepressants (TCAs/MAOIs) due to decreased adverse effects

- early adverse effects: nausea, diaphoresis, tremor, fatigue, drowsiness, weight loss

- later adverse effects: sexual dysfunction, weight gain, headache

- take with food in the AM on a daily basis

Meds for Anxiety & Trauma/Stressor-Related Disorders: SNRIs

Venlafaxine, Duloxetine

- complications: headache, nausea, dry mouth, sleep disturbances, hyponatremia in older adult clients taking diuretics, anorexia resulting in weight loss, hypertension, sexual dysfunction

- AVOID: alcohol, St. John's Wort (serotonin syndrome), NSAIDs/Ibuprofen (bleeding), and abrupt cessation of the med

How do we know medication is helping relieve anxiety?

- verbalized feeling of less anxiety
- maintenance of a normal sleep pattern
- improved ability to cope
- ability to perform ADLs

Other medications used for anxiety include

- Beta Blockers: propranolol for decreasing vitals
- Prazosin (minipress, anti-HTN) to help with nightmares
- Anticonvulsants used as mood stabilizers: Gabapentin

Nursing Care for Anxiety Disorders

- provide a structured interview to keep the client focused on the present; be direct; set limits
- provide a calm, quiet environment
- remain with the client to provide reassurance
- perform a suicide risk assessment
- provide a safe environment for other clients and staff
- milieu therapy: monitor for self-harm/suicide, therapeutic communication (open-ended qs)
- use relaxation techniques with the client as needed for relief of pain, muscle tension, and feelings of anxiety
- postpone health teaching until after acute anxiety subsides (may be unable to concentrate or learn)

Acute Stress Disorder (ASD)

Exposure to traumatic events causes anxiety, detachment and other manifestations about the event for at least 3 days but for NOT MORE THAN 1 month

Post-traumatic Stress Disorder (PTSD)

Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for longer than 1 month following the event. Manifestations can last for years

- military & first responders most at risk for PTSD

Post-traumatic Stress Disorder (PTSD): Therapy

- Eye Movement Desensitization and Reprocessing (EMDR) therapy can be used - uses rapid eye movements while recalling events

Depersonalization/Derealization Disorder

a temporary change in awareness often in response to stress

Depersonalization

the feeling that a person is observing one's own personality or body from a distance

Derealization

the feeling that outside events are unreal or part of a dream, or that objects appear larger or smaller than they should

- patient's often refer to themselves in the 3rd person

Grounding Techniques

using the senses to bring the patient back to reality (having the client clap hands or touch an object)
- often used as therapy for dissociative disorders

Dissociative Identity Disorder (DID)

a stressful event precipitates a client displaying two or more separate personalities. each personality can be very distinct and different from the other
- personalities can be male or female regardless of the gender of the client
- personalities may have different voice and dress differently
- AKA "split personality"

What antidepressants are used to treat ASD and PTSD?

- SSRIs: Paroxetine and Sertraline
- SNRIs: Venlafaxine
- Mirtazapine, a norepinephrine and serotonin specific antidepressant
- TCAs: Amitriptyline

Why is Prazosin used with ASD and PTSD?

to decrease manifestations of hyper-vigilance and insomnia

Therapeutic Procedures used for Trauma and Stressor Related Disorders

- CBT
- Prolonged exposure therapy
- psychodynamic psychotherapy
- Eye Movement Desensitization and Reprocessing (EMDR)
- group or family therapy
- crisis intervention
- somatic therapy for dissociative disorders
- hypnotherapy
- biofeedback/neurofeedback

Defense Mechanisms

used to protect self-esteem, decrease anxiety, and as a sense of coping
- reversible
- can be adaptive (good) or maladaptive (bad)

Which defense mechanisms are ALWAYS adaptive?

altruism and sublimation

Which defense mechanisms are ALWAYS maladaptive?

conversion, projection, and splitting

Altruism

Dealing with anxiety by reaching out to others
- adaptive use: a nurse who lost a family member in a fire is a volunteer firefighter

Sublimation

dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
- adaptive use: a person who has feelings of anger and hostility toward their work supervisor sublimates those feelings by working out vigorously at the gym during their lunch period

Suppression

voluntarily denying unpleasant thoughts and feelings
- adaptive use: a student puts off thinking about a fight they had with a friend so they can focus on a test
- maladaptive use: a person who has lost their job states they will worry about paying bills next week