Suicide, Self Harm, Substance Abuse, and Sexual Disorders

Suicide

  • Suicide is an act of individual meaning, known only to the person who attempts or commits it.
  • It is usually caused by more than one motive.

Suicide Precautions

  • Assessment Determines Level: Whether a patient is placed on basic or maximum precautions depends on their suicide risk assessment.

  • Maximum Precautions:

    • For patients constantly looking for ways to kill themselves and feeling a lack of control.
    • Requires one-on-one observation by a staff member within arm's length, 24 hours a day.
    • The staff member must remain within arm's length regardless of the patient’s activities (showering, bathroom).
    • Meals are served on an isolation tray.
    • Any food brought in must be approved by a doctor and inspected.
    • Patients cannot leave the unit and are placed in a jumpsuit (to prevent hanging with pants).

  • Basic Precautions:

    • Involve checks every 15 minutes, varying the timing to prevent predictability.
    • The patient's room should be near the nurses' station with the door left open.
    • If the patient leaves the unit, they must have support staff with them.
    • Nurses monitor the environment to ensure it remains safe (no items that could be used for self-harm).
    • Outside food must be inspected for hidden items.

Assessing Suicide Potential

  • Questions to Ask:

    • "What was the most difficult moment in your past?"
    • "Does death seem like an attractive option?"
    • "Have you ever thought about wanting to kill yourself?"
    • "How well can you control your behavior and keep from ending your life? (Scale of 1 to 5)"
    • "How badly do you want to die? (Scale of 1 to 5)"

  • Common Nursing Diagnoses:

    • Violence, risk for self-directed.
    • Self-mutilation, risk for.

General Reminders for Suicide Prevention

  • Q15 Checks and Documentation:
    • Document the time of the check, the patient's activities, location, and who they were talking to.
    • Note anything in the environment that could be used for self-harm.
    • Ensure the environment is safe; search the patient and their belongings.
    • Prohibited items include belts, shoestrings, sheets, plastic bags, and sharp objects.
    • Ensure that items used in activities (e.g., crafts) are accounted for and stored properly.

Interventions

  • One-on-One Observation: For very high-risk patients.
  • No Self-Harm Contract: Controversial; effectiveness is debated.
  • Removing Precautions: Requires a psychiatrist's order based on the nurse's assessment.
    • Precautions should be removed gradually, giving the patient increasing levels of freedom while monitoring them.

Suicide Triangle

  • Owning a gun, using alcohol, and having suicidal or homicidal ideations significantly increase the risk of suicide.

Self-Injury (Self-Harm/Self-Mutilation)

  • Not About Wanting to Die: Self-harm is a coping mechanism, not a suicide attempt.
  • Common Form: Cutting, but can also include swallowing objects.
  • Endorphin Release: Cutting releases endorphins, providing temporary relief from emotional pain related to past trauma.
  • Secrecy: True cutters hide their self-harm from others, cutting on concealed body parts (stomach, thighs).
  • Cycle: Relief is temporary, leading to repeated self-harm and a cyclical pattern.
  • Underlying Issue: The focus should be on addressing the past trauma, not just the self-harm.
  • Accidental Suicide Risk: Self-harmers have a higher risk of accidental suicide due to the severity of their wounds.
  • Prevalence: More common in women.
  • Forms of Self-Harm: Cutting, burning, hitting, swallowing objects, inserting objects into the skin, and putting oneself in danger.
  • Warning Signs: Unexplained wounds or scars (wrists, arms, thighs, chest), blood stains on clothes or bedding, frequent accidents.
  • Concealment: Self-injurers try to hide their wounds.
  • Carved Statements: Some patients carve statements into their skin.

Substance Abuse and Related Disorders

  • Substance Abuse: Repeated use of a substance leading to adverse social consequences.

  • Substance Dependence (Addiction): Repeated use with withdrawal symptoms upon cessation and tolerance.

    • Withdrawal: Physical and mental symptoms when stopping or reducing substance use.
    • Tolerance: Needing more of the substance to achieve the same effect.

  • Psychological Withdrawal: Mental preoccupation with obtaining the substance.

  • Physical Dependence: Tolerance and withdrawal symptoms.

  • Drinking and Pregnancy: Even small amounts of alcohol can cause problems.

    • Can lead to behavioral problems, hyperactivity, irritability, and delays in mental and physical development in children.

Alcohol

  • Misuse:

    • More than 1 drink daily for women or 7 per week.
    • More than 2 drinks daily for men or 14 per week.

  • Most Abused Substance: Alcohol accumulates in high-water content areas like the brain, leading to Korsakoff's syndrome (dementia).

  • Metabolism: Metabolized by the liver, leading to cirrhosis or pancreatitis with long-term use.

  • Alcohol Withdrawal Syndrome:

    • Elevated blood pressure, nausea, vomiting, tremors, and seizures.
    • Goal: Prevent seizures, which can be life-threatening.
    • Monitor blood pressure and intervene according to doctor-established parameters.
    • Withdrawal usually starts 24-48 hours after the last drink.
    • Seizure activity is highest around 24-48 hours after the last drink.

  • Common Medications for Alcohol Withdrawal:

    • Benzodiazepines (Ativan, Librium) mimic alcohol effects on the central nervous system.

Narcotics (Opiates)

  • Central nervous system depressants (morphine, heroin).
  • Treatment:
    • Methadone clinics for weaning off opioids.
    • Buprenorphine (given sublingually).
    • Suboxone (buprenorphine and naloxone).
  • Signs of Use: Constricted pupils, respiratory depression, drowsiness.
  • Overdose: Emergency situation.
  • Withdrawal Symptoms: Runny nose, runny eyes, sweating.

Determining Intoxication

  • To determine if a patient's behavior is due to substance abuse or a psychotic/bipolar break, perform a drug screen (lab work).

  • Dual diagnosis: A patient can have both a mental illness and a substance abuse problem.

  • Legal Drug Abuse (Methadone): Legal form of substance abuse to keep people from obtaining drugs illegally.

Stimulants

  • Cocaine, crack, amphetamine, methamphetamine, caffeine.

  • Symptoms: Rapid heartbeat, elevated blood pressure, sweating, psychotic symptoms (paranoia, hallucinations, delusions).

  • Cocaine:

    • Inhaled, injected, or snorted.
    • Immediate but short-lived rush (less than an hour), leading to repeated use.

  • Crack:

    • Snorted or smoked; often mixed with ammonia.
    • Delivered in chunks and used in pipes.

  • Methamphetamine:

    • Made illicitly; user are at risk of hyperactivity
    • Remains in the brain for a long time, causing stimulant effects.

Hallucinogens

  • Most taken orally; some can be inhaled.
  • LSD:
    • Common among young people; can be easily hidden (e.g., on blotter paper).
  • PCP (Phencyclidine):
    • Mimics schizophrenia symptoms.
    • Symptoms: High blood pressure, nystagmus (jumping of the eyes), belligerence, hallucinations, delusions, paranoia; often requires restraint.

Marijuana

  • Stored in reproductive organs long after use, affecting egg and sperm development and potentially impacting future offspring.
  • Psychosis Risk: Increases the risk of converting to a psychotic disorder (especially schizophrenia) in predisposed individuals.
  • Conversion: Increases the likelihood of conversion.
  • Legalization: The presenter notes that in states where marijuana has been legalized, such as Oregon, there has been a marked increase in psychotic breaks among users.

Designer Drugs

  • Created in underground labs by chemists altering medications to produce a high.

  • Common Examples: Retinol (date rape drug), MDMA (ecstasy/molly), bath salts, spice, synthetic marijuana, and crocodile.

  • Crocodile: Injected into the skin, causing it to deteriorate and resemble crocodile skin. Brought over by Russia according to what has been observed.

  • Signs and Symptoms of Designer Drug Use: Sleeping too much or not enough, mood swings, paranoia, aggression, relationship problems, memory issues, isolation.

Inhalants

  • Legal and easily accessible, making them popular among adolescents.
  • Examples: Markers, White Out, Elmer's Glue, aerosol paint, and computer cleaning products.
  • Effects: Brain damage, euphoria, dizziness, uncontrolled body movements, respiratory distress.

Stages of Addiction

  • Early Stage: Enjoyment and repeated use of the substance.
  • Middle Stage: Tolerance develops, requiring more of the substance to achieve the desired effect.
  • Chronic Stage: High tolerance, loss of control, and life revolves around substance use.

Treatment of Addiction

  • Support groups (AA, NA).
  • Methadone treatment.
  • Antabuse: If taken with alcohol, and death is the potential (the presenter says to watch out for things like cough medicine).
    • The drug is metabolized by the liver.
  • Campyl (acamprosate): Reduces cravings and withdrawal symptoms; not metabolized by the liver.

Relapse

  • Relapse is the behaviors leading up to substance use, not just the act of using again.
  • Example for those suffering from alcholism, avoid environments or situations that could trigger use, such as bars or friends who are drinkers. By spending time in the environment one is already relapsing even without drinking alcohol.

Cage Questions

  • Used to Assess the likelihood of excessive drinking Habits

  • Have you ever felt you needed to cut down on your drinking?

  • Have people annoyed you by criticizing your drinking?

  • Have you ever felt guilty about your drinking?

  • Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?

  • If the subject responds yes to two or more, it's an indicator of dependancy

Axis I Disorders -Sex Disorders

Definitions

  • Gender Identity: Individual's inner sense of being male, female, neither, or both.
  • Gender Role: Social obligations attached to gender.
  • Intersex: Ambiguous sex at birth due to developmental issues.
  • Sexual Orientation: Gender to which one is attracted.
  • Transgender: Gender identity and expression differ from assigned birth gender.

Healthy Sexual Response Criteria

  1. Between two consenting adults.
  2. Satisfying to both.
  3. Not forced or coerced.
  4. Conducted in privacy.

Terms To Know

  • Heterosexual-Attracted to Opposite Sex
  • Homosexual-Attracted to Same Sex
  • Bisexual-Attracted to both Sexes

*Transgender individuals have a tendency to believe they were born the wrong gender. It should be noted this belief usually begins to take root around 5 years old.

*Transvestism is now referred to as Transvestic Disorder

  • Paraphilia: Behaviors that depart from social modes of seeking to get sexual gratification.
    • Example: Sex Of Minor

*It should be noted Paraphilia's are on Axis 1

Transvestism (Cross Dressing): Now called Transvestic Disorder. Sexual excitement from dressing in the opposite gender's clothing.

  • Autogynephilia: Male has sexual arousal from fantasizing about himself as a woman.

Sexual Dysfunctions

Individual not able to perform sexually due to trauma event. Sexual assault or childhood trauma can be a causative factor.

  • Women: orgasmic disorder (inability to orgasm), pain with intercourse and Dysparenumia
  • Women: Vaginismus

Paraphilias

  • Coercive: Against someone's will.
  • Non-Coercive: with consenting partner.

Sexual Masochism

  • Also called auto erotic asphyxia: Self-inflicted asphyxiation for sexual gratification. Mostly impacts young men, and often results in their accidental deaths. Usually they don't release the knot in time, and end up killing themselves.

List of Terms

From DSM 5 Axis 1

  • Voyeurism: Peeping tom; observing an unsuspecting individual/s.
  • Exhibitionism: Exposing oneself to a non-consenting individual.
  • Frotteurism: Rubbing or touching a non-consenting person.
  • Sexual Masochism: Being humiliated, beaten, bound, or otherwise made to suffer.
  • Sexual Sadism: Inflicting suffering on others for sexual pleasure.
  • Pedophilia: Sexual activity with children.
  • Fetishism: Sex with non-living objects.
  • Transvestic Disorder: Cross-dressing (male dressing in female's clothing) for sexual pleasure.
    *Zoophilia: Having a relationship with animals or sexually abusing animals.

Gender Identity Disorder (GID) / Gender Dysphoria

  • Axis 1 psychiatric disorder.
  • Begins to emerge by age 5.
  • Transgender: In the transition.
  • Transsexual: Sexual parts have been changed.

Nursing Diagnoses for these patients

  • Sexual dysfunction.
  • Risk for injury (autoerotic asphyxia).
  • Risk for self-directed violence.

*Goal is for the patient to Adapt and be Happy in Cross Gender World

Some extra terms related to gender identity are Genderfluid, multi gender, trigender, genderqueer

Genderbread Person

*Identity-Located In Brain
*Orientation -Located In Heart
*Sex- Located In Pants

Sexual Addiction

  • Considered an addiction; treated in a 12-step program.
  • Can result in criminal behavior (rape).
  • SAA (Sexual Addiction Anonymous): Support groups for people with sexual addictions.
Treating Sexual Addiction
  1. 12 step program
  2. 90 meetings in 90 days post getting released
  3. Remove Sexual Addiction Temptations such as pornography and the internet. 9Can be compared to not having alcohol if you are an alcoholic)