NURS 460 Mental Exam 2

Substance Use Disorders

• Pathological use of a substance that leads to a disorder of use. 

• NOT an illness of choice

• Complex Brain Disease

• Chronic and relapsing

  • National Institute on Drug Abuse (NIDA): advance science on the causes and consequences of drug use and addiction and to apply that knowledge to improve individual and public health

  • Substance Abuse and Mental Health Administration: mission includes reducing the impact of substance misuse and also reducing the impact of mental illness on communities in the United States

• Symptoms fall into 4 major groups

  • Impaired control

  • Social impairment

  • Risky use

  • Physical effects (intoxication, tolerance, withdrawal)

Concepts Central to Addictive Use Disorders 

• Addiction: chronic medical condition with roots in the environment, neurotransmission, genetics, and life experiences 

  • Cycles of relapse and remission

  • Without treatment, addiction is progressive and often results in disability or premature death

  • unwilling or unable to recognize the extent to which the addictions are creating serious problems in functioning, interpersonal relationships, and emotional responses

• Intoxication: use of excess, may manifest in variety of ways 

• Tolerance: when a person no longer responds to the drug in the way that the person initially responded. 

  • It takes a higher dose of the drug to achieve the same level of response achieved initially. 

    • Ex: cocaine causes rapid physiological tolerance. 

    • Ex2: prescription pain medications may result in tolerance after weeks or months of use

• Withdrawal: set of physiological symptoms that occur when a person stops using a substance. 

  • can be mild or life threatening

  • more intense symptoms a person has, the more likely the person is to start using the substance again to avoid the symptoms

Substances That Lead to Use Disorders

• Alcohol 

• Caffeine 

• Cannabis 

• Hallucinogen 

• Inhalant 

• Opioid 

• Sedative- hypnotic 

• Stimulant 

• Tobacco 

• Other: Process addictions— Gambling, shopping, sex, etc.

Scheduled Drugs

• 5 Categories (The lower the schedule number, the higher the potential for misuse.)

  • Schedule I drugs carry a high potential for abuse and have no acceptable medical use. 

    • Examples are heroin and lysergic acid diethylamide (LSD). 

  • Schedule II drugs have a high potential for abuse, are considered dangerous, and are available only by prescription. 

    • Examples include methadone, meperidine (Demerol), and methylphenidate (Ritalin). 

  • Schedule III drugs have a low to moderate potential for mis- use and are available only by prescription. 

    • Examples are testosterone, acetaminophen/codeine (Tylenol with codeine), and buprenorphine (Suboxone).

  • Schedule IV drugs are low-risk drugs and are available by prescription. 

    • Examples of schedule IV drugs are alprazolam (Xanax), lorazepam (Ativan), and propoxyphene/acetaminophen (Darvocet). 

  • Schedule V drugs contain limited quantities of certain narcotics for the treatment of diarrhea, coughing, and pain. 

    • Examples are atropine/diphenoxylate (Lomotil), guaifenesin and codeine (Robitussin AC), and pregabalin (Lyrica), available over-the-counter.

• Based on drug’s acceptable medical use and the drug’s misuse potential

• How do these medications show up differently in our nursing practice?

Epidemiology + comorbidity + risk factors of substances

• National Survey on Drug Use and Health Survey is conducted annually in the United States

  • estimates that about 165 million people (about 60%) used substances (i.e., tobacco, alcohol, or illicit drugs) within the last month. 

  • The number of people with actual substance use disorders was estimated at about 20.3 million

  • 1. Alcohol 2.Illict drugs 3. Weed

Comorbidity

• Psychiatric comorbidity

  • Any combination of two or more substance use disorders and mental disorders 

Risk Factors

Genetic

• Addiction has a genetic vulnerability and can run in families.

• Twin studies support heritability of substance use disorders.

• Heritability estimates: 30–40% for hallucinogens/stimulants and 70–80% for cocaine/opiates.

Neurobiological

• Substance use affects neurotransmitter systems, especially:

  • Opioids

  • Dopamine/catecholamines

  • GABA

• Repeated opioid use can change normal opioid function, causing the person to need the drug just to feel normal.

• Dopamine neurons in the ventral tegmental area (VTA) are important for the brain's reward system.

Environmental

• Poverty and chronic stress can increase risk.

• Risk factors include:

  • Poor living conditions

  • Lack of parental supervision

  • Limited educational resources

  • Weak support systems

  • Negative social relationships

• Chronic stress can contribute to anxiety and depression.

• Drugs or acting-out behaviors may become maladaptive coping mechanisms, potentially leading to destructive behaviors and legal problems.

Substance use disorder in nursing

• Why nurses are at risk

  • Easy access to controlled medications

  • High stress and long, fatiguing shifts

  • Fear of losing licensure keeps nurses from seeking help

• Warning signs

• Behavior: frequent absences from the unit, lateness, medication errors, isolation

• Physical: declining appearance, drowsiness, confusion, memory lapses

• Diversion: excess wasting, documentation gaps, patients with unrelieved pain 

• What to do

  • Report concerns through facility policy and the chain of command

  • Know your state’s alternative-to-discipline program: treatment, monitoring, and a path back to practice

    • Reporting a colleague is how you get them help and keep patients safe.

Caffeine intoxication

• Most widely used psychoactive substance in the world 

• Can result in intoxication, overdose, and withdrawal – though not an official use disorder

• Stimulant effects begin within ~15 minutes and can last up to 6 hours

Caffeine Intoxication

• Usually occurs after >250 mg in a short period.

• Behavioral: restlessness, nervousness, excitement, agitation, rambling speech.

• Physical: flushed face, increased urination, GI upset, muscle twitching, tachycardia/arrhythmias.

• People with tolerance may have fewer intoxication effects.

Caffeine overdose + treatment

• Caffeine Overdose

  • More likely with energy drinks, diet aids, decongestants, bronchodilators, and stay-awake products.

  • Children/adolescents are especially vulnerable.

    • Symptoms:

      • Early: fever, tachycardia, hypertension

      • Later: hypotension

      • Severe: seizures, respiratory failure, possible death

      • Also: dilated pupils, rigidity, hyperreflexia, nausea/vomiting, agitation, hallucinations, delusions

Treatment: supportive care, hydration, activated charcoal if recent ingestion, gastric lavage in some cases, beta-blockers for tachycardia, vasopressors for hypotension.

• Caffeine Withdrawal

• Not usually medically dangerous.

• Symptoms: headache, drowsiness, irritability, poor concentration, sometimes nausea/vomiting and muscle aches.

• Begins 12–24 hr after last dose.

• Peaks: 24–48 hr

• Resolves: within ~1 week.

Cannabis intoxication

• Schedule I substance

• Other names and examples 

  • Marijuana, weed 

  • Flower, edibles, dabs, vapes 

• Intoxication 

  • Red eyes, increased appetite, dry mouth, tachycardia 

  • Depersonalization , derealization, hallucinations w/ reality testing 

  • Motor skills are impacted for 8 to 12 hours, and driving and the use of machinery may be hazardous

Cannabis withdrawal and treatment

• Withdrawal 

  • Within 1 week of cessation 

  • Irritability, anger, anxiety, depressed mood, insomnia 

  • Abdominal pain, shakiness, sweating, fever, headache 

• Treatment 

  • Abstinence/support

  • Therapy

Hallucinogens intoxication

• Schedule I substance

• Examples 

  • Classic: LSD 

  • Dissociative: PCP* and ketamine 

• Intoxication 

  • Paranoia, panic attacks, hallucinations, synesthesia (senses switch like sound, sight) 

  • Dilated pupils, tachycardia, sweating, blurred vision, tremors, and incoordination

  • Phencyclidine intoxication

    • Physical manifestations include nystagmus, hypertension, tachycardia, decreased pain response, ataxia, dysarthria, muscle rigidity, and hyperacusis (increased sensitivity to sound). 

    • Severe effects may include hyperthermia, seizures, and coma

Hallucinogens withdrawal and treatment

• Withdrawal 

  • No official withdrawal pattern 

  • Perceptual disturbances may persist for weeks, months, or even years 

• Treatment 

  • Talking patient down & providing reassurance 

  • Antipsychotics or benzodiazepines 

  • Physical restraints may be necessary

  • Mechanical cooling 

Inhalants (toxic gases)  intoxication + treatment

• Cause failure in major life roles and problems in interpersonal relationships. 

  • “Sudden sniffing death” from cardiac arrhythmias may occur with inhalants, particularly with butane and propane

• Examples 

  • Solvents 

  • Propellants 

  • Thinners 

  • Fuels 

• Intoxication 

  • Low doses: Disinhibition and euphoria 

  • High doses: fearfulness, illusions, hallucinations 

    • Apathy, diminished social and occupational functioning, impaired judgment, and impulsive and aggressive behavior

    • Physical effects of inhalant intoxication include nausea, loss of appetite, nystagmus, decreased reflexes, and diplopia (double vision). 

    • High doses or prolonged exposure can cause stupor, unconsciousness, amnesia, delirium, dementia, and psychosis

• Treatment 

  • Doesn't require any treatment 

  • Haloperidol for psychotic symptoms or agitation

Opioid Use Disorder + withdrawal timeline

• Heroin and prescription drugs

• Opioid intoxication

  • Cravings result in larger amounts, longer periods of use, increasing tolerance to its effects

  • Results in significant impairment in life roles, interpersonal conflict, and puts a person in physically hazardous situations 

  • CNS depression

Withdrawal timeline

• Morphine, heroin, methadone: begins 6–8 hr after last dose, peaks on day 2–3, subsides over the next week.

• Meperidine: begins within 8–12 hr and lasts about 5 days.

Intoxication vs. withdrawal: think opposites for opioid

	Intoxication (CNS depression)	Withdrawal (rebound arousal)
Pupils	Miosis (pinpoint)	Mydriasis (dilated)
Vital signs	Bradycardia, hypotension, hypothermia, slowed respirations	Tachycardia, hypertension, hyperthermia, increased respiratory rate
Mental status	Sedation, euphoria, calmness, slurred speech, head nodding	Anxiety, dysphoria, insomnia
GI	Decreased bowel sounds	Abdominal cramps, nausea, vomiting, diarrhea
Other	Analgesia, slowed movement, impaired memory; track marks	Lacrimation, rhinorrhea, yawning, piloerection, sweating, muscle/bone pain Males may experience sweating and spontaneous ejaculations while awake

Opioid overdose: recognize and respond

The classic triad

• Coma / unresponsiveness

• Pinpoint pupils

• Respiratory depression

• Also: hypotension, bradycardia, hypothermia. Death usually results from respiratory arrest.

Nursing priorities

1. Airway and breathing first: Aspirate secretions, insert an airway, support ventilation.

2. Give naloxone (Narcan): Intranasal, IM, subcut, or IV. Expect rising respirations and pupil dilation quickly.

3. Watch for re-sedation: Naloxone is shorter-acting than many opioids; repeat doses may be needed.

4. Watch for withdrawal: Too much naloxone can precipitate acute withdrawal (vomit / agitated)

Withdrawal management for opioid

• Methadone: full agonist; eases withdrawal and blocks euphoria. Dispensed only through SAMHSA-certified programs.

  • Would need to be withdrawn via tapering or substituting another medication

• Buprenorphine: partial agonist; start only in early withdrawal (12–24 hr opioid-free) or it can precipitate withdrawal.

  • Side effects include nausea, vomiting, constipation, muscle aches/cramps, insomnia, irritability, and fever. 

  • It is started after 12–24 hours of opioid abstinence during early withdrawal; giving it too early can trigger acute withdrawal, and its long-acting effects may allow every-other-day dosing after stabilization

• Clonidine, lofexidine: alpha agonists to reduce symptoms; ease sweating, tearing, restlessness, anxiety.

  • decrease anxiety and may shorten opioid detoxification

  • Lofexidine (Lucemyra) is FDA-approved to reduce opioid withdrawal symptoms during abrupt discontinuation and may allow withdrawal to be completed in a few days

• Maintenance (MOUD)

  • Methadone, buprenorphine/naloxone: reduce cravings; buprenorphine can move to alternate-day dosing once stable.

  • Naltrexone: antagonist; blocks euphoria. Oral daily or Vivitrol IM monthly, after withdrawal is complete.

    • prevent relapse after opioid detoxification and lasts for weeks, which can help with adherence. 

    • Side effects include GI distress, muscle cramps, dizziness, sedation, appetite changes, and injection-site reactions such as pain, swelling, and bruising

• Psychosocial support

  • Therapies: individual, CBT, family therapy, social skills training.

  • Peer support: Narcotics Anonymous (12-step).

  • Structured settings: residential treatment and therapeutic communities.

  • Teach patients on methadone to seek care for: shallow or difficult breathing, lightheadedness or fainting, chest pain or pounding heartbeat, facial or throat swelling, hallucinations or confusion.

Sedative, Hypnotic, and Antianxiety Medication Use Disorder

• Substances

  • Benzodiazepines

  • Benzodiazepine-like drugs

  • Carbamates

  • Barbiturates

  • Barbiturate-like hypnotics

• Symptoms: slurred speech, poor coordination, unsteady gait, nystagmus, impaired thinking, and impaired judgment. 

  • Severe intoxication can lead to inappropriate aggression or sexual behavior, mood changes, and coma.

• Overdose treatment : gastric lavage, activated charcoal, monitor vitals

  • If unconscious, an intravenous fluid line should be established. 

  • An endotracheal tube may be required to provide a patent airway, and mechanical ventilation can be used if necessary

• Withdrawal: gradual reduction to prevent seizures

  • symptoms such as autonomic hyperactivity, tremor, insomnia, psychomotor agitation, anxiety, and grand mal seizures

Stimulant Use Disorder

• Clinical Picture

  • Amphetamine-type, cocaine, or other stimulant drugs

  • Second only to cannabis as the most widely used illicit substance in the United States 

• Intoxication: euphoria, increased sociability, hypervigilance, anxiety, tension, and anger, with users sometimes feeling “superhuman.” 

  • Physical symptoms include chest pain, arrhythmias, abnormal BP/heart rate, dilated pupils, sweating, nausea/vomiting, weight loss, agitation, confusion, seizures, and coma.

• Withdrawal can cause tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia, and psychomotor slowing or agitation, which can impair functioning. 

  • The most serious symptoms are depression and suicidal thoughts

• Withdrawal treatment

  • Group and individual therapy

  • Possible diazepam for agitation

  • 1 to 2 weeks’ cocaine withdrawal requires no inpatient care; no drugs reduce symptoms

  • Depression treatment once withdrawal is complete (e.g., bupropion)

Tobacco + gambling disorder

• Withdrawal is distressing

  • Irritability, anxiety, depression, difficulty concentrating, restlessness, and insomnia. 

  • After quitting, heart rate decreases by 5–12 beats/min within days, and average weight gain during the first year is 4–7 lb. 

• Withdrawal treatment: behavioral therapy, hypnosis, nicotine replacement therapies; bupropion or varenicline

Gambling disorder 

• Usually develops over years and may be regular or episodic, with periods of heavy gambling followed by abstinence. 

• It is more commonly expressed early in males, but progresses more rapidly in females, and stress or depression may increase gambling behavior

• Gamblers Anonymous (GA) involves public confession, peer pressure, and peer counselors who are reformed gamblers

• Possible treatment with SSRIs, bupropion (Wellbutrin), mood stabilizers, and anticonvulsants

  • Naltrexone, an opioid antagonist, may be given to individuals with the most severe symptoms of gambling disorder.

Alcohol Use Disorder

• Sedative with initial euphoria

• Severity based on number of DSM-V symptoms

  • Mild: 2–3 symptoms

  • Moderate: 4–5 symptoms

  • Severe: 5 or more symptoms

Alcohol Use Disorder comorbidity and risk factors

• Bipolar disorder, schizophrenia, antisocial personality disorder, and major depressive disorder are associated with increased risk of alcohol use disorder, while alcohol can worsen depression, suppress the immune response, and increase infection risk

• Biological Factors

• Genetic: Alcohol use disorder runs in families; 40–60% of risk may be inherited, and children of affected parents have up to a 4× higher risk. Certain genes affecting alcohol metabolism may reduce risk by causing acetaldehyde buildup → flushing.

• Neurobiological: Family history is associated with changes in the amygdala, hippocampus, basal ganglia, and cerebellum, as well as altered inhibitory control, working memory, and reward processing.

• Environmental Factors

  • Social: Peer influence and low parental supervision can increase adolescent substance use; alcohol may be used as a “social lubricant” to increase belonging.

  • Cultural: Cultural and religious beliefs strongly influence alcohol use—some groups prohibit alcohol, while others consider it a normal part of daily life. 

Alcohol Use Disorder types of drinking and intoxication

• Types of drinking 

  • Binge: 4+ drinks for women or 5+ for men within 2 hours

  • Heavy: 8+ drinks/week for women or more than 14 drinks/week for men

• Alcohol intoxication

  • Legal definition of intoxication in most states: blood concentration of 80 or 100 mg ethanol per deciliter of blood (mg/dL). 

  • Often expressed as 0.08 to 0.10 g/dL

  • Quicker ingestion results in higher levels of blood alcohol. 

  • In the United States, a standard drink contains about 14 g of pure alcohol

• Cognitive disturbances

  • Blackouts due to alcohol’s ability to block the consolidation of new memories into ones through the hippocampus and related temporal lobe structures

  • Wernicke-Korsakoff syndrome: Long-term heavy alcohol use can cause thiamine deficiency, leading to Wernicke’s encephalopathy (acute, reversible confusion, gait and eye problems) or Korsakoff’s syndrome (chronic memory and cognitive impairment). 

    • Wernicke’s is treated with IV thiamine, while Korsakoff’s requires longer-term thiamine and nutritional support, though full recovery is uncommon

• Fetal alcohol syndrome during pregnancy can impair fetal growth and development, causing microcephaly, facial, limb, and heart defects

  • affected adults may have short stature

  • women with alcohol-related disorders have about a 35% risk of having a child with defects

Alcohol withdrawal: timeline and treatment

Time	6–8 hr	8–10 hr	12-24 hr	Up to 72 hr
Signs	Tremulousness "Shakes" or "jitters"; agitation, nausea, vomiting, poor appetite, insomnia, impaired cognition, mild perceptual changes.  BP, pulse, and temperature rise.	Psychotic and perceptual symptoms Medical emergency: risk of unconsciousness, seizures, and delirium.	Withdrawal seizures Generalized tonic-clonic seizures; more may follow within hours of the first.	Delirium tremens (DTs) Autonomic hyperactivity: tachycardia, hypertension, fever, diaphoresis, anxiety, insomnia.  Delusions; visual and tactile hallucinations. Up to 20% mortality if untreated.
Treatment	Chlordiazepoxide (Librium)	Lorazepam (Ativan) or chlordiazepoxide PO or IM, tapered over 5–7 days	Diazepam (Valium) IV	Medical emergency: treat underlying medical problems

Monitor withdrawal symptoms & guide medication management for alcohol

can guide medication management

Alcohol Use Disorder systemic effects

• Esophagitis (inflammation, at risk at bursting), gastritis (erodes mucosal stomach lining, may lead to ulcers/bleeding), and pancreatitis (results in malnutrition, weight loss, and diabetes mellitus) 

• Peripheral neuropathy: pins and needles 

• Alcoholic myopathy (muscle weakness/damage) and cardiomyopathy (fatigue/SOB/edema) 

• Alcoholic hepatitis -> dry mouth, jaundice, fever, etc 

• Cirrhosis of the liver -> easy bleeding/bruising, itching, jaundice, ascites, leg edema, weight loss, confusion, spider-like blood vessels (petechiae), and testicular atrophy

• Leukopenia

• Thrombocytopenia

• Cancer (especially head and neck, oral cavity, pharynx, larynx)

SBIRT & Substance Use Screening

SBIRT: Public health approach for early identification and treatment of substance use disorders or risk.

1. Screening: Assess severity of substance use and determine appropriate level of treatment.

2. Brief Intervention: Increase awareness, insight, and motivation to change substance-use behaviors.

3. Referral to Treatment: Connect individuals needing additional care with specialty treatment services.

Screening Tools

• AUDIT: Alcohol Use Disorders Identification Test; commonly used to screen for alcohol misuse.

• CAGE: Cut down, Annoyed, Guilty, Eye-opener. ≥2 = significant; 1 requires further assessment.

• CAGE-AID: CAGE adapted to include drug use.

• T-ACE: Tolerance, Annoyance, Cut down, Eye-opener.

• Nursing considerations: Use clear instructions and a nonjudgmental attitude. Look for progression/loss of control, tolerance, and withdrawal; a positive screen requires a more complete assessment

Nursing Process of alcohol use disorder

• Assessment

  • Screening Tools (SBIRT, AUDIT, CAGE, etc - check up for notes)

  • Family assessment (codependence)

    • Codependence can develop in families affected by substance misuse, causing family stress and overly responsible behaviors where people neglect their own needs while caring for others

  • Self-assessment

    • Nurses should recognize their own biases and feelings about alcohol use through self-reflection to provide objective, patient-centered care and avoid countertransference. 

    • Nurses with substance-use concerns can seek nonpunitive peer-assistance programs, which are available through many State Boards of Nursing

• Nursing diagnosis 

• Outcomes identification

  • may include detoxification and stabilization during withdrawal, abstinence from alcohol, motivation and engagement in early recovery, and maintaining a recovery lifestyle after discharge

• Planning

  • Identifying problem

  • Setting a goal

  • Determining the interventions that will accomplish the goal

Nursing Process

• Implementation

  • Promoting safety and sleep: first-line interventions

  • Reintroduce good nutrition and hydration

  • Support for self-care (hygiene)

  • Exploring harmful thoughts and spiritual distress

• Health teaching and health promotion

  • Prevention against genetic vulnerability

  • Public classes

  • Social activities build supportive relationships, reduce the effects of stress, and provide opportunities for community health education and promotion

Nursing Process (Cont.)

• Evaluation

  • Assessing the effectiveness of the treatment plan

  • Using objective data to check whether nursing actions addressed the patient’s symptoms

  • Measuring the changes in the patient’s behaviors for progress toward meeting stated goals 

Treatment Modalities for alcohol use disorder

• Pharmacotherapy

  • Disulfiram

  • Naltrexone

  • Benzodiazepines - dose determined by CIWA-AR scale

• Psychotherapy

  • Cognitive behavioral therapy (CBT) helps patients identify and challenge irrational beliefs, understand the consequences of alcohol use, and self-monitor and manage cravings realistically

• Motivational interviewing a person-centered approach based on the stages of change theory that strengthens motivation for behavior change, especially in substance use disorders

  • sessions typically lasting about 1 hour

Care Continuum for Substance Use Disorders

• Detoxification (detox): medically supervised process for people stopping substances that cause withdrawal, providing 24-hour monitoring to manage potentially severe or life-threatening symptoms, especially with comorbid conditions

• Rehabilitation: provides inpatient care for substance use, with medically managed programs offering 24-hour staff and specialized treatment for medical or psychiatric conditions

  • short-term rehab restores lost skills, while long-term rehab teaches new skills.

• Halfway houses: provide a substance-free living environment that supports continued sobriety, independent living, case management, and development of life skills while residents often work outside the home

• Other housing: Supportive housing, three-quarter-way houses, and therapeutic communities provide drug-free housing, peer support, and life-skills training while residents usually continue outpatient substance use treatment

• Partial hospitalization program: provide structured outpatient treatment, usually 5 days/week for about 6 hours/day, combining psychotherapy and education for people who do not need 24-hour residential care

• Intensive outpatient programs (IOP): structured nonresidential programs with group therapy and regular individual sessions, typically at least 3 days/week for about 3 hours/day, with medication management available but not closely monitored

• Outpatient treatment: least-intensive, nonresidential option, offering individual or group therapy and education based on the person’s needs, usually with no more than 5 contact hours per week

• Alcoholics Anonymous (AA): well-known 12-step program that supports sobriety through peer support and the 12 steps, with meetings available in person and online

  • Al-Anon and Alateen provide support for family members and teens affected by another person’s substance use

• Relapse prevention: involves identifying triggers, developing healthy coping and stress-management skills, and preparing strategies to regain abstinence, with technology such as smartphone apps helping monitor relapse warning signs

Harm Reduction + stigma

• Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. 

  • Syringe/needle exchanges

  • Drug checking ex. Fentanyl Test Strips

  • “Start low, go slow”

• Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.

Words Matter- Stigma and substance use disorder

• Stigma often rests on the outdated belief that addiction is a moral failing, rather than a chronic, treatable disease from which people recover.

• How stigma causes harm

• Keeps people from care

  • Feeling stigmatized reduces willingness to seek treatment.

• Fuels avoidance and isolation

  • Stereotypes provoke pity, fear, anger, and a desire to avoid people with SUD.

• Shapes clinical care

  • Stigmatizing terms can bias clinicians' perceptions of patients and the care they give.

• Clinicians are often the first point of contact, so our language can model a destigmatizing approach.

Instead of this, say this

Instead of...	Use...
Addict, user, junkie, drug abuser	Person with a substance use disorder
Alcoholic, drunk	Person with alcohol use disorder
Former / reformed addict	Person in recovery; person who previously used drugs
Abuse	Use (illicit drugs); misuse or used other than prescribed (medications)
Clean / dirty (tox screen)	Testing negative / testing positive
Clean (person)	Person in recovery; person who previously used drugs
Habit	Substance use disorder
Replacement therapy, MAT	Medication for opioid use disorder (MOUD)
Addicted baby	Newborn exposed to substances; neonatal opioid withdrawal syndrome

Key principles

• Person-first: someone has a disorder; they are not the disorder.

• Let people choose how they are described.

• Use severity specifiers (mild, moderate, severe).

• Model clinical language even when patients use slang.

Anxiety + levels + defense mechanisms

• Anxiety—apprehension, uneasiness, uncertainty, or dread from real or perceived threat

• Fear—reaction to specific danger

• Normal anxiety—necessary for survival

  • vague sense of dread related to an unspecified or unknown danger.

  • Anxiety motivates people to make and survive change. 

Levels of Anxiety

• Mild

  • occurs in the normal experience of everyday living and allows an individual to perceive reality in sharp focus. 

  • Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension- relieving behaviors 

• Moderate

  •  sees, hears, and grasps less information and may demonstrate selective inattention, where only certain things in the environment are seen or heard unless they are pointed out.

  •  ability to think clearly is hampered, but learning and problem solving can still take place, though not at an optimal level.

  •  may experience tension, a pounding heart, increased pulse and respiratory rates, perspiration, and mild somatic symptoms. Voice tremors and shaking may be noticed

  • Selective in attention

• Severe

  • may focus on one particular detail or on many scattered details and have difficulty noticing what is going on in the environment, even when another person points it out.

  • Learning and problem solving are not possible at this level, and the person may be dazed and confused

  •  Trembling and a pounding heart are common, and the person may experience hyperventilation and a sense of impending doom or dread.

  • Perpetual fields are greatly reduced. 

• Panic

  • the most extreme level of anxiety and results in markedly dysregulated behavior. 

  • Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality. 

  • may be manifested as pacing, running, shouting, screaming, or with drawal. Hallucinations, which are false sensory perceptions, such as seeing something that is not really there or hearing voices, may be experienced. Physical behavior may become erratic, uncoordinated, and impulsive. 

Defense mechanisms are automatic coping styles that protect people from anxiety and enable them to maintain their self- image by blocking feelings, conflicts, and memories.

• Adaptive use of defense mechanisms helps people to lower their levels of anxiety and to achieve their goals in acceptable ways

• Maladaptive use of defense mechanisms occurs when one or several are used to excess, particularly immature defenses.

Types of anxiety disorder pt 1

Separation Anxiety Disorder 

• exhibit developmentally inappropriate levels of concern over being away from a significant other. 

Specific phobias

• persistent irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation.

• characterized by the experience of high levels of anxiety or fear in response to certain objects or situations

Social Anxiety Disorder

• characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others.

Panic Disorder

• sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. 

Types of anxiety disorder pt 2

Agoraphobia 

• intense excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or where help might not be available.

Other Anxiety Disorder

• Selective mutism is a condition where children do not speak owing to fears of negative responses or evaluations. 

  • Tend to speak at home and around immediate family

• Substance- induced anxiety disorder is characterized by symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance 

• Anxiety due to a medical condition, the individual’s symptoms of anxiety are a direct physiological result of a medical condition

Anxiety Disorders

• use rigid, repetitive, and ineffective behaviors to try to control their anxiety. The common element of such disorders is that those affected experience a degree of anxiety that interferes with personal, occupational, or social functioning.

• Most common mental health problem

Application of the Nursing Process for anxiety

• Assessment

  • General assessment of symptoms

  • Self-assessment

  • Assessment guidelines: anxiety

• Nursing diagnosis

• Outcomes identification 

• Planning

Assessment

• Sound physical (tachy) and neurological exam

• Determine source of anxiety (primary vs. secondary)

• Determine current level of anxiety

• Assess for potential self-harm

• Complete psychosocial assessment 

  • Ask patient about causes they can identify

• Self-assessment

Nursing Diagnoses and Outcome Identification

• Anxiety & Fear

  • Self-monitors intensity; uses reduction techniques 

• Difficulty coping

  • Identifies ineffective and effective patterns; asks for assistance and information; modifies as needed

• Impaired socialization & low self-esteem

  • Self-monitors anxiety and desire for avoidance; uses techniques to reduce anxiety to maintain role performance

Planning

• Patients do not usually require inpatient admission

• Planning involves selecting community-based interventions

• Encourage active participation in planning to increase positive outcomes

• Patient experiencing severe levels may not be able to participate in planning

Implementation of anxiety

• Mild to moderate levels of anxiety

  • is still able to solve problems

  •  help to focus and solve problems when you use specific nursing communication techniques such as asking open-ended questions, giving broad openings, and exploring and seeking clarification

  • Do NOT close off topics of communication and bring up irrelevant topics. 

• Severe to panic levels of anxiety

  • unable to solve problems and may have a poor grasp of what is happening in the environment. 

  • Priority nursing interventions are aimed at providing for the safety of the patient and others and to meet physical needs, such as the requirement for fluids and for rest to prevent exhaustion.

    • 1.  Use counseling, milieu therapy, promotion of self-care activities, pharmacotherapy, biological, and health teaching interventions.

    • 2. Guide patients through slowing exercises along with progressive muscle relaxation.

    • 3. Identify community resources that can offer the patient specialized treatment proven to be highly effective for people with a variety of anxiety disorders.

    • 4. Identify community support groups for people with specific anxiety disorders and their families.

• Counseling

  • counseling to reduce anxiety, enhance coping and communication skills, and intervene in crises.

• Health teaching and health promotion

• Teamwork and safety

• Promotion of self-care activities

  • Nutrition and Fluid Intake

  • Personal Hygiene and Grooming

  • Sleep

Evaluation

• Is the patient experiencing a reduced level of anxiety?

• Does the patient recognize symptoms as anxiety-related?

• Does the patient continue to display signs and symptoms such as obsessions, compulsions, phobias, worrying, or other symptoms of anxiety disorders? If still present, are they more or less frequent? More or less intense?

• Is the patient able to use newly learned behaviors to manage anxiety?

• Does the patient adequately perform self-care activities?

• Can the patient maintain satisfying interpersonal relations?

• Is the patient able to assume usual roles?

Treatment Modalities for anxiety

• Biological: Pharmacotherapy

  • SSRIs and SNRIs- first line of defense in most anxiety- related disorders

    • paroxetine (Paxil), fluoxetine (Prozac), escitalopram (Lexapro), and sertraline (Zoloft)

  • Antianxiety drugs

    • Benzodiazepines are most commonly used because they have a quick onset of action. 

      • Only used for short period of time

  • Other categories

    • Beta blockers, antihistamines, anticonvulsants, and antipsychotics

  • Integrative Medicine

Psychological Therapies

• Behavioral therapy

  • Modeling

    • The therapist or significant other acts as a role model to demonstrate appropriate behavior in a feared situation, and then the patient imitates it.

  • Systematic desensitization

    • Patient is gradually introduced to a feared object or experience through a series of steps, from the least frightening to the most frightening (graduated exposure).

  • Flooding

    • Exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response. 

  • Thought stopping

    • Through this technique a negative thought or obsession is interrupted.

    • This distraction briefly blocks the automatic undesirable thought and cues the patient to select an alternative, more positive idea

  • Cognitive-behavioral therapy

    • includes cognitive restructuring, psychoeducation, breath restraining and muscle relaxation, teaching of self- monitoring for panic and other symptoms, and in vivo (real-life) exposure to feared objects or situations.

Obsessive-Compulsive Disorders + risk factors

• Obsessions

  • Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind

• Compulsions

  • Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety 

Obsessive-Compulsive Disorders (Cont.)

• DSM-5 Criteria for Obsessive-Compulsive Disorder

  • Obsessions, compulsions or both

  • Not due to a substance or condition

  • Not explained by another psychiatric disorder

  • Time-consuming (in excess of 1 hour per day)

Risk Factors for OCD

• Child abuse & trauma

• Post-infectious autoimmune syndrome. 

• Genetics: First-degree relatives = twice the risk

• Comorbidity with anxiety disorders, eating disorders, and/or tic disorder 

Obsessive-Compulsive Disorders  types

•  exists along a continuum

•  Presence of obsessions, compulsions, or both.

  • Obsessions are defined by (1) and (2):

    •  1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

    •  2.  The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion).

    •  3.  Compulsions are defined by (1) and (2):

    •  4.  Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

    •  5.  The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

• Body dysmorphic disorder

  • Patients tend to have a normal appearance, their preoccupation with an imagined defective body part results in obsessional thinking and compulsive behavior such as mirror checking and camouflaging. 

  • False assumptions about the importance of appearance, fear of rejection by others, perfectionism, and the conviction of being disfigured lead to overwhelming emotions of disgust, shame, and depression. 

• Hoarding disorder

  • The accumulation of belongings that may have little or no value prevents some people from leading normal lives.

• Trichotillomania (hair pulling) disorder 

• Excoriation (skin picking) disorder 

• Other Compulsive Disorders

  • Medication- or substance-related

  • Medical condition-related

Nursing Process of OCD

• Assessment

• Nursing Diagnosis

  • Anxiety

  • Impaired skin integrity

  • Disturbed body image

  • Risk for self-destructive behavior

  • Risk for impaired socialization, fear, difficulty coping, and chronic low self-esteem 

Nursing Process (Cont.)

• Outcomes Identification

  • Reduced anxiety

  • Improved skin integrity

  • Reduced self-destructive behavior

  • Improved body image

  • Improved socialization

  • Reduced fear

  • Improved coping

  • Improved self-esteem

Nursing Process (Cont.)

• Basic-Level Nursing Interventions

  • Promotion of self-care activities

  • Monitor skin integrity for excoriation or trichotillomania disorder

  • Health teaching

  • Relevant to obsessions/compulsions

• Advanced Practice Nursing Interventions

  • Flooding

  • Cognitive-behavioral therapy

    • Exposure-and response prevention

Treatment Modalities of OCD

• Biological Treatments

  • SSRIs for OCD (FDA-approved)

    •  fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). 

  • Others: Clomipramine (TCA), Venlafaxine (SNRI)

  • Some antipsychotics

  • None for: Body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder 

  • Exceptions:

    • SSRIs can be helpful in those disorders displaying obsessive-compulsive features in these other disorders

Treatment Modalities (Cont.)

• Surgical treatments

  • Gamma Knife: creates lesions to form a disconnect of overactive circuits

  • Deep brain stimulation (DBS): implanted pulse generator uses low-dose current to reduce symptoms

Psychological Therapies

• Exposure and response prevention

  • First-line cognitive-behavioral intervention for obsessive-compulsive behaviors

  • Expose patient to triggers of OCD symptoms

  • Message: anxiety does subside even when the ritual is not completed 

• Flooding

  • Expose patient to large amount of trigger to extinguish response

Trauma + types

Trauma involves exposure to actual or threatened death, serious injury, or sexual violence

• direct experience

• witnessing the event

• learning that it occurred to a close contact

Trauma-Related Disorders

• Traumatic life events associated with a wide range of psychiatric and other medical disorders 

• Understanding of long-term effects of trauma expanded

  • Effective treatments available

  • People in need of treatments do not always get the care they need 

• Trauma-informed care - a treatment framework that involves recognizing and responding to the effects of all types of trauma

Trauma-Related Disorders (Cont.)

• Attachment Disorders

  • Reactive attachment disorder

  • Disinhibited social engagement disorder

• Posttraumatic Stress Disorder (PTSD)

  • PTSD in children

  • PTSD in adults

• Acute Stress Disorder

• Adjustment Disorder

Posttraumatic Stress Disorder in Children & Adolescents

• Clinical picture

  • Posttraumatic stress disorder (PTSD) is seen even in preschool children 

  • Manifestations

    • Reduction in play or play reflecting aspects of the trauma

    • Self-blame, detachment, estrangement, loss of interest in significant activities

    • Mood changes, sleep disturbances, hypervigilance, loss of concentration

Application of the Nursing Process of tramua children

• Assessment

  • Essential assessment data

  • Developmental assessment

• Nursing diagnoses

  • Post trauma response

  • Impaired caregiver-child attachment

  • Impaired adolescent development

Implementation Stages

• Stage 1: Provide safety and stabilization

• Stage 2: Reduce arousal and regulate emotion through symptom reduction and memory work

• Stage 3: Catch up on developmental and social skills; develop a value system

• Window of Tolerance

Interventions for Child with PTSD

• Use interactive process 

• Establish trust and safety 

• Use developmentally appropriate language 

• Teach relaxation techniques before trauma exploration to restore a sense of control 

• Use art and play to promote expression of feelings

Interventions for Child with PTSD (Cont.)

• Involve 

  • Involve caretakers in 1:1s, unless they are the cause of trauma 

• Educate 

  • Educate child and caretakers about grief process and response to the trauma 

• Assist 

  • Assist caretakers in resolving their own emotional distress about the trauma 

• Coordinate 

  • Coordinate with social work for protections

Treatment Modalities of children tramua

• Biological Treatments

  • Pharmacotherapy combined with EMDR therapy or CBT

  • Target symptoms and comorbidities like ADHD or MDD

• Psychological Therapies

  • CBT

  • EMDR (Eye Movement Desensitization and Reprocessing)

Trauma-Related Disorders in Adults

• Posttraumatic Stress Disorder (PTSD)

• Acute Stress Disorder

• Adjustment Disorder

Post-traumatic Stress Disorder in Adults

• Examples of PTSD-Inducing Events

  • Military combat or hostage situations

  • Crime-related events

  • Assault

  • Natural disasters

  • Human disasters (accidents)

  • Medical care

Application of the Nursing Process for adult tramua

• Assessment

  • Primary Care PTSD Screen (PC-PTSD) 

  • PTSD Checklist (PCL-5) 

• Nursing Diagnoses

  • Post-trauma response

  • Anxiety (moderate, severe, panic) 

  • Ineffective coping

  • Social isolation

  • Insomnia

  • Sleep deprivation

  • Hopelessness

  • Chronic low self-esteem

  • Self-care deficit

Application of the Nursing Process (Cont.)

• Outcome Identification

  • Manages anxiety

  • Experiences enhanced self-esteem

  • Exhibits an enhanced ability to cope

• Implementation

  • Use same stage model of treatment used for children 

  • Health teaching & promotion

  • stages

  • 1. Safety 2. reduce 3. Develop skills 

Application of the Nursing Process (Cont.)

• Evaluation: The patient…

  • Recognizes symptoms as related to the trauma 

  • Uses learned strategies to manage anxiety 

  • Has no flashbacks or intrusive thoughts 

  • Sleeps adequately without nightmares                                                                

  • Assumes usual roles

  • Has satisfying interpersonal relationships

Treatment Modalities for adult tramua

• Biological Treatment 

  • Pharmacotherapy 

  • Antidepressants 

  • SSRIs 

• Psychological Therapies 

  • Components of exposure and/or cognitive restructuring and EMDR therapy (eye movement desensensitive and reprocessing therapy)

Discussion

A patient is being evaluated in terms of successful outcomes. Identify things the nurse would look for as evidence of success in each of these three areas:

• Manages anxiety

• Experiences enhanced self-esteem

• Exhibits an enhanced ability to cope

Acute Stress Disorder

• Develops after exposure to a highly traumatic event

• Diagnosed 3 days to 1 month after traumatic event

Acute Stress Disorder (Cont.)

• Diagnosis: 8 or more of the following, during or after traumatic event 

  • A subjective sense of numbing

  • Derealization

  • Inability to remember at least one important aspect of the event

  • Intrusive distressing memories of the event

  • Recurrent distressing dreams

  • Feeling as if the event is recurring

  • Intense prolonged distress or physiological reactivity (racing heart, sweating) 

• Avoidance of thoughts or feelings about the event

• Sleep disturbances

• Hypervigilance

• Irritable, angry or aggressive behavior

• Exaggerated startle response

• Agitation or restlessness 

Application of the Nursing Process of acute stress disorder

• Assessment

• Nursing Diagnoses

  • Post-trauma response

  • Impaired adaptation 

  • Anxiety (specify level) 

• Outcomes Identification

  • Reduced response to trauma

  • Improved adaptation

  • Decreased anxiety

Application of the Nursing Process (Cont.)

• Implementation

  • Establish therapeutic relationship

  • Assist to problem solve

  • Connect person to supports

  • Educate about ASD

  • Collaborate for coordination of care 

  • Ensure and maintain safety

  • Monitor response and/or adherence to treatment 

• Evaluation (similar to that for PTSD)

Adjustment Disorder

• A milder, less specific version of ASD and PTSD 

• Precipitated by stressful event (retirement, breakup) 

• Symptoms may include all forms of distress (guilt, depression, anxiety, anger) 

  • These feelings may be combined with other manifestations of distress (physical complaints, social withdrawal, impaired occupational function, academic decline)

Dissociative Disorders

• Dissociative Amnesia

• Depersonalization/Derealization Disorder

• Dissociative Identity Disorder

Dissociative Disorders

• Occur after significant adverse experiences/traumas 

• Individuals respond to stress with severe interruption of consciousness

• Unconscious defense mechanism

• Protects individual against overwhelming anxiety through emotional separation

• Results in disturbances in memory, consciousness, self-identity, perception 

Dissociative Disorders (Cont.)

• Risk Factors

  • Biological: genetic, neurobiological

  • Cognitive

    • Dissociation is a defense mechanism using separate parts of the personality that are not fully integrated, each becoming dominant depending on the situation

  • Environmental

    • Response to acute overwhelming trauma

  • Cultural

Dissociative Amnesia

• Inability to recall important personal information

• Often of traumatic or stressful nature

• Dissociative fugue 

  • Subtype characterized by sudden, unexpected travel and inability to recall one’s identity/information about the past

Depersonalization/Derealization Disorder

• Persistent or recurrent episodes of…

  • Depersonalization—focus on self: extremely uncomfortable feeling of being an observer of one’s own body or mental processes 

  • Derealization—focus on outside world: recurring feeling that one’s surroundings are unreal or distant. Person feels as if walking around in a fog, bubble, or dream. 

    • Diagnosed when other disorders cannot be explained like ptsd 

Dissociative Identity Disorder 

• Presence of two or more distinct personality states 

• Each alternate personality (alter) has own pattern of

  • Perceiving

  • Relating to and 

  • Thinking about the self and environment

• Cognitive distortion

  • an insistence that the “alters” inhabit separate bodies and are unaffected by the actions of one another

Application of the Nursing Process of dissociative disorders

• Assessment

  • Memory assessment

  • History (especially of self-harm)

  • Mood

  • Impact on patient and family

  • Suicide risk

  • Self-assessment

Application of the Nursing Process (Cont.)

• Nursing Diagnosis

  • Disturbed personal identity

  • Impaired role performance

  • Anxiety (specify level) 

• Outcomes Identification (personality integration) 

  • Improved personal identity

  • Improved role performance

  • Reduced anxiety

Application of the Nursing Process (Cont.)

• Planning

  • Phase 1: safety, stabilization, symptom reduction 

  • Phase 2: confronting and integrating traumatic memories

  • Phase 3: Identify integration and rehabilitation 

Application of the Nursing Process (Cont.)

• Implementation 

  • Process of integration and linking previously disconnected neural networks 

  • Interventions offering emotional presence

  • Health Teaching and Promotion 

    • Normalize experiences by explaining symptoms are adaptive responses to past overwhelming events 

    • Teach grounding techniques 

Application of the Nursing Process (Cont.)

• Evaluation

  • Treatment effectiveness for dissociative identity disorder is “integration”

  • Treatment considered successful when outcomes are met:

    • Patient safety maintained

    • Anxiety reduced

    • Integration of fragmented memories 

    • New coping strategies 

    • Stress is handled adaptively, without use of dissociation 

Treatment Modalities of dissociative disorder

• Biological Treatment: Pharmacotherapy

  • No specific medications

  • Medications for hyperarousal and intrusive symptoms

• Psychological Therapies

  • CBT, psychodynamic psychotherapy, exposure therapy, modified EMDR therapy, hypnotherapy, neurofeedback, ego state therapies, somatic therapies, and medication

• Somatic Therapy

Grounding Techniques

• 3-3-3: 

  • Name 3 things you hear, 3 things you see, and move 3 parts of your body

• 4-7-8 breathing

  • Deep breathe in for 4 seconds

  • Hold breath for 7 seconds

  • Breathe out for 8 seconds (optional: make a “wooo” sound)

• Drink cold water