NURS 432 psych lec unit 3

Ben Martin

Department of Health and Human Services’ five-point program to address the opioid crisis

•Access: Better prevention, treatment, and recovery services

•Data: Better data on the epidemic

•Pain: Better pain management

•Overdoses: Better targeting of overdose-reversing drugs

•Research: Better research on pain and addiction

*the current crisis may have been triggered by careless over-prescription of opioid analgesics, exacerbated by recreational use of heroin and illicit synthetic opioids

dementia

Progressive cognitive impairment; multiple cognitive deficits; initially memory, later the following may be seen-

• Aphasia (deterioration in language fxn)

• Apraxia (impaired ability to execute motor functions despite intact motor abilities)

• Agnosia (inability to recognize or name objects despite intact sensory abilities)

  • echolalia- echoing what is heard

  • palilalia- repeating words or sounds over and over

Disturbance in executive function- significant decline from earlier functioning. May need assistance with ADLs.

• MEMORY is a significant impairment

• also learning new material

• may also underestimate the risks associated with activities or overestimate their ability to function in certain situations

• loses items & gets extremely anxious

tx

• meds to manage sx

vA client makes up answers to fill in memory gaps. The nurse identifies this as which of the following?

confabulation - common in dementia

types of dementia

🧠 Alzheimer Disease (most common)

• Cause: Unknown; brain atrophy + plaques/tangles (neurodegeneration)

• Onset: Gradual, progressive

• Key signs: Memory loss → language + motor decline, personality changes

🧠 Lewy Body Dementia

• Cause: Lewy body protein deposits

• Key signs: Visual hallucinations (early hallmark), Fluctuating cognition, Parkinson-like motor symptoms

• Nursing tip: High sensitivity to antipsychotics ⚠

🧠 Vascular Dementia

• Cause: ↓ cerebral blood flow (strokes, vascular lesions)

• Onset: Sudden → stepwise decline (plateaus)

• Key signs: Similar to Alzheimer but more abrupt changes

• Nursing tip: Focus on stroke prevention (BP, diabetes, smoking)

🧠 Frontotemporal Dementia (Pick disease)

• Cause: Degeneration of frontal/temporal lobes (often genetic)

• Onset: Earlier (50–60 yrs)

• Key signs: Personality changes FIRST, Disinhibition, poor judgment, Language problems

• Course: Rapid (2–5 years)

• Nursing tip: Behavioral management is priority early

🧠 Prion Disease

• Cause: Infectious misfolded proteins (prions)

• Key signs: Rapid dementia + motor dysfunction

• Course: Very rapid (months)

• Nursing tip: Rare but fatal; strict infection control

🧠 HIV-Associated Dementia

• Cause: Direct CNS infection or opportunistic infections

• Nursing tip: Manage HIV + prevent infections

🧠 Huntington Disease

• Cause: Genetic

• Onset: 30s–40s

• Key signs: Chorea (involuntary movements), Personality changes → dementia

• Course: Long (10–20 years)

🧠 Traumatic Brain Injury (TBI) Dementia

• Cause: Head trauma (single or repeated)

• Course: Single injury → stable; Repeated injury → progressive

• Nursing tip: Prevention (helmets, safety) + monitor cognition

delirium

Syndrome involving disturbance of consciousness with change in cognition

• Usually develops over short period

• Etiology: almost always results from identifiable physiological, metabolic, or cerebral disturbance, or disease or from drug intoxication or withdrawal

Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. they also experience disturbances in the sleep–wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy.

common in elderly, esp inpatient or post-procedure, and terminally-ill

worsens at night

tx- address underlying problem. This is a transient condition so it will pass

• sedation, benzos, or antipsychotics for agitated / symptomatic patients. even tho benzos may worsen delirium in the elderly

• restraints only if needed

disruptive behavior disorders

Characterized by persistent patterns of behavior that involve: Anger, Hostility, Aggression,

• Toward people and/or property

• ex- oppositional defiant disorder (ODD), conduct disorder, and intermittent explosive disorder (IED)

• also kleptomania (stealing) and pyromania (setting fires)

• often diagnosed from adolescence to young adulthood

Oppositional Defiant Disorder (ODD)

Enduring pattern of uncooperative, defiant, disobedient, hostile behavior toward authority figures. ODD is diagnosed only when behaviors are more frequent and intense than in unaffected peers and cause dysfunction in social, academic, or work situations.

• Certain level of this behavior is common in children and adolescents (2-3 years; early adolescence)

• Limited ability to make connection between behaviors and consequences

• genes, temperament, and adverse social conditions interact to create ODD

• Treatment—no meds. Parent management: Parents learn to ignore maladaptive behaviors rather than giving the behaviors negative attention, positive behaviors are rewarded with praise and reinforcers, and consistent consequences for the child’s defiant behavior are implemented every time the behavior occurs

Intermittent Explosive Disorder (IED)

Repeated episodes of impulsive, aggressive, violent behavior; angry verbal outbursts lasting <30 mins. Reaction is grossly out of proportion to the stressor or situation

• May physically injure others and self, or destruct property

• May feel guilty after outbursts; this does not prevent future outbursts

• Most common in adolescence and adulthood

Usually they have a comorbid psych disorder, usually SUD.

Tx-

Psychopharmacology:

• SSRIs- Fluoxetine

• mood stabilizers- Lithium

Cognitive–behavioral therapy, Anger management, Relaxation techniques, Avoidance of alcohol and other substances

Conduct Disorder

Persistent behavior that violates social norms and others’ rights.

Symptoms are clustered in four areas:

• aggression to people and animals

• destruction of property

• deceitfulness and theft

• serious violation of rules

• They have little empathy for others, do not feel “bad” or guilty, or show remorse for their behavior, have shallow or superficial emotions, and are unconcerned about poor performance at school or home.

• Frequently associated with reckless/risky behaviors- sexual behavior, drinking, smoking, use of illegal substances

Childhood-onset conduct disorder: sx before age 10; physical aggression toward others and disturbed peer relationships. These children are more likely to have persistent conduct disorder and develop antisocial personality disorder as adults.

Classifications:

• Mild: The child has some conduct problems that cause relatively minor harm to others (repeated lying, truancy, minor shoplifting, staying out late without permission)

• Moderate: The number of conduct problems increases as does the amount of harm to others (vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity)

• Severe: The person has many conduct problems that cause considerable harm to others (forced sex, cruelty to people & animals, physical fights, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements)

Related problems

• Some children externalize their emotional issues: directing anger and frustration into aggressive or delinquent behavior (hitting, throwing things, taking risks, SUD)

• Other children internalize their emotions: resulting in somatic complaints, withdrawal, isolative behavior, and problems with anxiety and depression.

Treatment:

• Must be geared toward developmental age

• Early intervention/prevention*; parenting education, social skills training, family therapy, individual therapy

• medications (in conjunction with treatment) for specific sx- the client who presents a clear danger to others (physical aggression) may be prescribed an antipsychotic medication (Risperidone/ Risperdal). Clients with labile moods may benefit from mood stabilizers (lithium, carbamazepine/Tegretol, valproic acid/ Depakote)

• Parents who have anger issues or engage in risky behavior negatively influence children with conduct disorder, so they must stop

SNAP-IV Teacher and Parent Rating Scale

an assessment tool that can be used for initial evaluation in many areas of concern such as ADHD, ODD, conduct disorder, and depression.

• Such tools can identify problems or potential problems that signal a need for further evaluation and follow-up

somatic symptom illnesses- general

• Psychosomatic: connection between mind (psyche) and body (soma)

• Hysteria: multiple physical complaints with no organic basis.

  • Freud proposed that people can convert unexpressed emotions into physical symptoms

  • hypnosis and expressing emotions helps w this

  • women used to be murdered for experiencing this- boys were taught to be tough and suck it up, childhood sexual abuse can cause this and that’s more common in girls, women more likely to seek medical help

• Somatization: transference of mental experiences/ states into body symptoms

• also called “medically unexplained symptoms” / MUS

Essentially, mental states can worsen physical symptoms.

• ex- tension headaches after a stressful day

Three central features:

1. Physical complaints suggest major medical illness but have no demonstrable organic basis.

2. Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining physical symptoms.

3. Sxs or magnified health concerns are NOT under client’s conscious control.

Many clients suffering from these diseases hop from one provider to another searching for answers. They’re pessimistic and believe they could be helped if providers were more competent or listened better.

Treatment

• manage sx

• be empathetic and listen

• education

• SSRIs (fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil)) for associated depression

• NSAIDs, no opioids

• CBT, group therapy

• for pain disorder, refer to pain clinic

etiology of somatic symptom disorders

Psychosocial Theories

• People with somatic symptom illnesses keep stress, anxiety, or frustration inside rather than expressing them outwardly (internalization). Clients express these internalized feelings and stress through physical symptoms (somatization). Clients are not consciously aware of these processes, and they do not voluntarily control it.

• Alexithymia- the inability to identify/ express emotions. This is different than an unwillingness or refusal to identify emotions. They have tremendous difficulty dealing with interpersonal conflict. When placed in situations involving conflict or emotional stress, their physical symptoms appear to worsen. The worsening of physical symptoms helps them meet psychological needs for security, attention, and affection through primary and secondary gain.

• Primary gains are the direct internal benefits that being sick provides, such as relief of anxiety, conflict, or distress.

• Secondary gains are the external or personal benefits received from others because one is sick, such as attention from family members and comfort measures (e.g., being brought tea, receiving a back rub).

Biologic Theories

• Clients with somatoform disorders may regulate and interpret stimuli incorrectly. They cannot sort relevant from irrelevant stimuli and respond equally to both types. In other words, they may experience a normal body sensation such as peristalsis and attach a pathologic rather than a normal meaning to it. Too little inhibition of sensory input amplifies awareness of physical symptoms and exaggerates response to bodily sensations.

  • minor discomfort such as muscle tightness becomes amplified because of the client’s concern and attention to the tightness.

  • Visceral hypersensitivity is associated with the severity of gastrointestinal (GI) sx

nursing process for treating clients with somatic symptom illnesses

first, collect a h&p to rule out pathologic issues.

these clients usually give an extensive hx, including screenings, tests, maybe procedures and surgeries. They’re usually mad at medical professionals.

They exaggerate their sx in a vague way.

They may appear sad and depressed when explaining their sx, but excited to discuss the story of how they had to go to the ER in the middle of the night.

Conversion disorder = la belle indifference = not caring ab their physical sx

they have a hard time fulfilling job or family roles bc of absenteeism or being consumed with health issues.

if they’ve been taking anxiolytics, consider withdrawal sx.

Cyberchondria

excessive or repeated online searches for health-related information that is distressing or anxiety-provoking for the person

types of somatic symptom disorders & related disorders

somatic symptom disorders- clients feel real pain, but there’s no physical medical reason.

Conversion disorder / conversion reaction- (mental pain is CONVERTED into physical pain)- involves unexplained, usually sudden, severe deficits in sensory or motor function (e.g., blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. There may be an attitude of la belle indifférence, a seeming lack of concern or distress, about it.

Pain disorder- primary physical symptom is pain; generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance.

Illness anxiety disorder (formerly hypochondriasis)- preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia).

Malingering- (they maLINGER in the ER until they get drugs)- the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. No real sx. People who malinger can stop the physical symptoms as soon as they have gained what they wanted.

Factitious disorder, imposed on self- (Munchausen)- occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. People with factitious disorder may even inflict injury on themselves to receive attention.

• Factitious disorder, imposed on others (Munchausen syndrome by proxy)- occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a “hero” for saving the victim.

• ex- a nurse gives excess IV potassium to a client and then “saves his life” by performing CPR.

• Occurs most often in people who are in or are familiar with medical professions, such as nurses, physicians, medical technicians, or hospital volunteers.

• illegal

cultural considerations of somatoform disorders

• Pseudoneurologic symptoms of somatization disorder in Africa and South Asia include burning hands and feet and the nondelusional sensation of worms in the head or ants under the skin.

• Dhat- a hypochondriacal concern about loss of semen.

• Koro- in Southeast Asia; the belief that the penis is shrinking and will disappear into the abdomen, causing the man to die.

• Falling-out episodes- a sudden collapse during which the person cannot see or move.

• Hwa-Byung is a Korean folk syndrome attributed to the suppression of anger and includes insomnia, fatigue, panic, indigestion, and generalized aches and pains.

• Sangue dormido (sleeping blood) occurs among Portuguese Cape Verde Islanders who report pain, numbness, tremors, paralysis, seizures, blindness, heart attacks, and miscarriages.

• Shenjing shuairuo occurs in China and includes physical and mental fatigue, dizziness, headache, pain, sleep disturbance, memory loss, GI problems, and sexual dysfunction

intellectual disabilities

AKA mental retardation

below-average intellectual functioning (intelligence quotient [IQ] <70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self-care, home living, social or interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, and health and safety.

causes- hereditary conditions (Tay–Sachs disease or fragile X chromosome syndrome); early alterations in embryonic development (trisomy 21 or maternal alcohol intake →FAS) pregnancy or perinatal problems (fetal malnutrition, hypoxia, infections, and trauma); medical conditions of infancy (infection or lead poisoning); and environmental influences (deprivation of nurturing or stimulation). Sometimes, the cause is unknown or not yet discovered.

autism spectrum disorder (ASD)

Pervasive, usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns. Range from mild to severe behaviors and limitations

• Present by early childhood (18 months to 3 years); more prevalent in boys

• Little eye contact, few facial expressions, limited gestures to communicate, limited capacity to relate to peers or parents, lack of spontaneous enjoyment, express no moods or emotional affect, inability to engage in play or make-believe with toys, little intelligible speech

• stereotyped motor behaviors- hand flapping, body twisting, or head banging

genetic link

MMR vaccine does NOT cause autism!

Treatment:

• Goals: reduce behavioral symptoms, promote learning and development

• Special education, language therapy; medications for specific target symptoms

• may take months or years of therapy to see positive results

• pharmacologics:

  • antipsychotics (Haldol, Risperdal, Abilify)- treat specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors

  • Naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres)- diminish self-injury and hyperactive and obsessive behaviors

  • There are no medications approved for the treatment of ASD itself.

tic disorders

• Sudden, rapid, recurrent, nonrhythmic stereotyped motor movement or vocalization- blinking, jerking the neck, shrugging the shoulders, grimacing, and coughing. Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, and barking. Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene), palilalia (repeating one’s own sounds or words), and echolalia (repeating the last-heard sound, word, or phrase).

• tics can be suppressed temporarily. Stress exacerbates tics, but they diminish during sleep or during an engaging activity.

• significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious

• Tx- atypical antipsychotics - risperidone (Risperdal) or olanzapine (Zyprexa)

learning disorders

• Achievement in reading, mathematics, written expression below expected for child’s age, formal education, level of intelligence

• likely to drop out of school

• Early identification, intervention, no coexisting problems associated with better outcomes

motor skill disorders

Developmental coordination disorder; Stereotypic movement disorder

• Characterized by rhythmic, repetitive behaviors

• Self-inflicted injuries are common, pain is not a deterrent to the behavior.

• This disorder becomes evident as a child attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks.

communication disorders

Deficit in language, speech, communication severe enough to hinder development, academic achievement, or ADLs, including socialization

Language disorder, Speech sound disorder, Stuttering, Social communication disorder

• diagnosed when deficits are sufficient to hinder development, academic achievement, or activities of daily living, including socialization

• primarily treated by speech and language therapists.

Attention-Deficit / Hyperactivity Disorder (ADHD)

Persistent pattern of inattentiveness, hyperactivity, impulsiveness

• Often diagnosed when child starts school, more common in boys

• Fidgeting, noisy, disruptive, unable to complete tasks, failure to follow directions, blurting out answers, easily distracted, lost or forgotten homework

• As infants→ fussy and temperamental and have poor sleeping patterns

• As toddlers→ “always on the go”, “into everything,” dismantling toys and cribs; can’t tolerate sedentary activities

• kid may be excluded bc they can’t take turns, cooperate, or are perceived as aggressive

• Misdiagnosing ADHD - overly active children may suffer from psychosocial stressors at home, inadequate parenting, or other psychiatric disorders.

• etiology → genetic, environmental (prenatal exposure to drugs/alc/lead), *frontal lobe doesn’t metabolize glucose as well

Tx

• Goals: managing symptoms, reducing hyperactivity and impulsivity, increasing child’s attention

• Most effective approach = Combination of medications, behavioral, psychosocial, and educational interventions

• ADHD is lifelong

• Pharmacologics- *Stimulants: methylphenidate (Ritalin), amphetamine compound (Adderall) → help reduce hyperactivity, impulsivity, and mood lability and helps the child pay attention more appropriately.

  • s/e- insomnia, loss of appetite, and weight loss or failure to gain weight

  • if stimulants don’t work, give antidepressant Atomoxetine (Strattera) — need a second STRAT to treat ADHD, but caution if they have liver damage

The SNAP-IV Teacher and Parent Rating Scale

an assessment tool that can be used for initial evaluation in many areas of concern such as ADHD, ODD, conduct disorders, and depression.

• can identify problems or potential problems that signal a need for further evaluation and follow-up.

• early intervention needed, esp in autism bc they need support to develop normally

• Dr. Andrew Wakefield → published a medical hoax paper that claimed the MMR vaccine causes autism. This is NOT TRUE and has been very damaging due to people fearing getting vaccines.

elimination disorders

Encopresis: repeated passage of feces into inappropriate places like clothing or the floor (child at least age 4)

• Often involuntary → constipation from psychological issues

• if intentional → often oppositional defiant disorder (ODD) or conduct disorder.

Enuresis: repeated urination during day or night in clothes or bed after age 5

• Most often involuntary

• if voluntary / Intentional enuresis → often disruptive behavior disorder

Tx = imipramine (Tofranil), an antidepressant with a side effect of urinary retention

assessing for eating disorders

Eating Attitudes Test- a widely used screening tool to measure symptoms and behaviors related to eating disorders

• often used in studies of anorexia and bulimia

• can also be used at the end of treatment to evaluate outcomes because it is sensitive to clinical changes

self-harm and suicide risk*

school nurses- Sample Screening Questions

•How often do you feel dissatisfied with your body shape or size?

•Do you think you are fat or need to lose weight, even when others say you are thin?

•Do thoughts about food, weight, dieting, and eating dominate your life?

•Do you eat to make yourself feel better emotionally and then feel guilty about it

TPN or tube feedings may be needed

When clients can eat, a diet of 1,200 to 1,500 calories/day is ordered, with gradual increases. Nurse provides protein drink to fill up calories if a meal is missed. Nurse watches to ensure client actually eats, and the client must not be left alone after eating for 1-2 hrs so they don’t purge.

anorexia nervosa

“a life-threatening eating disorder characterized by the client’s restriction of nutritional intake necessary to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists.”

restrictive- dieting, fasting, or excessive exercise

binging / purging - self-induced vomiting, or misuse of laxatives, enemas, and diuretics.

they may have weird rituals or habits around food to gain a sense of control (not eating in front of ppl, counting calories, not letting food touch their lips)

• Onset usually between the ages of 14 and 18

• usually perfectionists

• slow, lethargic, and fatigued; they may be emaciated

• Denial early on; depression and lability with progression; isolation; medical complications

• may develop paranoia & think their family and everyone wants them to be fat

• significantly increases risk of death from suicide or from actual medical complications (bradycardia, hypotension, arrhythmias, cold extremities, valve prolapse, GI upset, gastroparesis, hepatitis, reproductive and menstrual dysfunction, osteoporosis, muscle atrophy, lanugo, hair loss, hypokalemia, hyponatremia, leukopenia, anemia, dizziness, fainting)

• abusing laxatives = MOST DANGEROUS

need hospital admission= severe fluid, electrolyte, and metabolic imbalances; cardiovascular complications; severe weight loss and its consequences; suicide risk

Treatment- often difficult bc client is resistant, uninterested, denies problem

pharmacology:

• Amitriptyline (Elavil) & the antihistamine cyproheptadine (Periactin) - promote weight gain

• Olanzapine (Zyprexa)- used because of its antipsychotic effect (on bizarre body image distortions) and associated weight gain.

• Fluoxetine (Prozac)= prevents relapse in clients whose weight has been partially or completely restored. However, close monitoring is needed because weight loss can be a side effect. may need family/ individual therapy or CBT

bulimia nervosa

“an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising".”

Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt.

• may appear to be a NORMAL weight

• teeth / enamel get destroyed from vomiting- dentists often identify bulimia

• typical onset 18-19 yrs

• usually impulsive, may have personality disorder, anxiety, SUD

• may restrict foods between binging periods

• they go to great lengths to hide the disorder

tx

• CBT most effective

• SSRIs

other eating disorders

• binge eating disorder - overweight / obese, psychological distress, mostly middle-aged men

• night eating syndrome- anorexia in the morning, hyperphagia in the evening (consuming 50% of daily calories after the last evening meal), and nighttime awakenings (at least once a night) to consume snacks. It is associated with life stress, low self-esteem, anxiety, depression, and adverse reactions to weight loss. tx= SSRIs

• orthorexia nervosa- obsession with healthy eating. Not technically a disorder. Includes compulsive checking of ingredients; cutting out increasing number of food groups; eat only “healthy” or “pure” foods; unusual interest in what others eat; hours spent thinking about food, what will be served at an event; and obsessive involvement in food blogs

childhood eating disorders

• pica - eating nonfood substances

• rumination- repeated regurgitation of food that is then rechewed, reswallowed, or spit out.

• ^ both more common in persons with intellectual disability.

etiology of eating disorders

specific cause unknown, but there are ideas.

biologic factors - runs in families, could be personality type, general susceptibility to psychologic disorders, or dysfunction of the hypothalamus (hunger sensations)

developmental factors-

• Struggle for autonomy, identit

• Overprotective or enmeshed families

• Body image disturbance

• Self-perceptions of the body

• Family influences (family dysfunction, childhood adversity)

• Sociocultural factors (media, pressure from others)

substance abuse treatment

• AA (Alcoholics Anonymous) - a self-help group, includes a 12-step program model for recovery. Says total abstinence is essential, and that alcoholics need the help and support of others to maintain sobriety. Includes sponsors to help each other. Women for Sobriety (exclusively for women) and Rainbow Recovery (for gay and lesbian individuals) do the same thing.

• criticisms- religious-based, confrontational in group setting

• other groups- Narcotics Anonymous (NA); Al-Anon- a support group for spouses, partners, and friends of alcoholics; and AlaTeen, a group for children of parents with substance problems

pharmacologics

• focus on SAFE WITHDRAWAL (alcohol, sedative–hypnotics, and benzos) and PREVENTING RELAPSE

• For clients who abuse alcohol, vitamin B1 (thiamine) is often prescribed to prevent or to treat Wernicke–Korsakoff syndrome- neurologic conditions that can result from heavy alcohol use

• meds help manage sx

dual diagnosis

Substance abuse + another psychiatric illness- 50% of ppl with SUD also have mental health diagnoses.

very hard to treat.

They need a LOT OF ASSISTANCE & positive environmental factors.

alcohol use

“sipping” at age 8, first intoxication in teens, significant dependency / issues arise in 20s-30s

• blackout = an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior.

• As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person.

• periods of abstinence → the person stops drinking after a significant even like a DUI, and tries to control their drinking, but then they often bounce back & drink more, & the cycle continues

• spontaneous remission / natural recovery = some people with alcohol-related problems can modify or quit drinking on their own without a treatment program

• Poor outcomes: earlier age at onset, longer periods of substance use, and the coexistence of a major psychiatric illness.

• Increases risk of *hepatitis, liver damage, suicide

alcohol

CNS depressant: relaxation, hypotension, loss of inhibitions

Intoxication: Slurred speech, unsteady gait, lack of coordination, and impaired attention, memory, judgment. Aggressive behavior or display of inappropriate sexual behavior

• May experience a blackout

Overdose: vomiting, unconsciousness, respiratory depression

• Treatment: gastric lavage (stomach pumping) or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit

Withdrawal: Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; usually peaks on the second day and complete in about 5 days

• Symptoms: hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety

• Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs).

• Tx- Benzodiazepines (lorazepam/ Ativan, chlordiazepoxide/ Librium, or diazepam /Valium) based on the CIWA score:

  • <8 = mild withdrawal (may be treated at home)

  • 8 to 15 = moderate withdrawal (marked arousal)

  • >15 = severe withdrawal

etiology of substance / alcohol use

biologic - children with parents who use substances, & twins are more likely

neurochemical - some people have the internal desire to stop after a 1-2 drink buzz, while others just want to keep drinking until intoxicated

psychological - children who grew up with parents who weren’t the best. Can’t cope or form relationships as well

younger ppl- alcohol and cannabis (cheaper & available)

older ppl- cocaine and opioids

cannabis

Used for psychoactive effects. Can be smoked or eaten.

Many people view the social use of cannabis, though still illegal in most states, as not harmful. Many advocate legalizing the use of marijuana for social purposes.

Currently in the United States, there is a federal law that still classifies marijuana as a Schedule 1 drug, but some individual states have or are in the process of legalizing medical use or recreational use or both.

• sx- Lowered inhibitions, relaxation, euphoria, increased appetite, impaired motor control, impaired judgment

• potentially Delirium, cannabis-induced psychotic disorder

• No overdose; No clinically significant withdrawal syndrome- Possible symptoms of insomnia, muscle aches, sweating, anxiety, tremors

cultural considerations of substance use

Muslims do not drink alcohol.

Jews drink wine.

Some Native American tribes use hallucinogens as part of rituals.

Japanese ppl drink alcohol everywhere & it’s normal.

Russian men drink alcohol a lot & are likely to become violent or die

Sedatives, Hypnotics, and Anxiolytics

CNS depressants

Intoxication sx: slurred speech, lack of coordination, unsteady gait, labile mood, stupor

• Barbiturate overdose possibly lethal; coma, respiratory arrest, cardiac failure, death

withdrawal: Symptoms opposite of drug’s acute effect. so it causes anxiety & tremors

Detoxification via drug tapering

Stimulants (Amphetamines & Cocaine)

AKA “uppers” - high risk for abuse

Methamphetamine= extremely dangerous due to psychotic behavior & brain damage

Intoxication: High or euphoric feeling, hyperactivity, hypervigilance, talkativeness, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment.

• Physiological s/e- tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias

OD: seizures & coma

tx: Antipsychotics (chlorpromazine/ Thorazine) → controls hallucinations, lowers blood pressure, and relieves nausea

Withdrawal- Onset within hours to several days. Not life-threatening.

• Primary symptom = marked dysphoria (unease or distress).

• fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation.

• “Crashing” → the person may experience depressive symptoms, including suicidal ideation

• Not treated pharmacologically

SUDs & HCWs

Health care professionals have increased rates of substance use problems, particularly involving opioids, stimulants, and sedatives.

• Reporting suspected substance abuse in colleagues is an ethical (and sometimes legal) responsibility of all health care professionals.

substance abuse in elderly clients

Risk factors for late-onset substance: chronic illness that causes pain, long-term use of prescription medication (sedative–hypnotics, anxiolytics), life stress, loss, social isolation, grief, depression, and an abundance of discretionary time and money

misconceptions ab substance use

•“It’s a matter of willpower.”

•“I can’t be an alcoholic if I only drink beer or if I only drink on weekends.”

•“I can learn to use drugs socially.”

•“I’m OK now; I could handle using once in a while.”

opioids

popular drugs of abuse because they desensitize the user to both physiological and psychological pain and induce a sense of euphoria and well-being.

Opioid compounds:

• prescription analgesics (morphine, meperidine (Demerol), codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, and propoxyphene)

• illegal substances (heroin, illicitly produced fentanyl, and normethadone)

• Fentanyl = a synthetic opioid used in clinical settings for anesthesia. It is 50 to 100 times more potent than morphine. Illicitly produced fentanyl use has skyrocketed in the past decade and is responsible for the dramatic increase in deaths from opioid overdose.

sx of Intoxication: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory

• *hepatitis or HIV from injecting drugs

Overdose: coma, respiratory depression, pupil constriction, unconsciousness, death

• give IN Naloxone / Narcan → reverses opioid toxicity

Withdrawal:

• Initial symptoms are anxiety, restlessness, aching back and legs, and cravings for more opioids.

• As withdrawal progresses- nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia.

• Methadone may be used for safe withdrawal for 2 weeks.

• ^sx cause significant distress, do not require pharmacologic intervention.

hallucinogens

substances that distort the user’s perception of reality.

ex- mescaline, psilocybin (mushrooms), lysergic acid diethylamide (LSD/ acid), ecstasy (molly), Phencyclidine (PCP), salvia

• Reality distortion; similar to psychosis (visual hallucinations, depersonalization)

• Cause increased pulse, blood pressure, and temperature; dilated pupils, blurred vision, hyperreflexia

• Intoxication: maladaptive behavioral / psychological changes, anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behaviors

• No overdose; toxic reactions are primarily psychological- not lethal

• *PCP toxicity: seizures, hypertension, hyperthermia, respiratory depression

• Medications to control seizures and blood pressure; Cooling devices

• Mechanical ventilation

no withdrawal from hallucinogens, but flashbacks of the effects can occur for up to 5 years

inhalants

anesthetics, nitrates, and organic solvents that are inhaled for their effects.

• most common: aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint

sx of intoxication: dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Stupor and coma can occur. Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function.

Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias. Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus.

tx- supporting respiratory and cardiac functioning until the substance is removed from the body. There are no antidotes or specific medications to treat inhalant toxicity

• People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders, such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases.

• *lung or neurologic damage