Involuntary and Emergency Psychiatric Admission & Anxiety Disorders Overview

Voluntary admission

Patient presents to the facility of their own volition for treatment.

Patient Consents

Involuntary commitment

Individual is a danger to self or other, unable to acquire basic necessities, and done without patient's consent.

Requirements for petition

- Exhibiting danger to self

- Exhibiting danger to other

- Being persistently or acutely disables (PAD)

- Being gravely disabled

Emergency admission

A temporary admission process requiring an application filed with the county attorney.

Anyone with eyewitness, clear evidence can request/ file a petition to county attorney/s office

• Can be law enforcement, family members, friends, outpatient providers, ANYONE who is a witness

Used for observation, diagnosis, and treatment

Generally can remain inpatient for 24-96 hours (72 for Arizona)

Involuntary commitment steps

Once it is determined a petition is needed, the individual is brought to the facility and receives an evaluation

· Must be seen by a psychiatrist

· If psychiatrist recommends inpatient care, individual is admitted (by court order)

· Can be held in Arizona for 72 hours involuntarily for more evaluation

Individual is entitled to a court hearing at 72 hours

· Psychiatrists present diagnostic findings and treatment plan to the court

· Patient can comment and provide their own details

· Judge can dismiss or place patient under court-ordered treatment (COT)-Title 36

· COT is one year in length and at time of expiration, patient must be evaluated for compliance and COT is either dismissed or renewed.

Patient must comply with all inpatient AND outpatient care

· Failure to comply results in revocation and patient is involuntarily admitted to Level 1 facility (locked inpatient) for evaluation and stabilization.

Court-ordered treatment (COT)

A treatment plan mandated by the court for one year, requiring evaluation for compliance at expiration.

Court ordered treatment and implications to nursing care

Patients under the 72-hour petition can refuse all care, including medications

• -If they exhibit dangerous behaviors to themselves, other patients, or to staff, they can receive PRN medications against their consent.

• -Behaviors, including refusal to medications, is documented and can be used to support a COT request during court hearings

After 72 hours, patients who are court-ordered MUST comply with all treatment, including medications

• -Oral (first offered) or injectable (voluntarily or without consent) medications.

• -Includes outpatient requirements (weekly check-in with case manager, attending all appointments and maintaining contact).

Who can be admitted against their will?

Individual is a danger to self or other

Unable to acquire basic necessities

• Done without patient's consent

A person needing petition is behaving abnormally and must meet at least one of the following:

• Exhibiting danger to self

• Exhibiting danger to other

• Being persistently or acutely disables (PAD)

• Being gravely disabled

What is an emergency petition

An emergency petition is a legal process to place someone in a psychiatric hospital on an immediate and involuntary basis. The legal statute for petitions is taken from AZ State Statute Title 36 and is often referred to as "Title 36". The process is initiated using an "Emergency Application" that is filed with the county attorney where the person being petitioned resides or action takes place. This application is "good" for 24 hours. Police can bring a patient to a psychiatric facility against their will during that time.

Purpose of petition

A petition is used to protect the public and/or the person considered for involuntary admission from behaviors that are a danger to oneself (DTS), a danger to others (DTO), or that show signs of persistent and acute symptoms that cause safety concerns.

Who can complete the application for a petition?

Anyone. You must be an eyewitness and have first-hand knowledge of the information that can be used as evidence that a person shows dangerous behaviors. Healthcare personnel can and do submit applications if a patient they are caring for is exhibiting dangerous behaviors (example: suicidal patient in the ED).

What kinds of behavior are considered "Dangerous"?

You can call 9-1-1 for the police/sheriff if you are concerned about a family member, friend, or neighbor. Additionally, you can bring the person in question to the nearest Emergency Department.

People can be admitted to a hospital despite their wishes, or involuntarily, if they are unable to function in certain defined ways. There must be a 'substantial disorder of the person's emotional processes, thought, cognition, or memory." The actual diagnosis is not the primary factor; it is the individual's ability to function.

In Arizona, involuntary mental health treatment can be sought for four reasons:

• Exhibiting danger to self

• Exhibiting danger to others

• Being persistently or acutely disabled.

• Being gravely disabled.

72-hour hold

The maximum duration an individual can be held involuntarily for evaluation in Arizona.

Patients rights under the law

Right to treatment

Right to refuse treatment

Right to informed consent

- Indicates that the patient has been provided with basic understanding of risks, benefits, and alternatives

- Person must voluntarily accept treatment

- To be effective legally, the consent must be accompanied by information provided by a physician or advanced practice provider.

Can my patient be forced to take medication?

Patients have the right to refuse treatment in any setting, including psychiatric settings. Patients who are admitted voluntarily can refuse or withdraw consent at any time.

EXCEPTIONS to this include

1) emergency situations where a person needs to be prevented from serious harm to self or others (including staff)

2) a patient who has COT in place. Even with COT, a patient has the right to the least invasive route for medication (oral tablet vs. injection).

Does my patient have any control over his/her care?

Yes. All patients have the following rights:

• 1. The right to quality treatment.

• 2. The right to be free from excessive/unnecessary medication.

• 3. The right to privacy and confidentiality (remember HIPAA, no social media, etc.).

• 4. The right to the least restrictive environment (restraints, seclusion, proper settings for care).

• 5. The right to an attorney, clergy, private care providers.

• 6. The right to fully informed consent for treatments.

Are there any exceptions to these rights?

Yes.

1. Healthcare providers have the duty to warn people who may be intended targets of a patient who is threatening harm to them.

2. Child abuse/elder abuse/disabled adult abuse must be reported to governmental agencies.

Positive therapeutic communication techniques

Communication techniques that promote a positive interaction between healthcare providers and patients.

o Active listening

o Silence (allow the patient to speak, not to be confused with ignoring)

o Clarifying

o Questions

Nontherapeutic communication

Nontherapeutic techniques may be done unintentionally. When this happens, it is best to try and redirect the conversation in a positive way using the above positive techniques. The nontherapeutic techniques include:

o Excessive questioning

o Giving approval or disapproval

o Giving advice (even when asked)

o Asking "why" questions

Mild anxiety

• Normal anxiety/ mind anxiety is necessary for survival

• Perceptual field: heightened perceptual field

o Focus is flexible and is aware of the anxiety

• Ability to solve problems: Able to work effectively toward and goal and examine alternatives

• Can grasp more information effectively

• Mild and moderate levels of anxiety can alert the person that something is wrong and can stimulate appropriate action.

Ability to solve problems in mild anxiety

Individuals can work effectively toward goals and examine alternatives.

Physical Characteristics of Mild Anxiety

o Slight discomfort

o Attention-seeking behavior

o Restlessness

o Easily startled

o Irritability or impatience

o Mild tension-relieving behavior (foot or finger tapping, lip chewing, fidgeting)

Moderate anxiety

A level of anxiety that is more intense than mild but not as severe as panic.

• Not beneficial anymore

• Narrowed perceptual field (selective inattention, only focused on the problem)

• Grasps less of what is going on

• Focuses on the source of the anxiety

• Less able to pay attention

• Able to solve problems but not at optimal level

• Sympathetic and nervous system symptoms begin

physical characteristics of moderate anxiety

o Voice tremors

o Change in voice pitch

o Poor concentration

o Shakiness

o Somatic complaints (urinary frequency, headache, backache, insomnia)

o Increased respiration, pulse, and muscle tension

o More tension-relieving behavior (pacing, banging hands on table)

Severe anxiety

An intense level of anxiety that can lead to panic.

• Greatly reduced and distorted perceptual field (tunnel vision)

• Focuses on details or one specific detail

• Confused and automatic behavior

• Attention is scattered

• Problem solving feels impossible

• Unable to see connections between events or details

• Critical thinking is not possible

• Somatic symptoms increase

o Increased HR, headache, upset stomach

• Severe and panic levels of anxiety prevent problem solving. Unproductive relief behaviors perpetuate a vicious cycle.

Physical characteristics of severe anxiety

o Feelings of dread

o Confusion

o Purposeless activity

o Sense of impending doom

o More intense somatic complaints (chest discomfort, dizziness, nausea, sleeplessness)

o Diaphoresis (sweating)

o Withdrawal

o Loud and rapid speech

o Threats and demands

Panic

An overwhelming sense of fear or anxiety that can lead to physical symptoms.

• Unable to attend to the environment

• Focus is lost; may feel unreal (depersonalization) or that the world is unreal (derealization)

• Completely unable to process what is happening

• Markedly disturbed behavior - running, shouting, screaming, pacing

• Unable to process reality; impulsivity

• Disorganized or irrational reasoning

Physical characteristics of panic

o Experience of terror

o Immobility, severe hyperactivity, or flight

o Unintelligible communication or inability to speak

o Amplified or muffled sounds

o Somatic complaints increase (numbness or tingling, shortness of breath, dizziness, chest pain, nausea, trembling, chills, overheating, palpitations)

o Severe withdrawal

o Hallucinations or delusions

o Likely out of touch with reality

Nursing interventions for mild to moderate anxiety

Help the patient identify the anxiety and assist in problem solving.

o What are you feeling? How uncomfortable are you?

o Help patients identify thoughts and feelings driving the anxiety

o Assist in problem solving

o Assist them in getting involved in activities

Nursing interventions for severe to panic anxiety

Focus on patient safety and meeting physical needs.

o Can guide person to quiet environment

o Use of seclusion or restraints may have to be considered

o they need to know that they are safe from their own impulses

o Teamwork and safety (keep eye on patient at all times)

o Quiet demeanor and calm environment

o Set limits if patient expresses anxiety physically

o Walk with them

o PRN medications

o Provide fluids - anxious patients may not be eating or drinking enough

o Firm, short, and simple statements are useful

Pharmacologic therapy for anxiety

o Antidepressants - SSRIs (long term)

o Anti-anxiety drugs - lorazepam, gabapentin, hydroxyzine

o For unsafe behaviors may need injectable of antipsychotic, lorazepam, and diphenhydramine

Positives of mild anxiety

· Increased ability to problem solve

· Increased focus

panic nursing actions

Maintain a calm manner

·calm will calm

Always remain with the person experiencing an acute, severe, or panic level of anxiety

· Alone with immense anxiety, a person feels abandoned.

Minimize environmental stimuli. Move to a quieter setting, and stay with the patient

· Helps to minimize further escalation of the patient's anxiety.

Use clear statements and repetition

· A person experiencing a severe to panic level of anxiety has difficulty concentrating and processing information.

Use a low pitched voice, speak slowly

· A high-pitched voice can convey anxiety.

Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present).

· Anxiety can be reduced by focusing on and validating what is going on in the environment.

Listen for themes in communication.

· In severe to panic levels of anxiety, verbal communication themes may be the only indication of the patient's thoughts or feelings.

Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact).

· High levels of anxiety may obscure the patient's awareness of physical needs.

Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you."

Staff must offer the patient and others protection from destructive and self-destructive impulses.

Provide opportunities for exercise (e.g., walk with nurse, punching bag, ping-pong game).

· Physical activity helps channel and dissipate tension and may temporarily lower anxiety.

When a person is constantly moving or pacing, offer high-calorie fluids.

· Dehydration and exhaustion must be prevented.

Assess need for medication or seclusion after other interventions have been tried and have been unsuccessful.

Adaptive coping strategies

Problem focused counseling and cognitive-behavioral therapy

emotional focused; mindfulness, yoga, humor, spiritual practices, exercise.

Maladaptive coping strategies

Avoidance or withdrawal

substance use.

Defense mechanism

Automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories.

Can be healthy or unhealthy

Conversion

Unconscious transformation of anxiety into a physical symptom with no organic cause. Never adaptive.

Example: A man becomes blind after seeing his wife enter a hotel room with another man.

Projection

Unconscious rejection of emotionally unacceptable features and attributing them to others. Immature defense mechanism. Not positive ever.

Example: A woman who has repressed an attraction toward other women refuses to socialize. She fears that another woman will come on to her.

Splitting

Inability to integrate the positive and negative qualities of oneself or others into a cohesive image. No positive examples.

Example: A 26-year-old woman initially values her acquaintances yet invariably becomes disillusioned when they turn out to have flaws.

Regression

Reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been exhibited previously.

Adaptive example: A 4-year-old boy with a new baby brother temporarily starts sucking his thumb and asking for a baby bottle.

Maladaptive example: A man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.

Displacement

Transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation.

Adaptive example: A child yells at his teddy bear after being picked on by the school bully.

Maladaptive example: A child who is unable to acknowledge fear of his father becomes fearful of animals.

Panic Disorder

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

- feelings of terror

- perceptual field severely limited

- misinterpretation of reality may occur

- may believe that they are losing their minds or having a heart attack

- Typically come out of the blue

- People who experience these attacks begin to "fear the fear." They become so preoccupied with the possibility of future episodes that they avoid what could be pleasurable and adaptive activities, experiences, and obligations.

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

- Situations that are commonly avoided are being alone outside; being alone at home; traveling in a car, bus, or airplane; being on a bridge; and riding in an elevator

- Adverse childhood experiences and stressful life events are associated with the development of agoraphobia

- Can develop from panic disorders

- Strong heritability factor

Separation Anxiety Disorder

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

- fear that something horrible will happen to the other person and that it will result in permanent separation

• feelings are appropriate in childhood not in adulthood

- characteristics: harm avoidance, worry, shyness, uncertainty, fatigability, and a lack of self-direction

- so intense that it distracts sufferers from their normal activities and causes sleep disruptions and nightmares

- often manifested in physical symptoms, such as gastrointestinal disturbances and headaches

Characteristics of Separation Anxiety Disorder

harm avoidance, worry, shyness, uncertainty, fatigability, and a lack of self-direction

Generalized Anxiety Disorder

Characterized by overall excessive worry

- Worry that last for months

- Common worries in generalized anxiety disorder are inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members

- huge amounts of time are spent in preparing for activities

- putting things off and avoidance are key symptoms and may result in lateness or absence from school or employment and overall social isolation

- Sleep disturbance

- Parental overprotection and adverse experiences are associated with anxiety disorders

Common worries in Generalized Anxiety Disorder

inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members

Symptoms of Generalized Anxiety Disorder

huge amounts of time are spent in preparing for activities; putting things off and avoidance are key symptoms

Phobias

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

Impact of Phobias

compromise a person's daily functioning, and phobic people go to great lengths to avoid the feared object or situation

Obsessive-Compulsive Disorders - Obsessions

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

- often seem senseless to the individual who experiences them (they are said to be ego dystonic), and their presence causes severe anxiety

- Example: My hands are dirty/ I am contaminated

Ego dystonic

obsessions often seem senseless to the individual who experiences them and their presence causes severe anxiety

Obsessive-Compulsive Disorders - Compulsions

ritualistic behaviors individuals feel driven to perform in an attempt to reduce anxiety or prevent an imagined calamity

- Performing the compulsive act temporarily reduces anxiety, but because the relief is only temporary, the compulsive act must be repeated again and again

- Example: I am going to wash my hands

Obsessive-Compulsive Disorder

symptoms that occur on a daily basis and may involve issues of sexuality, violence, contamination, illness, or death

- Pathological obsessions or compulsions cause marked distress to individuals who often feel humiliation and shame regarding these behaviors

- rituals are time-consuming and interfere with normal routines, social activities, and relationships with others

- Sexual and physical abuse or trauma in childhood increase the risk of this disorder

Nursing actions for patients

Patients usually do NOT 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.

Benzodiazepines

Promote the activity of GABA by binding to a specific site on the GABAA receptor complex.

Example: Xanax

Buspirone

Acts as a partial serotonin (5-HT)-1A receptor agonist.

Antidepressant medications

Possess antianxiety effects and are first-line treatment options for anxiety and anxiety-related disorders.

•The symptoms, neurotransmitters, and circuits associated with anxiety disorders overlap extensively with those of depressive disorders

•Antidepressant medications possess antianxiety effects and are first-line treatment options for anxiety and anxiety-related disorders

•antidepressants require 4 to 8 weeks for onset of antianxiety effects

•first line treatment

Onset of antianxiety effects for antidepressants

Require 4 to 8 weeks.

Generalized anxiety disorder treatment options

SSRIs, SNRIs, and Benzodiazepines.

SSRIs examples for Generalized anxiety disorder

Escitalopram (Lexapro), Paroxetine (Paxil).

SNRIs examples for Generalized anxiety disorder

Venlafaxine (Effexor), Duloxetine (Cymbalta).

Benzodiazepines examples for Generalized anxiety disorder

Alprazolam (Xanax), Chlordiazepoxide (Librium), Clorazepate (Tranxene), Diazepam (Valium), Lorazepam (Ativan), Oxazepam (Serax).

SSRIs examples for Panic disorder

Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft).

Benzodiazepines examples for Panic disorder

Alprazolam (Xanax), Clonazepam (Klonopin).

SSRIs examples for Social anxiety disorder

Paroxetine (Paxil), Sertraline (Zoloft).

How long do drugs take to work?

· Buspirone - 2-4 weeks

· Antidepressants: 4-8 weeks for anti-anxiety

Short acting/ emergency drugs vs long acting

· Buspar (buspirone)

- Ongoing basis

· Ativan (lorazepam)

o PRN

· Elavil (amitriptyline)

o TCA

o Ongoing basis

· Lexapro (escitalopram)

o Ongoing

· Vistaril/Atarax (hydroxyzine)

o As needed

Exposure and Response Prevention

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

the patient is exposed to stimuli that trigger the specific OCD symptoms. For patients with contamination fears, this might involve having them touch a doorknob or faucet handle. Patients then prevent themselves from performing the compulsive ritual of handwashing. The patient learns that anxiety does subside even when the ritual is not completed. After trying this in the office, the patient learns to set time limits at home to gradually lengthen the time between rituals until the urge fades away.

Cognitive Behavioral Therapy

Combines cognitive therapy with specific behavioral therapies to reduce the anxiety response.

- 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 situation

- cognitive model of anxiety disorder is based on the premise that people with these disorders overestimate the danger of situations and underestimate their own ability to handle them

- triggering situations lead to catastrophic automatic thoughts. Patients are taught to monitor the thoughts that occur prior to anxiety responses, learn to challenge these thoughts, and replace them with a more realistic appraisal.

Cognitive model of anxiety disorder

Based on the premise that people with these disorders overestimate the danger of situations and underestimate their own ability to handle them.

Somatic Symptom Disorder

Expression of stress through physical symptoms that are often manifestations of psychological and emotional distress.

•Expressed in place of anxiety, depression, or irritability

•Holistic approach: multidimensional interplay of biological, psychological, and sociocultural needs and its effect on somatization

focus on somatic (physical) symptoms, such as pain or fatigue, to the point of excessive concern, preoccupation, and fear

•One or more distressing symptoms

•Suffering is authentic

Patients' suffering is authentic, and they typically experience a high level of functional impairment

Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one's symptoms

2. Persistently high level of anxiety about health or symptoms

3. Excessive time and energy devoted to these symptoms or health concerns

tends to be a high level of help seeking

Illness anxiety disorder

Characterized by extreme worry and fear about the possibility of having a disease.

- Misinterpretation of physical sensations

- Preoccupation with having or acquiring serious illness for at least 6 months

- High anxiety

- worry leads to frequent self-scanning for signs of illness.

- Actual symptoms and complaints of symptoms are either mild or absent

- Thoughts about illness may be intrusive and hard to dismiss even when patients realize their fears are unrealistic

- May be care seeking or care avoidant

Conversion Disorder

Manifests itself as neurological symptoms in the absence of a neurological diagnosis.

- presence of deficits in voluntary motor or sensory functions, including paralysis, blindness, movement disorder, gait disorder, numbness, paresthesia (tingling or burning sensations), loss of vision or hearing, or episodes resembling epilepsy

- many patients show a lack of emotional concern about often dramatic symptoms. This response is called la belle indifference "the grand" indifference

La belle indifference

A lack of emotional concern about often dramatic symptoms.

Psychological Factors Affecting Medical Conditions

Psychological factors may increase the risk of medical disease or magnify and adversely affect a medical condition.

- psychiatric disorders are connected with cardiovascular disease

- Major depressive disorder is a risk factor in the occurrence of coronary heart disease

- association between depression and cancer incidence has been suggested

- Loneliness and weak interpersonal connections are associated with negative health outcome

- Adverse childhood experiences (ACEs) have been shown to contribute to more negative health outcomes in adulthood

- can cause neurobiological changes such as alterations in the volume and activity levels of major brain structures

Factitious Disorder

Consciously ************* ill to have their emotional needs met and achieve the status of patient.

- consciously pretend to be ill to have their emotional needs met and achieve the status of patient

- patients with this disorder artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury with the goal of assuming the sick role

- An older term for factitious disorder is Munchausen syndrome

Munchausen syndrome

An older term for factitious disorder.

Factitious Disorder Imposed on Self

Admission to the hospital often begins in the emergency department with a dramatic description of an illness using unusually proper medical terminology.

- often reluctant for professionals to speak with family members, friends, or previous healthcare providers

- patient is frequently demanding and requests specific treatments and interventions.

- Negative test results are often followed by new symptoms

- Patients go from one primary care provider or hospital to another.

- Serious complications and sepsis may result from self-injections of toxins such as E. coli.

- Patients may have "crisscrossed" or "railroad-track" abdomens due to scars from numerous exploratory surgeries to investigate unexplained symptoms

Factitious Disorder Imposed on Another

Also known as Munchausen syndrome by proxy.

- caregiver deliberately falsifies illness in a vulnerable dependent

- The diagnosis is imposed on the perpetrator and not the victim.

- People with this disorder may receive awards such as insurance money or other compensation

- Even in the absence of awards, they do it for the purpose of attention and excitement and to perpetuate the relationship with the healthcare providers of that dependent

Malingering

Consciously motivated act of fabricating an illness or exaggerating symptoms for secondary gain.

- conscious fabrication

This is done for secondary gain to become eligible for such things as disability compensation, committing fraud against insurance companies, obtaining prescription medications, evading military service, or receiving a reduced prison sentence

In somatic disorder the patient realty feels the symptoms, in malingering there is no symptoms or they are exaggerated. Purposeful deceitfulness

Priority Outcomes for ETOH Detox

Short-term acute detox, long-term residential, medically managed inpatient programs, halfway houses, partial hospitalization program, intensive outpatient programs, and outpatient treatment.

Halfway Houses

Residential treatment in a substance-free communal or family environment that provides opportunities for independent growth.

focus is on extending the period of sobriety; getting case management assistance in addressing educational, economic, and social needs; and integrating new life skills into a solid modeled recovery program.

Partial Hospitalization Program

Intensive form of outpatient programming for those individuals who do not need a 24-hour residential treatment.

Partial programs tend to run 5 days a week for about 6 hours a day with planned programming

Intensive Outpatient Programs

Nonresidential program, highly structured with scheduled treatment groups and at least one individual session regularly.

Participants attend at least 3 days a week for about 3 hours/day.

Outpatient Treatment

Structured, drug-free, and nonresidential programming consisting of not more than 5 contact hours a week.

Blood Alcohol Content (BAC)

Correlation between BAC and expected detox; the higher the BAC, the more severe the detox likely to be.

Addiction

Compulsive or chronic requirement where the need is so strong that if not fulfilled causes distress in the person.

- chronic medical condition with roots in the environment, neurotransmission, genetics, and life experiences

- cycles of relapse and remission

- addiction is progressive and often results in disability or premature death

- interferes with the ability to fulfill role obligations

- Cannot cut down or control use

- Intense cravings

Intoxication

- process of using a substance to excess

- Reversible symptoms once the substance has been processed by the body

- Persons can be intoxicated but NOT addicted

- individuals who are using substances are considered to be under the influence, intoxicated, or high

- Occurs when BAC reaches 100-200 mg/ dL

Tolerance

Occurs when a person no longer responds to the drug as initially, requiring a higher dose to achieve the same level of response.

Behavioral Addictions

Such as gambling, result in psychological withdrawal symptoms, including cravings, sleep disruption, anxiety, and depression.

Withdrawal

- set of physiological symptoms that occur when a person stops using a substance

- specific to the substance being used, and each substance will have its own characteristic syndrome

- can be mild or life threatening

- Behavioral addictions such as gambling result in psychological withdrawal symptoms, including cravings, sleep disruption, anxiety, and depression

Dependence

Distinction between substance abuse and dependence; dependence is a more severe manifestation seen in long-term use.

- Seen in long term use

- The body goes through a withdrawal period when the substance is removed

- Patient experiences physical symptoms which is unpleasant

- Removal of substance may be deadly

Clinical Picture of Opioid Use Disorder

The body goes through a withdrawal period when the substance is removed, and the patient experiences unpleasant physical symptoms.

S/S Opioid Intoxication

Signs and symptoms of intoxication include

• Bradycardia (slow pulse)

• Hypotension (low blood pressure)

• Hypothermia (low body temperature)

• Sedation/ drowsiness

• Miosis (pinpoint pupils) - pupil constriction

• Hypokinesis (slowed movement)

• Slurred speech

• Head nodding

• Euphoria

• Analgesia (pain-killing effects)

• Calmness

• Impaired judgement

S/S Opioid Withdrawal

Signs and symptoms of withdrawal include

• Tachycardia (fast pulse)

• Hypertension (high blood pressure)

• Hyperthermia (high body temperature)

• Insomnia

• Mydriasis (enlarged pupils)

• Hyperreflexia (abnormally heightened reflexes)

• Diaphoresis (sweating)

• Piloerection (gooseflesh)

• Increased respiratory rate

• Lacrimation (tearing), yawning

• Rhinorrhea (runny nose)

• Muscle spasms

• Abdominal cramps, nausea, vomiting, diarrhea

• Bone and muscle pain

• Anxiety

• Yawning

• Yawning and runny nose big indicators that are different in opioid withdrawal

Naloxone

A reversal agent that can be given intranasally, intramuscularly, subcutaneously, or intravenously.

• can be given intranasally, intramuscularly, subcutaneously, or intravenously

• Methadone and clonidine can be used in opioid withdrawal

Alcohol Use Disorder

A disorder characterized by excessive alcohol consumption leading to various health issues.

Alcohol Intoxication

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

Wernicke-Korsakoff Syndrome

Memory deficits due to lack of thiamine