Exam 2 - Study Material Flashcards
What is anxiety?
- A diffuse apprehension that is vague in nature and associated with feelings of uncertainty and helplessness
- It is provoked by the unknown and precedes all new experiences
What are some characteristics of anxiety?
- Anxiety is an emotion without a specific object
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Anxiety is communicated interpersonally
- Anxiety can be transmitted from person to person
- Necessary for survival
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The crux of anxiety is self-preservation
- Anxiety occurs as a result of a threat to a person’s selfhood, self-esteem, or identity
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- Anxiety occurs as a result of a threat to a person’s selfhood, self-esteem, or identity
How is culture related to anxiety?
- Culture can influence the values one considers most important
- Underlying every fear is the anxiety of losing one’s own being
- A person can grow from the anxiety to the extent that the person confronts, moves through, and overcomes anxiety-creating experiences
What is fear?
- cognitive appraisal of threatening stimulus
- Fear has a specific source or object that the person can identify and describe
- Fear involves the intellectual appraisal of a threatening stimulus
- Anxiety is the emotional response to that appraisal
- Fear produces anxiety
What are the different levels of anxiety?
- Mild
- Moderate
- Severe
- Panic
Describe mild anxiety
- Associated with the tension of day-to-day living
- During this stage the person is alert and the perceptual field is increased.
- The person sees, hears, and grasps more than before.
- This kind of anxiety can motivate learning and produce growth and creativity
Describe moderate anxiety
- The person focuses only on immediate concerns, involves the narrowing of the perceptual field.
- The person sees, hears, and grasps less.
- The person blocks selected areas but can attend to more if directed to do so.
Describe severe anxiety
- Marked by a significant reduction in the perceptual field.
- The person tends to focus on a specific detail and not think about anything else.
- All behavior is aimed at relieving anxiety, and much direction is needed to focus on another area
Describe panic
- Associated with awe, dread, and terror, and the person feeling it is unable to do things even with direction.
- Involves the disorganization of the personality and can be life threatening.
- Increased motor activity, decreased ability to relate to others, distorted perceptions, and loss of rational thought. Unable to communicate or function effectively
- Prolonged period of panic would result in exhaustion and death
What is biofeedback?
The use of a machine to reduce anxiety and modify behavioral responses. Small electrodes are connected to the biofeedback equipment which are attached to the patient’s forehead to measure vital signs
What are ego defense mechanisms?
- First line of psychic defense
- Use to cope successfully with mild and moderate levels of anxiety
- Protects from feelings of inadequacy and worthlessness
- Prevents awareness of anxiety
- Extreme use distorts reality, interferes with interpersonal relationships, limits ability to work
What are some Ego defense mechanisms?
- Compensation
- Denial
- Displacement
- Dissociation
- Identification
- Intellectualization
- Introjection
- Projection
- Reaction formation
- Repression
- Sublimation
- Undoing
- Isolation
- Rationalization
- Regression
- Splitting
- Suppression
What is the “Compensation” defense mechanism? Give an example
Process by which people make up for a perceived weakness by strongly emphasizing a feature they consider more desirable
- EX: A businessman perceives his small physical stature negatively. He tries to overcome this by being aggressive, forceful, and controlling in business dealings
What is the “denial” defense mechanism? Give an example
Avoidance of disagreeable realities by ignoring or refusing to recognize them; the simplest and most primitive of all defense mechanisms
- EX: Ms. P has just been told that her breast biopsy indicates a malignancy. When her husband visits her that evening, she tells him that no one has discussed the laboratory findings with her
What is the “displacement” defense mechanism? Give an example
Shift of emotion from a person or object to another, usually neutral or less dangerous, person or object
- EX: A 4-year-old boy is angry because he has just been punished by his mother for drawing on his bedroom walls. He begins to play war with his soldier toys and has them fight with each other
What is the “dissociation” defense mechanism? Give an example
The separation of a group of mental or behavioral processes from the rest of the person’s consciousness or identity
- EX: A man is brought to the emergency room by the police and is unable to explain who he is and where he lives or works
What is the “identification” defense mechanism? Give an example
Process by which people try to become like someone they admire by taking on thoughts, mannerisms, or tastes of that person
- EX: Sally, 15 years old, has her hair styled like that of her young English teacher, whom she admires
What is the “intellectualization” defense mechanism? Give an example
Excessive reasoning or logic is used to avoid experiencing disturbed feelings
- EX: A woman avoids dealing with her anxiety in shopping malls by explaining that shopping is a frivolous waste of time and money
What is the “Introjection” defense mechanism? Give an example
Intense identification in which people incorporate qualities or values of another person or group into their own ego structure. It is one of the earliest mechanisms of the child, important in formation of conscience
- EX: Eight-year-old Jimmy tells his three-year-old sister, “Don’t scribble in your book of nursery rhymes. Just look at the pretty pictures,” thus expressing his parent’s values
What is the “Isolation” defense mechanism? Give an example
Splitting off of emotional components of a thought, which may be temporary or long term
- A medical student dissects a cadaver for her anatomy course without being disturbed by thoughts of death
What is the “projection” defense mechanism? Give an example
Attributing one’s thoughts or impulses to another person. Through this process one can attribute intolerable wishes, emotional feelings, or motivation to another person
- EX: A young woman who denies she has sexual feelings about a co-worker accuses him without basis of trying to seduce her
What is the “rationalization” defense mechanism? Give an example
Offering a socially acceptable or apparently logical explanation to justify or make acceptable otherwise unacceptable impulses, feelings, behaviors, and motives
- EX: John fails an examination and complains that the lectures were not well organized or clearly presented
What is the “reaction formation” defense mechanism? Give an example
Development of conscious attitudes and behavior patterns that are opposite to what one really feels or would like to do
- EX: A married woman who feels attracted to one of her husband’s friends treats him rudely
What is the “regression” defense mechanism? Give an example
Retreat to behavior characteristic of an earlier level of development
- EX: Four-year-old Nicole, who has been toilet trained for more than 1 year, begins to wet her pants again when her new baby brother is brought home from the hospital
What is the “repression” defense mechanism? Give an example
Involuntary exclusion of a painful or conflicted thought, impulse, or memory from awareness. It is the primary ego defense, and other mechanisms tend to reinforce it
- EX: Mr. R does not recall hitting his wife when she is pregnant
What is the “splitting” defense mechanism? Give an example
Viewing people and situations as either all good or all bad; failure to integrate the positive and negative qualities of oneself
- EX: A friend tells you that you are the most wonderful person in the world one day and how much she hates you the next day
What is the “sublimation” defense mechanism? Give an example
Acceptance of a socially approved substitute goal for a drive whose normal channel of expression is blocked
- EX: Ed has an impulsive and physically aggressive nature. He tries out for the football team and becomes a star tackle
What is the “suppression” defense mechanism? Give an example
A process often listed as a defense mechanism, but really it is a conscious counterpart of repression. It is intentional exclusion of material from consciousness. At times, it may lead to repression
- EX: A young man at work finds he is thinking so much about his date that evening that it is interfering with his work. He decides to put it out of his mind until he leaves the office for the day
What is the “undoing” defense mechanism? Give an example
Act or communication that partially negates a previous one; a primate defense mechanism
- EX: Larry makes a passionate declaration of love to Sue on a date. At their next meeting he treats her formally and distantly
What are some familial factors that can contribute to anxiety?
o Anxiety disorders run in families & are common
o 40% heritability
o Family Hx of a psych. Illness are 3x more likely to develop Post-Traumatic Stress disorder following a traumatic event
o No single or specific gene identified – b/c of the critical role that environment plays in modulating genetic susceptibility in mental disorder
o Anxiety disorder overlap – ex. Anxiety & depression
What are some psychological factors that can contribute to anxiety?
Parents play a huge role in how children will develop based on their reactions
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Self-esteem-
- People who are easily threatened or has a low level of self-esteem are more likely to develop anxiety
- Anxiety is caused by perception of ability or self-concept
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Resilience-
- Associated with a number of protective psychosocial factors, including active coping style, positive outlook, interpersonal relatedness, moral compass, social support, role models, and cognitive flexibility
- Those that are able to deal with major stressors at a young age will likely be able to deal with stressors at adulthood
- Uncontrolled stress during childhood may make the adult more vulnerable to future stressors
What are some neurotransmitters that affect anxiety?
GABA system
- regulator of anxiety; controls anxiety or firing rates of neurons in parts of the brain that are responsible for producing anxiety (limbic system)
- most common inhibitory neurotransmitter
- when it crosses the synapse & binds to the GABA receptors à channels open à exchange of ions à exchange inhibits / reduces cell excitability à slows cell activity
- Clinical result: person becomes less anxious
Norepinephrine system
- mediates flight or flight
- Anxiety is caused by the inappropriate activation of the NE in the locus ceruleus
- Imbalance btw NE & other neurotransmitters
Serotonin system
- pts experiencing anxiety d/o can have hypersensitive 5-HT receptors
- SSRIs effectively treat anxiety!!
What are the different types of anxiety disorders?
- Separation anxiety disorder
- Selective mutism
- Specific phobia
- Social anxiety disorder (social phobia)
- Panic disorder
- Agoraphobia
- Generalized anxiety disorder
What are some characteristics of Separation Anxiety Disorder?
- Associated with times of transition
- May present with sudden fear or discomfort with somatic symptoms
- Fearful of accidents befalling the parent
- Often lack insight about feeling anxious
What are some nursing interentions for Separation Anxiety Disorder?
- Through assessment of child/adolescent (e.g. occurrence of recent, traumatic event)
- Collection of data related to home and/or school environment (e.g. presence of bullying behavior at school)
What is the criteria to be diagnosed with Selective Mutism?
- Consistent failure to speak in specific social situations (e.g., at school) despite speaking in other situations
- Disturbance interferes with other achievements
- Failure to speak not attributable to lack of knowledge of, or comfort with language; occurrence: rare
What is the criteria to be diagnosed with specific phobia?
- Marked fear/anxiety about a specific object or situation (e.g., flying, animals, heights, receiving an injection, seeing blood, etc.)
- The fear/anxiety is out of proportion to the actual danger posed by object/situation
What are some nursing nursing interventions for specific phobia?
- Support & reassurance
- Progressive relaxation techniques
- Systematic desensitization approaches
- The treatment of choice for specific phobias is exposure-based procedures, particularly in vivo exposure.
- In general, pharmacological treatments have not proved effective for specific phobias
What are some treatments for specific phobias?
- The treatment of choice for specific phobias is exposure-based procedures, particularly in vivo exposure.
- In general, pharmacological treatments have not proved effective for specific phobias
What is the criteria to be diagnosed with social anxiety disorder (social phobia)?
- Marked fear/anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny by others
- The fear/anxiety is out of proportion to the actual event.
- Individual has intense fears of being negatively evaluated, humiliated, embarrassed, or rejected
- Leads to social withdrawal in some individuals
What are some treatments for social anxiety disorder?
- The most common treatment approaches to social phobia include social skills training, relaxation techniques, exposure-based methods, and multicomponent cognitive behavioral treatments, with the latter two attaining the highest levels of treatment efficacy
- SSRIs are an attractive first-line treatment for social phobia
What are some nursing interventions for social anxiety disorder?
- Cognitive restructuring
- Learning to monitor thoughts & feelings
- Reframing situations
- Learning new behaviors
- Role playing
- Social skills training
- Encourage patient to express thoughts & feelings.
- Assist patient to distinguish between actual phobic trigger & problems related to avoidance behavior.
- Teach patient & family about phobic reactions when necessary.
What is the criteria to be diagnosed with panic disorder?
Recurrent unexpected panic attacks, which involve abrupt surges of intense fear/discomfort that reach a peak within minutes & involve:
- Palpitations, pounding heart, or tachycardia
- Sweating
- Trembling or shaking
- Shortness of breath or smothering sensation
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or hot flushes
- Paresthesias (numbness or tingling)
- Derealization (feelings of unreality)
- Depersonalization (being detached from oneself)
- Fear of losing control or “going crazy”
- Fear of dying
What are some nursing interventions for panic disorder?
- Stay with patient & acknowledge discomfort
- Use short, simple, and clear statements, give directions one at a time, give brown bag for hyperventilation
- Remain calm in your approach
- DO NOT ASK “WHY” QUESTIONS TO THE PATIENT
- Decrease external stimuli
- Protect the patient
- Be aware of own feelings
- Administration of anxiolytic when indicated
What are some treatments for panic disorder?
- Cognitive behavioral treatments are effective for persons with panic disorder with no more than mild agoraphobia. These treatments focus on cognitive therapy, exposure to interoceptive sensations similar to physiological panic sensations, and breathing
- SSRIs are now considered to be the first-line pharmacological treatment for PD, affecting panic frequency, generalized anxiety, disability, and phobic avoidance
What is Agoraphobia?
fear of open spaces
What is the criteria to be diagnosed with Agoraphobia?
- Marked fear/anxiety about 2 (or more) of the following:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd
- Being outside of the home alone
What are some nursing interventions for Agoraphobia?
- Accept patients and their fears with a non-critical attitude
- Ivolve patients in activities that do not increase anxiety
- Involve patients in activities that will increase involvement rather than avoidance
What is the criteria to be diagnosed with generalized anxiety disorder?
- Excessive anxiety & worry that is hard to control, occurs most days, & has been present for the past 6 months
Associated with 3 or more of the following:
- Restlessness, feeling keyed up or on edge
- Easily fatigued
- Difficulty concentrating; mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
What are some nursing interventions for generalized anxiety disorder?
- Teaching relaxation techniques
- Exercise
- Cognitively-oriented therapy
- Move pt. to calm quiet envi, ask pt to identify how they feel, encourage pt. to describe/discuss feelings, help pt. identify possible causes of feelings
- Listen to pt. expression of hopelessness/helplessness, ask pt if they feel suicidal
What are the treatments for generalized anxiety disorder?
- The pharmacological treatments of choice are buspirone and antidepressants, including SSRIs and venlafaxine
- The most successful psychological treatments for GAD combine relaxation, exercise, and cognitive therapy with the goal of bringing the worry process under the patient’s control
What are some treatments for obsessive-compulsive disorder (OCD)?
- Cognitive behavioral therapy involving exposure and ritual prevention is a well-established treatment for OCD in adults.
- SSRIs have been shown repeatedly to be efficacious in the treatment of OCD.
- Behavior therapy and perhaps cognitive therapy may be superior to medication with respect to risks, costs, and enduring benefit
What is the difference between anxiety and depression?
Anxiety:
- Predominantly fearful or apprehensive
- Difficulty falling asleep (initial insomnia
- Depersonalization (feeling detached from one’s body)
- Derealization (feeling that one’s environment is strange, unreal, or unfamiliar
- Selective and specific negative appraisals that do not include all areas of life
- Sees some prospects for the future
- Does not regard defects or mistakes as irrevocable
Depression:
- Depersonalization (feeling detached from one’s body)
- Derealization (feeling that one’s environment is strange, unreal, or unfamiliar
- Inability to experience pleasure
- Loss of interest in usual activities
- Selective and specific negative appraisals that do not include all areas of life
- Thoughts of death or suicide Sees the future as bleak and has given up all hope
- Regards mistakes as beyond redemption
What is obsessive-compulsive disorder?
Involves presence of obsessions, compulsions, or both:
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Obsessions – recurrent persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive & unwanted, and that in most individuals cause marked anxiety or distress
- 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)
- EX: Fear of dirt and germs or Fear of burglary or robbery
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Compulsions – repetitive behaviors (e.g. hand washing, 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
- Aimed at preventing or reducing anxiety or distress, or preventing some dreaded situation
- EX: Excessive hand washing or Repeated checking of door and window locks
What impact does OCD have on patients?
- Time-consuming
- Cause clinically significant distress or impairment
- Negatively affect quality of life
- Not attributable to the physiological effects of a substance or another medical condition
- Not better explained by another medical disorder
What are the treatment options for a patient with OCD?
Psychotherapy
- Cognitive behavioral therapy
Medications (antidepressants)
- Clomipramine (Anafranil)
- Fluvoxamine (Luvox)
IF medications and psychotherapy are not effective enough in controlling OCD symptoms of some individuals. In rare cases, other treatment options may include:
- Psychiatric hospitalization
- Residential treatment
- Electroconvulsive therapy (ECT)
- Transcranial magnetic stimulation
- Deep brain stimulation
What are some nursing interventions for patients with OCD?
- Ensure that basic needs are met.
- Provide patients with time to perform rituals (unless they are in specialized OCD program, such as ERP).
- Discuss program expectations, routines, and goals.
- Be empathic toward patients and aware of their need to perform compulsions (rituals).
- Assist patients with connecting behaviors with thoughts and feelings
- Structure simple tasks, activities, or games for patients.
- Reinforce positive non-ritualistic behaviors.
What is the criteria to be diagnosed with body dysmorphic disorder (BDD)?
- Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others
- Repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his/her appearance with that of others) in response to the appearance concerns
- Results in significant distress and/or impairment in functioning
What are the characteristics of body dysmorphic disorder (BDD)?
- Usually begins during adolescence & can occur in childhood.
- Appears to occur about equally in males & females
- Major depression—most common comorbid disorder
- May be difficult to diagnose, as many patients are too ashamed to reveal their symptoms.
- Possibility of BDD should be explored when patients are:
- Housebound,
- Have unnecessary surgery or dermatologic treatment
- Have social anxiety, depression, or suicidal ideation.
What are the treatment options for patients with body dysmorphic disorder?
Medications
- SSRIs—may require higher doses than for depression
Psychotherapy
- Cognitive behavioral therapy
Psychoeducation:
- For patient & family
What is Obsessive-Compulsive Personality Disorder?
- Extremely rigid and controlling
- Perfectionistic
- Overly organized
- Pays extreme attention to detail in an exaggerated manner
- No obsessive compulsions
What is the criteria to be diagnosed with a hoarding disorder?
- Persistent difficulty discarding or parting with possessions, regardless of their actual value
- Results in accumulation of possessions that congest & clutter active living areas
- Compromises having safe environment for self & others
- Hoarding not attributable to another medical condition
- Does excessive acquisition of items occur?
- (Occurs in 80-90% of cases)
- Insight may be in the “good to delusional” range.
- Nationally representative prevalence studies of this disorder not available.
What are some treatment options for patients with hoarding disorders?
Challenging: Many “hoarders” lack insight & do not see their behavior as a problem
Options:
- Medications—SSRIs
- Might use CCB’s + SSRI’s to treat this – they help with the obsessiveness of keeping all of that stuff
- Cognitive behavioral therapy
What is the criteria to be diagnosed with trichotillomania?
- Recurrent pulling out of one’s hair, resulting in hair loss
- Repeated attempts to decrease of stop hair pulling
- Behavior causes significant distress or impairment
- Not attributable to another medical condition
- Not better explained by symptoms of another mental disorder
What are the symptoms associated with trichotillomania?
- Symptoms usually seen in children:
- Uneven appearance to the hair
- Bare patches or diffuse loss of hair
- Bowel obstruction if individuals eat the hair they pull out
- Frequent tugging, pulling, or twisting the hair
- Denying the hair pulling
- Hair regrowth that feels like stubble in the bare spots
- Increasing sense of tension before the hair pulling
- Other self-injury behaviors
- Sense of relief, pleasure, or gratification after the hair pulling
What are the treatment options for patients with trichotillomania?
Medications:
- Naltrexone (ReVia) & SSRIs effective in reducing some symptoms
Psychotherapy:
- Behavioral therapy (e.g., habit reversal training)
What is posttraumatic stress disorder and what are the symptoms?
Essential feature — development of characteristic symptoms following exposure to one or more traumatic events
Symptoms may be:
1) Fear-based emotional re-experiencing of event
2) Anhedonic or dysphoric mood states
3) Arousal & reactive responses
4) Dissociative states
5) Combinations of the above symptoms
What is the criteria to be diagnosed with PTSD?
Exposure to actual or threatened death, serious injury, or sexual violence
- Directly experiencing the event
- Witnessing, in person the event as it occurred to others
- Learning that event (violent or accidental)
- occurred to close family member/friend
- Experiencing repeated or extreme exposure to aversive details of traumatic event
Presence of one (or more) intrusion symptoms, beginning after traumatic event, such as:
- Recurrent , involuntary, & intrusive distressing memories of traumatic event
- Recurrent distressing dreams in which the content and/or affect of dream are related to traumatic event
- Dissociative reactions (e.g., flashbacks) in which individual feels as if event were still occurring
Negative alterations in cognitions & mood associated with the traumatic event(s) beginning or worsening after the traumatic event occurred, as evidenced by:
- Inability to remember an important aspect of the traumatic event (usually due to dissociative amnesia)
- Persistent & exaggerated negative beliefs or expectations about oneself, others, or the world
Marked alterations in arousal & reactivity associated with traumatic event(s) occurred, as evidenced by:
- Irritable behavior & angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
- Reckless or self-destructive behavior
- Hypervigilance & exaggerated startle response
Sometimes accompanied by dissociative symptoms such as depersonalization & derealization
To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance
What are some interventions for patients with PTSD?
- Approach the individual in a professional, nonthreatening manner; avoid startling patients with PTSD.
- Encourage expression of feelings in a safe environment.
- Encourage patient to identify & contact supportive resources in the community or on the internet.
- Encourage use of stress management & relaxation techniques.
What are some treatment options for patients with PTSD?
Medications:
- SSRIs (best side effect profile)
- TCAs
- MAOIs
P_sychosocial treatments_:
- Past-focused: repeated exposure to memories & emotions of traumatic events to neutralize their impact
- Present-focused: teaching coping skills
How are Benzodiazepines used to treat anxiety?
- The BZs are thought to reduce anxiety because they are powerful receptor agonists of the inhibitory neurotrans- mitter GABA
- The BZ molecule and GABA bind to each other at the GABA receptor site. The result is an enhancement of the actions of GABA, resulting in an inhibition of neurotransmission (a decrease in the firing rate of neurons) and thus a clinical decrease in the person’s level of anxiety.
What is a nonbenzodiazepine medication and how is it used for anxiety?
- Buspirone (Buspar), a non-BZ anxiolytic drug, is a potent antianxi- ety agent with no addictive potential and has FDA approval for the treatment of GAD.
- It is most effective in patients who have never taken BZs and therefore are not expecting immediate effects from drug treatment.
What are some Nonbenzodiazepine sedative-hypnotic agents and what are some characteristics of these drugs?
- Zolpidem, zaleplon, and eszopiclone are a new class of com- pounds for treatment of insomnia.
- Are well tolerated and have few antianxiety, anticonvulsant, or muscle-relaxant properties.
- Side effects include daytime drowsiness, dizziness, and gastrointestinal upset.
- The pri- mary difference among these drugs is their half-life and sub- sequent length of action.
- All three drugs are Schedule IV controlled substances.
Why do people use drugs?
- They make us feel good.
- Relaxation
- Euphoria
- Stimulation of senses
- Altered awareness
What is substance withdrawl?
Symptoms that result from a biological need that develops when the body becomes adapted to having the drug in the system.
What is substance dependence?
Indicates a severe condition, usually considered a disease. There may be physical problems and serious disruptions in the person’s work, family, and social life.
What is a dual diagnosis?
It is the co-existence of substance abuse and one or more psychiatric disorders in the same person
What is tolerance?
Describes an increased need of a substance to produce the same effect that a lower dose once produced.
What is codependence?
Reffers to people who had problems as a result of living in a committed relationship with a person with alcoholism (or another drug abuse problem)
Describe substance abuse related disorders in nurses
Nurses are at high risk for substance use problems due to high job stress and access to drugs. As it is in the general population, alcohol is the drug of choice for nurses, and nurses’ choice of substance is influenced by availability and exposure. Of all health care professionals, physicians and nurses use parenteral narcotics the most in their practices, and they are more likely to choose these drugs for their own use. Among narcotics, the drug of choice for nurses is meperidine (Demerol).
Describe the prevalence of substance use disorders
- U.S.– high prevalence
- Adolescence—most common first use
- Involved in many illnesses, emergency room visits, hospitalizations, deaths
- Increases motor vehicle accidents, suicide, sexual assault, high-risk sexual behaviors
- Teenagers tend to progress from nicotine to alcohol to marijuana, then more dangerous drugs
Describe underdetection of substance abuse disorders
Substance-Related Disorders (SRDs) often not detected in primary care settings & other medical settings.
Underdetection due to:
- Clinicians’ lack of knowledge & awareness
- Difficulty distinguishing substance abuse disorders from psychiatric disorders
- Clients’ denial of problem
- Co-existing psychotic, cognitive & other impairments related to psychiatric illness
What is TPAPN?
- It is the Texas Peer Assistance Program for Nurses and is a non-punitive, confidential, and voluntary alternative to reporting RNs and LVNs whose practice is suspect of being impaired by chemical dependency or mental illness to the licensing board. TPAPN is the only “in lieu of” reporting provision available to nurses and employers.
- A person who is required to report under the Nurse Practice Act for RNs, because the RN is impaired or suspected of being impaired by chemical dependency or mental illness, may report to a peer assistance program approved by the board instead of reporting to the board or requesting review by a nursing peer review committee.
What do you do if you suspect a nurse is impaired?
- Report incident to immediate supervisor.
- Document in writing & follow protocol of your agency of employment.
What types of drugs do health professionals abuse?
- Alcohol is the drug of choice for nurses (as in the general adult population).
- Nurses and physicians use parenteral narcotics more than other health care professionals.
- Among narcotics, nurses prefer meperidine (Demerol).
- Nurse anesthetists and anesthesiologists prefer fentanyl.
How would you intervene for an impaired colleague? (due to drugs)
For the safety of the nurse and the nurse’s patients, it is necessary to identify an impaired colleague and take action, reporting is an ethical and a legal obligation. The concerned colleague should report incidents of this nature to the supervisor. It is also important that these incidents be documented in writing, with the time, date, place, description of the incident, and the names of others who were present. This documentation will make it easier to intervene and help the nurse seek treatment.
What are the different parts of the CAGE questionnaire?
- Have you felt you ought to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you every felt bad or Guilty about your drinking?
- Have you even had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Scoring: Two “yes” answers indicate probable alcohol abuse and warrant further assessment.
What are some behaviors associated with drug use/dependence?
- Accidents
- Violence
- Self-neglect
- Complications during pregnancy with risks of fetal abnormalities
- IV drug users: HIV, AIDS, hepatitis B virus (HBV), hepatitis C virus (HCV).
- Major problem: needle sharing
What would you assess for in a patient with a substance abuse problem?
- Any stressors in client’s current life
- Motivation to change
- Social supports
- General health
- Social skills
- Coping mechanisms: presence of minimization, denial, rationalization, projection
What type of drug is alcohol and what are some symptoms of using it?
- Sedative — but creates euphoria in small to moderate doses
- Symptoms of use: relaxation, loss of inhibition, lack of concentration, drowsiness, slurred speech, sleep
How would a nurse intervene with a patient having withdrawl symptoms?
Interventions depend on the current and potential withdrawal symptoms that the patient may experience:
- Withdrawal from the general depressants and opiates is usually treated by substitution with a longer-acting drug in the same class, which is then gradually tapered.
- Withdrawal from opiates and amphetamines can be extremely uncomfortable but usually not dangerous, although a patient may become suicidal during the acute phase of cocaine withdrawal.
- Symptom-specific medications may be used to treat symptoms of stimulant withdrawal.
- Phenobarbital may be prescribed for inhalant withdrawal symptoms.
- No acute withdrawal pattern associated with marijuana, hallucinogens, or PCP has been identified
For patients who are experiencing drug withdrawal, the highest priority is given to patient safety. This involves stabilizing the patients physiological status until the crisis of withdrawal has subsided. After safety needs are met, abstinence and support system issues must be addressed.
What are symptoms of alcohol intoxication?
- disinhibition
- mood lability
- impaired judgment
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- flushed face
What are symptoms of alcohol withdrawl?
- coarse tremor of hands, tongue, or eyelids
- nausea & vomiting
- weakness
- tachycardia –> can lead to cardiac collapse
- sweating
- elevated blood pressure
- anxiety
- depressed mood or irritability
- headache
- insomnia
- seizures
- delirium
How would you manage patients with alcohol withdrawal?
The treatment of alcoholism is enhanced by the opiate antagonist naltrexone, which reduces alcohol reward and results in decreased alcohol craving and reduced drinking.
The principles of alcohol detoxification, according to evidence-based practice guidelines, are as follows:
- The long-acting benzodiazepines are the drugs of choice in treating alcohol withdrawal because they effectively reduce signs and symptoms of withdrawal, prevent seizures, and have a better margin of safety than many other drugs.
- A symptom-triggered dosing regimen is preferred over fixed-schedule dosing because it is effective, requires significantly less medication, and appears to prevent seizures as well as fixed schemes.
- The use of a clinically valid and reliable withdrawal assessment tool, such as the Clinical Institute Withdrawal Assessment–Alcohol, Revised (CIWA-AR), is recommended as the basis for medication determinations. This reduces overmedication resulting from patient overreporting of symptoms or fixed regimens and undermedication resulting from staff reluctance to treat. A score of 9 or less on the CIWA-AR indicates mild withdrawal, 10 to 18 indicates moderate withdrawal, and a score more than 18 indicates severe withdrawal.
- The CIWA-AR should be used with caution in patients with co-occurring medical or psychiatric illnesses and in those with concurrent withdrawal from other drugs because it rates signs and symptoms that may be caused by conditions other than alcohol withdrawal. The assessment should be repeated every 1 to 2 hours.
- Although neither magnesium nor thiamine reduces seizures, administration of thiamine is recommended to prevent Wernicke disease and Wernicke-Korsakoff syndrome.
- Symptoms of alcohol withdrawal do not always progress from mild to severe in a predictable manner. A grand mal seizure may be the first sign of acute withdrawal.
What is the difference between symptom triggered dosing & fixed-schedule dosing for alcohol withdrawal?
A symptom-triggered dosing regimen is preferred over fixed-schedule dosing because it is effective, requires significantly less medication, and appears to prevent seizures as well as fixed schemes.
Symptom-Triggered Regimen:
- Administer one of the following every hour when CIWA-AR scores are more than 8 to 10:
- Chlordiazepoxide, 50 to 100 mg
- Diazepam, 10 to 20 mg
- Repeat CIWA-AR 1 hour after every dose to assess need for further medication.
Fixed-Schedule Regimen
- Chlordiazepoxide, 50 mg every 6 hours for four doses, then 25 mg every 6 hours for eight doses
- Diazepam, 10 mg every 6 hours for four doses, then 5 mg every 6 hours for eight doses
- Provide additional medication as needed when symptoms are not controlled (e.g. CIWA-AR result of more than 8 to 10) with the previous measures.
- Other benzodiazepines may be used at equivalent doses.
What is antabuse and why is it used?
Disulfiram (Antabuse) interrupts the metabolism of alcohol, causing a buildup of a toxic substance in the body if the person uses alcohol in any form. The physiological response may include a severe headache, nausea and vomiting, flushing, hypotension, tachycardia, dyspnea, diaphoresis, chest pain, palpitations, dizziness, and confusion.
- Antabuse taken with alcohol can lead to respiratory and cardiac collapse, unconsciousness, convulsions, and death.
- Antabuse should never be given without the patient’s stated willingness to comply. It is important that the patient agree to take Antabuse only after careful instruction about the potential consequences of drinking while taking the drug. This instruction should include a written list of alcohol-containing preparations to be avoided, including cough medicines, rubbing compounds, vinegar, aftershave lotions, and some mouthwashes.
- Drinking must be avoided for 14 days after Antabuse has been discontinued. This medication cannot prevent someone who is determined to drink from drinking. The person can wait until the Antabuse has been excreted. However, it does help prevent impulsive drinking because the person has to wait for the Antabuse to clear the body to be able to drink safely. This treatment should be used in conjunction with other supportive therapies, not by itself.
What are some symptoms of early alcohol withdrawal?
anxiety, psychomotor agitation; tremors, diaphoresis, restlessness, nausea, vomiting, increased HR, BP and temperature, impaired concentration and memory, increased sensitivity to sound and light, insomnia, headache.
What medications are used for alcohol detoxification an what would you monitor for?
- Long-acting BZs are drugs of choice (vallium & libium)
- Monitor for toxicity of BZs
- Ataxia
- Nystagmus
- Thiamine and vitamin B12 may help prevent Wernicke encephalopathy, Korsakoff psychosis
Describe the onset of alcohol withdrawal and some symptoms?
Onset is 6-24 hr, peaks 24-36 hrs. It usually last 2 weeks.
- Seizures: generally major motor seizures. Onset: 8-24 hr. peak 24 hr. Occurs singly or in a burst of several over 1-6 hr.
- Hallucinosis: Auditory, visual, tactile hallcinations (may describe as nightmare or vivid dreams) NOT disoriented. Onset: about 48 hr, usually last up to 1 day, can last 2 weeks
What are some symptoms of severe alcohol withdrawal symptoms?
medical emergency, disorientation, delusions (usually paranoid type), visual hallucinations, continuation of early withdrawal symptoms but much more pronounced. Onset: 3-5 days, Lasts: 2-3 days, Confusion can last up to 50 days.
How long does alcohol detoxification last and what are some symptoms associated with it?
- Withdrawal/detox usually resolves in 7 days
- Alcohol withdrawal seizures (grand mal type) occur in 5-15% of patients.
- Alcohol hallucinosis occurs in 3-10% of patients – auditory, visual, or tactile in nature
- Delirium tremens is the most severe form of withdrawal; occurs in 5%-20% of patients
What tool would you use to score alcohol withdrawl symptoms?
Use Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-AR) or similar tool to score symptoms
- Provides effective treatment with less medication
- Monitor every 1-2 hours, decreasing to 4-8 hours until score below 10 for 24 hours
- This method is symptom treated dosing, it is more effective at treating symptoms
What type of drug are barbiturates and what are the symptoms of use?
Sedative — but creates euphoria in small to moderate doses
Symptoms of use: relaxation, loss of inhibition, lack of concentration, drowsiness, slurred speech, sleep
ex: Phenobarbitol
What are some examples of benzodiazepines?
- Alprazolam (Xanax)
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
- Oxazepam (Serax)
What are the common side effects of using benzodiazepines and what are the nursing considerations for those side effects?
Common s/x:
- Drowsiness, sedation – Activity helps; use caution when using machinery
- Ataxia, dizziness – Use caution with activity; prevent falls
- Feelings of detachment – Discourage social isolation
- Increased irritability or hostility – Observe; support; be alert for disinhibition
- Anterograde amnesia – Inability to recall events that occur while on drug
- Cognitive effects with long-term use – Interference with concentra- tion and memory of new material
- Tolerance, dependency, rebound insomnia/ anxiety – Short-term use; discontinue, using a slow taper; contraindicated with drug or alcohol abuse
What are some **rare side effects **of benzodiazepines?
- Nausea – Dose with meals; decrease dose
- Headache – Usually responds to mild analgesi
- Confusion – Decrease dose
- Gross psychomotor impairment – impairment
Dose related; decrease dose - Depression – Decrease dose; antidepres- sant treatment
- Paradoxical rage reaction – Discontinue drug
What are the symptoms of Benzodiazepines,, Barbiturates, or Other Sedative-Hypnotics drug intoxication?
- disinhibition
- mood lability
- impaired judgment
- slurred speech
- incoordination
- unsteady gait
- nystagmus
- flushed face
What are symptoms of Benzodiazepines, Barbiturates, or Other Sedative-Hypnotics withdrawal?
- nausea/vomiting
- Headache
- malaise
- weakness
- tachycardia
- sweating
- anxiety
- irritability
- orthostatic hypotension
- tremor
- insomnia
- seizure
- delirium
Withdrawal can be life-threatening
How would you manage a patient with benzodiazepine, bartiturate, and other sedative-hypnotic withdrawal?
Management of benzodiazepine, bartiturate, and other sedative-hypnotic withdrawal
- Considered therapeutic discontinuation if treating physical dependence from drug taken as prescribed
- Called detoxification if drug was abused
May treat high-dose withdrawal by gradual reduction
May substitute phenobarbital for average daily dose, divided into 3 doses
What are the symptoms of stimulant use?
Symptoms of use:
- Amphetamines and related drugs: euphoria, hyperactivity, agitation, insomnia, loss of appetite
- Cocaine: euphoria, hyperactivity, restlessness, talkativeness, increased pulse, dilated pupils, rhinitis
What are the symptoms of stimulant intoxication?
- fighting
- grandiosity
- hypervigilance
- psychomotor agitation
- impaired judgment
- tachycardia
- Pupillary dilation
- perspiration or chills
- evidence of weight loss
- nausea/vomiting
- additional symptoms for cocaine - hallucinations, delirium
What are symptoms of stimulant withdrawl?
- anxiety
- depressed mood
- irritability & fatigue
- insomnia or hypersomnia
- psychomotor agitation
- paranoid or suicidal ideation
Withdrawal is extremely uncomfortable but not dangerous
How would you treat patients with stimulant withdrawl?
administer symptom-specific medications (.e.g antidepressants)
What are the effects of cocaine?
- Cocaine causes disturbances in brain structure and function causing cognitive deficits in verbal learning, memory, and attention
- Effects of snorted cocaine occur within 15 minutes
- Crack is a smokable form which causes euphoria; within seconds produces mania like symptoms
What are the effects of metamphetamines and what are the routes of administration?
- Fastest growing drug problem in the world
- Injected, smoked, snorted (3-5 min) or taken orally (20 min); when injected or smoked has instantaneous effects
- Releases high levels of dopamine in the brain, rapid, powerful, euphoric rush
What are the symptoms of opiate intoxication?
euphoria, lethargy, somnolence, apathy, dysphoria, impaired judgment, pupillary constriction, drowsiness, slurred speech, constipation, nausea, decreased respiratory rate and blood pressure
What are the symptoms of opiate withdrawl?
craving for the drug, nausea/vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilation, piloerection or sweating, diarrhea, yawning, fever, insomnia, hypertension
How would you manage patients with opiate withdrawal?
Withdrawal from opiates and amphetamines can be extremely uncomfortable but usually not dangerous, although a patient may become suicidal during the acute phase of cocaine withdrawal.
Treatment: Methadone, Clonidine, Buprenorphine
All opiates produce similar withdrawal signs and symptoms, but the time of onset and the duration vary. Treatment is aimed at alleviating the acute symptoms. This may be done by substitution with the long-acting opiate methadone or the partial opiate agonist buprenorphine or by management of the withdrawal symptoms with medications such as clonidine.
Methadone substitution involves initial administration of methadone—an opiate agonist—to stabilize symptoms of heroin withdrawal
Buprenorphine-aided opiate withdrawal is initiated after the patient begins showing symptoms of withdrawal. This is necessary because buprenorphine is a partial opiate agonist (partially stimulates the receptor) and may induce significant withdrawal symptoms
Clonidine is available in oral, sublingual, or transdermal patch preparations.The blood pressure should initially be checked every 45 minutes, because some patients are extremely sensitive to clonidine and experience profound hypotension, even at low doses. If the blood pressure drops below 90/60 mm Hg, the next dose should be withheld and subsequent doses adjusted according to patient response. Although clonidine effectively relieves several symptoms of opiate withdrawal, it is not helpful for muscle aches, insomnia, and drug craving, which require additional medication.
What medications help control opiate withdrawl?
- Methadone substitution
- Buprenorphine
- Clonidine (Catapres) –> used to treat hypertension
- Use of withdrawal assessment tool
- Opiate withdrawal usually not life-threatening but very uncomfortable
What are experimental treatments used to try to treat cocaine?
Therapeutic vaccine that induces anti-cocaine antibodies and prevents the drug from crossing the blood-brain barrier is being used in experimental animal trials with some success.
What are the symptoms of using marijuana?
- Symptoms of use – relaxation, euphoria, dyscoria, spatial misperception, time distortion, food cravings
- Long-term use results in a cluster of symptoms known as amotivational syndrome
- No clear withdrawal pattern documented
What is amotivational syndrome?
Prolonged use of marijuana may lead to apathy, lack of energy, loss of desire to work or be productive, diminished concentration, poor personal hygiene, and preoccupation with marijuana. This cluster of symptoms is known as the amotivational syndrome. Although study findings are controversial, there seems to be general support for the existence of such a syndrome.
What are the effects of hallucinogens?
- Creates experiences to those of psychosis with perceptual distortions, not true hallucinations; have been called psychedelic or mind-revealing drugs
- Self-destructive behaviors are possible with “bad trips,” resulting in frightening psychotic episodes, flashbacks
- Has no acute withdrawal pattern
What are the symptoms of using Phencyclidine (PCP)?
- Euphoria, floating feeling, heightened emotionality, incoordination, distorted perceptions (at low doses)
- Psychosis with extreme agitation, violence (high doses)
- PCP-intoxicated people feel little or no pain because the drug is an anesthetic
What are the symptoms of Phencyclidine (PCP) intoxication?
belligerence, assaultiveness, impulsiveness, psychomotor agitation, impaired judgment, nystagmus, increased heart rate and blood pressure, diminished pain response, ataxia, muscle rigidity, seizures, delirium
No acute withdrawl pattern has been identified
How would a nurse intervene with toxic psychosis?
- Individuals who use LCD, PCP, or stimulants may present at ER with toxic psychosis
- Resembles paranoid schizophrenia
- Need environment with minimal stimulation.
- Monitor vital signs.
- BDZs may be effective for PCP toxic psychosis.
- PCP induced psychosis do not respond well to attempts at interaction
- do not perform procedures without a thorough explanation
- do not touch the patient without permission – Redirect and stay calm.
- avoid rapid movements in the patient’s presence
*
What are the symptoms of nicotine withdrawl?
craving for the drug, irritability, anger, frustration, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased weight gain, tremor, headaches, insomnia
What medications would you use to manage a patient with nicotine withdrawl?
- Nicotine gum
- Nicotine patch
- Bupropion (Wellbutrin, Zyban) - (first FDA approved non-nicotine replacement therapy; first-line treatment)
- Barenicline (Chantix)
What is the goal of treatment with substance abuse users?
- If abstinence is the goal of treatment, it is important to remember that the first few months after cessation of substance use represent the highest risk for relapse.
- Many clients will experience “slips” of using the given substance, but can avoid a full relapse when support is available.
What can be used to prevent relapse with alcohol relapse?
- Attendance at AA
- Naltrexone (ReVia)
- Nalmefene (Revex)
- Acamprosate (Campral)
- Citalopram (Celexa)
- Ondansetron (Zofran)
- Disulfiram (Antabuse)
What can be used to prevent relapse with opiate patients?
- Methadone
- LAAM (L-alpha acetyl methadol)
- Buprenorphine (Subutex)
What can be used to prevent relapse with nicotine patients?
- The various nicotine replacement therapies (NRTs) such as transdermal patch, gum, nasal spray, & inhaler) all appear to be effective in reducing withdrawal from nicotine and subsequent use.
- However, 1-year relapse rates are high.
What are some nursing interventions for substance detoxification?
- Assist with position changes, ambulation, changing damp clothing
- Give medications and vitamins per physician orders
- Monitor vital signs
- Give fluids if dehydrated, encourage eating
- Frequent sips of milk for GI distress, antidiarrheal or analgesic meds as needed
- Seizure precautions
- Cool cloth on forehead can help if patient too warm or diaphoretic
What are some different cognitive-behavioral strategies?
- Self-control strategies
- Social-skills training
- Behavioral contracting
- Contingency management
How are dual diagnosed patients handled?
The best possible treatment is an integrated one, with both addiction and mental health services offered by program staff qualified in both areas. Additionally, there should be excellent coordination of other community services
How should treatment be structured for patients with a dual-diagnosis?
- Establish a therapeutic alliance with the patient.
- Help the patient evaluate the costs and benefits of continued substance use.
- Individualize goals for change that include harm reduction as an alternative to total abstinence for the patient.
- Help the patient build an environment and lifestyle supportive of abstinence.
- Acknowledge that recovery is a long process, and help the patient cope with crises by anticipating triggers of relapse and coping with setbacks as they occur.
What are the short term goals for patients in withdrawl from drugs or alcohol?
Short-term goals related to this phase of recovery may include the following:
- The patient will overcome withdrawal safely and with minimal discomfort.
- The patient will withdraw from dependence on the abused substance.
- The patient will be oriented to time, place, person, and situation.
- The patient will report symptoms of withdrawal.
- The patient will correctly interpret environmental stimuli.
- The patient will recognize and talk about hallucinations or delusions.
What are the short-term goals for patients dependent on drugs or alochol?
Short-term goals related to abstinence may include the following:
- The patient will abstain from all mood-altering chemicals.
- The patient will agree to remain drug and alcohol free for 1 week, with the agreement to be renewed weekly.
- The patient will make a daily commitment to abstain.
Studies have shown that most people who are dependent on a drug or alcohol cannot safely return to any level of use of any addictive drug. If they do, most eventually return to their old addictive patterns. However, patients often become very anxious at the thought of never again using the substance to which they are addicted, and it may be helpful to focus on short-term goals.
What are some long term goals for patients with substance use disorders?
- Abstinence or reduction in the use and effects of substances
- Reduction in the frequency and severity of relapse
- Improvement in psychological and social functioning
The nurse should be aware that it is rare for an addicted person to suddenly stop substance use forever. Most addicted people try at least once and usually several times to use the substance in a controlled way. It is important for them to know that they should return to treatment after these relapses. They can learn from what they did and try to prevent further relapses. These issues should be addressed openly in the planning process.
How are psychological interventions helpful in substance abuse patients?
Medications alone are less effective in the treatment of drug and alcohol dependence. Most patients have optimal benefit with a comprehensive treatment program that includes the addition of psychological, behavioral, social, and spiritual treatments.
Before intervening with a substance-abusing patient, the nurse must develop self-awareness of feelings and attitudes about the problem
What are personality disorders?
- Enduring patterns of perceiving and relating
- Result in significant social and occupational impairment
- Pattern deviates markedly from the expectations of the individual’s culture
Define personality
Set of deeply ingrained, enduring patterns of thinking, feeling, and behaving
What is the diagnostic criteria for personality disorders?
Manifested in at least two of the following areas:
- cognition
- affect
- interpersonal functioning
- impulse control
- Lack of resilience in stressful situations.
Lasting pattern is inflexible and pervasive across a broad range of personal and social situations
Pattern leads to clinically significant distress or impairment in functioning
Pattern is stable and of long duration
Onset can be tracked to adolescence or early adulthood
To diagnose in persons under 18, patterns must persist for at least 1 year.
What are some common personality disorders by gender?
More frequent in men:
- Antisocial
More frequent in women:
- Borderline
- Histrionic
- Dependent
What are some nursing interventions for patients with personality disorders?
- It is helpful for the nurse to identify the patient’s behavior and link it to the feeling of anxiety (e.g., “I noticed you have been tapping your foot since we started talking about your sister. Are you feeling anxious?”)
- Once the patient is able to recognize anxiety, the nurse can help the patient gain insight by asking him to describe the situations, interactions, and thoughts that immediately precede the increase in anxiety.
- Most of all, the patient needs to assume responsibility for his own decisions and actions.
- Limit setting must occur in the context of the patient and nurse working together toward the process of change.
- Manipulative patients should be held responsible for their behavior.
-
Patients with maladaptive social responses often are effective leaders within the patient group
- They are often intelligent and can participate actively in planning their own care
- However, they are often resistant to recognizing or dealing with feelings and need consistent encouragement to verbalize these emotions
- Nursing interventions should focus on mobilizing their strengths to enhance self-esteem and using adaptive defenses and positive coping skills
-
Patients with maladaptive social responses often are effective leaders within the patient group
- They are often intelligent and can participate actively in planning their own care
- However, they are often resistant to recognizing or dealing with feelings and need consistent encouragement to verbalize these emotions
-
Nurses may become frustrated with these patients because they seem to be so aware of what is happening and so in control of most situations, yet so unaware of others’ needs
- Remember that these patients have little tolerance for intimacy
- Maneuvering of others is a way to keep them at a safe distance
What are some medications used to treat personality disorders?
Medications have a limited role in the treatment of personality disorders. They are used primarily to relieve symptoms such as anxiety, mood swings, and impulsive aggression
- Patients with cluster A personality disorders who show subtle psychotic symptoms may respond to antipsychotic medications.
- Patients with cluster B disorders who show subtle signs of bipolar disorder may benefit from mood-stabilizing medication or atypical antipsychotic drugs, either alone or in combination with antidepressant medication.
- Patients with cluster C anxiety-related personality disorders may benefit from the use of serotonergic antidepressants.
What are the different clusters of personality disorders and describe each
- Cluster A includes personality disorders of an odd or eccentric nature (paranoid, schizoid, and schizotypal personality disorders)
- Cluster B includes disorders of an erratic, dramatic, or emotional nature (antisocial, borderline, histrionic, and narcissistic personality disorders)
- Cluster C includes disorders of an anxious or fearful nature (avoidant, dependent, and obsessive-compulsive personality disorders)
What personality disoders are in Cluster A Odd and Eccentric?
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
What are some features of a Paranoid Personality Disorder?
- Suspicious
- Mistrustful
- “On guard”; hypervigilant
- Fear others will hurt them
- Lack the “milk of human kindness”
“I only trust me and thee and I’m not so sure of thee.”
What are some features of a Schizoid Personality Disorder?
- Lack social and close relationships
- Usually isolated
- Self absorbed
- Anhedonic
- Show little emotion
- Indifferent to praise or criticism
- Appear emotionally cold or flat
- “Hermit” like
What are some features of a SchizotypalPersonality Disorder?
- Odd peculiar speech, thought, and behavior
- Eccentric
- Cognitive distortions
- Behaviors may seem like a milder non-psychotic state of schizophrenia
What personality disoders are in Cluster B Emotional, erratic?
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
What are the principles of milieu treatment for patients with cluster B personality disorders?
- Establish control with no option to escape involvement.
- Provide an experienced, consistent staff.
- Implement a clear structure with rules that are fair, firm, and consistently enforced.
- Provide support while the patient learns to experience painful feelings and try out new behavioral responses.
What are some features of a Antisocial Personality Disorder?
- Lack of concern for rights of others
- No problem violating rights of others
- They project their feelings unto others
- Display irresponsible behaviors
- Lying
- Stealing
- Cheating
- Physical fights
- Disregard for others’ safety
“Why do I rob banks? Because that’s where the money is.”
What are some features of a borderline Personality Disorder?
- One of the most disruptive personality disorders
- Unstable and intense interpersonal relationships, they may use threats such as suicide
- They fear abandonment
- Hallmark
- “Splitting”
- Manipulative
- Demanding
- Needy
- Angry
“Don’t leave me, I hate you.”
Describe how dialectial behavior theraoy works to treat borderline personality disorder
- Dialectical behavioral therapy (DBT) has been found to reduce rates of suicide attempt, hospitalizations for suicidal ideation, and overall medical risk. Patients treated with DBT were less likely to drop out of treatment and had fewer psychiatric emergency room visits and psychiatric hospitalizations.
- Strong evidence supports the efficacy of the atypical antipsychotic medication olanzapine in reducing anger, impulsivity-aggression, possibly depression, and interpersonal sensitivity in borderline personality disorder.
What are some features of a Histrionic Personality Disorder?
- Can be very enthusiastic at first, superficially, they are very insecure.
- Can misinterpret relationships
- Attention seeking
- Flamboyant
- Provocative
- Portray themselves as victims
“Seeing is believing, but feeling is God’s own truth.”
What are some features of a Narcissistic Personality Disorder?
- Extreme sense of arrogance, entitlement, and self-importance
- They overvalue their personal worth
- Takes advantage of others
- Lacks empathy
- Grandiose
- Manipulative
“Please get me a tissue, I have a runny nose.” – Patient asking a nurse, who is attempting to resuscitate a collapsed patient in the hallway.
What personality disoders are in Cluster C Anxious, fearful?
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder
What are some features of an Avoidant Personality Disorder?
- Extreme anxiety
- Fear of rejection in social and intimate relationships
- Highly sensitive to rejection
- Isolated
- Longs for relationships, but feel inferior
You can help this patient by slowly introducing them to new people, work on their selfesteem.
What are some features of an Dependent Personality Disorder?
- Over-reliance on others
- Unable to make decisions and expect others to make them
- May prefer abusive relationships to being alone
- Tend to agree with others rather than state a different opinion
- They don’t like conflicts or disagreements
To help these patient, encourage them to make their own life decisions, help them with IADL
What are some features of an Obsessive-compulsive Personality Disorder?
- NO OBSESSIVE COMPULSIONS
- Extremely rigid and controlling
- Perfectionistic, difficulty completing tasks
- Overly organized & devoted to work – hurts personal relationships
- Pays extreme attention to detail in an exaggerated manner
To help these patients
What are some nursing interventions for patients with personality disorders?
- Milieu therapy
- Therapeutic communication strategies
- Promotion of healthy interactions
- Patient and family education
- Strategies for preventing or reducing violence to self or others
Who gets Milieu Therapy and what does it focus on?
Appropriate for patients:
- With self-destructive behaviors
- Who require a structured environment
Focuses on:
- Realistic expectations
- Process of decision making
- Process of interactional behaviors in the here-and-now
What is Dialectical behavior therapy?
- A specific type of cognitive behavioral therapy called dialectical behavior therapy (DBT) is an empirically validated treatment approach for patients with borderline personality disorder
- DBT uses behavioral and cognitive techniques that include psychological education, problem solving, training in social skills, exercises in monitoring moods, modeling by the therapist, homework assignments, and meditation. It is based on the assumption that temperament and an
How would you promote healthy interactions with manipulative patients?
- Set clear, realistic expectations
- Determine the goal behind the manipulation
- Give positive reinforcement
- Avoid collusion with “splitting” behaviors
- Use supervision and consultation with other staff
- Review patient’s behavior with interdisciplinary staff to promote consistency
How would you promote healthy interactions with dependent patients?
- Strongly encourage self-care
- Promote participation in activities that encourage accomplishment
- Role model taking responsibility for decisions and actions
- Give positive feedback
- Point out behaviors that are undermining the patient’s care
How would you promote healthy interactions with angry patients?
- Identify triggers to angry remarks and behaviors
- Role model appropriate behavior
- Set limits on excessive complaining or degrading remarks
- Use written contract to reinforce appropriate behaviors
- Problem solve alternative ways to manage anger
What is projective identification?
Examples of splitting & projective identification (These are coping mechanisms to cope with anxiety r/t threatened or actual loneliness. People with antisocial personality disorder often use the defenses of projection and splitting.)
What is manipulation?
- a behavior in which people treat others as objects and form relationships that center around *control issues. *
- No desire to change because manipulative behavior has self-rewards. The person is skilled at giving the impression of involvement with others.
What is narcissisim?
self-centeredness; problems occur when person does not gain the status he/she thinks is deserved or loses status or **tries to have interpersonal relationships. ** People with narcissistic personality disorders have fragile self-esteem, driving them to search constantly for praise, appreciation and admiration.
What is impulsive agression?
impulsive aggression is the hallmark of borderline personality disorder, and it plays a pivotal role in the borderline person’s self-mutilation, unstable relationships, violence and completed suicides.
What is anorexia nervosa?
- a life-threatening condition characterized by disturbed body image, emaciation, & intense fear of becoming obese
- Although hungry, person refuses to eat because of distorted self-perception of fatness
- Starvation ensues
What are some characteristics of Anorexia Nervosa?
- Onset—usually not overweight to begin with
- Occurs in approx. 0.5%-1% of females usually occurs b/w 13 & 20 but can be any age, males make up 5%-10% of anorexic pop.
- Often perfectionistic & conscientious
- Often excel in athletics or academics
- Feelings of great inadequacy
What are the clinical features of anorexia nervosa?
- Distorted body image
- Excessive diet & exercise
- Unpleasant mealtimes, anxious before eating
- May hoard food
- May develop rituals around eating
- Physiological:
- amenorrhea
- cachexia - low body mass, have a greater chance of death
- Low temperature, pulse & blood pressure
- Dry, scaly skin
- Widespread lanugo
- Dry, thin hair
- Vitamin deficiencies
What are some EKG changes seen with anorexia nervosa?
- Cardiac muscle may atrophy.
- Reduced left ventricular wall thickness
- Decreased cardiac output
- Prolonged QT interval, they can die from a cardiac arythmia from electrolyte imbalances
What are some medical complications with anorexia nervosa?
Effects of starvation along with osteoporosis, amenorrhea, constipation, cold intolerance, bradycardia, acid-base & fluid-electrolyte disturbances including pedal edema
Describe the treatment plan for a patient with anorexia nervosa?
- Goal: weight restoration & reintegration of patient into health family and social life. (1st goal)
- Question: Can the patient be treated without being hospitalized?
- Cognitive - behavioral therapy
- Family therapy
- Body Image interventions (relaxation, dance, movement)
What are the medications used to treat anorexia nervosa?
- Antidepressants may be helpful with comorbid depression, mood swings, or irritability, and obsessions about food and fat
- Patients with anorexia often resist medication; no drugs completely effective
- Do not use medications as primary treatment for anorexia
What is Bulimia nervosa?
It is characterized by uncontrollable consumption of large amounts of food (binge eating), followed by attempts to eliminate the body of the excess calories (usually by purging)
What are some clinical features of bulimia nervosa?
- Onset typically is 15 to 18 years of age
- Female/male ratio is 11:1
- Intense guilt, shame, disgust at conclusion of binge
- Binging done in secret
- Self-induced vomiting and/or laxative abuse often follow.
- Some don’t purge—will just exercise excessively to counteract binges
- May experience weight fluctuations
What are some characteristics of bulimia nervosa?
- More common than Anorexia Nervosa
- May consume huge number of calories (e.g., 4,000-8,000) in short period, induce vomiting, & repeat cycle several times a day.
- Cakes, pies, ice cream, cookies, breads often preferred.
- May develop dental caries
What are some physiologic findings with bulimia nervosa patients?
- Parotid gland enlargement
- Esophagitis
- Gastric dilatation
- Menstrual irregularities
- Electrolyte changes (e.g., hypokalemia)
- Russell’s sign (scarring on knuckles on back of hand due to repeated self-induced vomiting over long periods of time)
What are the treatment options for bulimia nervosa?
- Cognitive behavioral therapy
- Medications
- Antidepressants have therapeutic effect on many patients with bulimia
- May decrease frequency of binge eating, vomiting
- Family therapy
- Body Image interventions
What are medical complications associated with bulimia nervosa?
- Potassium depletion & hypokalemia (from vomiting & laxative abuse) resulting in muscle weakness, cardiac arrhythmias, conduction abnormalities, hypotension, etc.
- Also, erosion of dental enamel, enlargement of parotid glands
What is a binge eating disorder?
- Consume large amount of calories in contained amount of time
- Differs from bulimia because person does not attempt to prevent weight gain
- Purging behaviors not used
- Prevalence: about 2 – 4% of pop.
- Important to assess for this problem
What is binge eating?
- It is a rapid consumption of a large number of calories in a brief period of time
- Usually binges secretively, often feels shame
- Find out what patient considers a binge.
What are some medical complications associated with binge eating disorders?
hypertension, cardiac problems, sleep apnea, difficulties with mobility, diabetes mellitus
What is night eating syndrome?
- Recurrent episodes of night eating
- Manifested by eating after awakening from sleep or excessive food consumption after the evening meal
- Estimated 1.5% of population
- Make up 27% of severely obese population seeking surgical treatment
What would you assess for in patients with eating disorders?
Comprehensive physical exam:
- Vital signs
- Weight for height & age.Skin
- Cardiovascular system
- Abuse of laxatives, diet pills, diuretics
- Dental exam
- Russell’s sign
- Psychiatric history
- Secret eating
- Impact of eating patterns on quality of life
- Unusual beliefs about nutrition
Describe the fasting or restricing eating behaviors
- May be obsessive-compulsive regarding food choices & eating habits
- Although obsessed with food, may choose to cook for others
- Intake may be 200 – 700 calories, e.g.
What is purging and what are some methods for purging?
It is forced vomiting due to:
- OTC or prescription diuretics
- Diet pills, laxatives
What are some comorbidities associated with eating disorders?
- Depression or dysthymia in 50%-75% of people with anorexia and bulimia
- Obsessive-compulsive disorder in up to 25% of patients with anorexia nervosa
- Patients with bulimia have increased rates of anxiety disorders, posttraumatic stress disorder, substance abuse, mood disorders
What are some predisposing factors for eating disorders?
Biological:
- Can run in families – Esoecially females
- Focus on appetite regulation center in hypothalamus
- Reduced serotonin (5-HT)—associated with reduced satiety, increased food intake & dysphoric mood
- Reduced dopamine (DA)—may increase pathological eating as way to compensate for decreased activation of reward circuits modulated by DA
Psychological:
- rigidity, perfectionism
Environmental:
- medical illnesses, sexual abuse, drug abuse, media influences
Sociocultural:
- shifting cultural norms for young women to face multiple, ambiguous, often contradictory role expectations
What is the desired outcome for patients with eating disorders?
- The patient will restore healthy eating patterns and normalize physiological parameters related to body weight and nutrition.
- For patients with anorexia or bulimia, this means eating 100% of all meals without bingeing, purging
- The expected outcome of nursing care is that the patient will obtain maximum satisfaction by establishing and maintaining self-enhancing relationships with others.
- The plan of nursing care must be realistic, considering the patient’s ability to tolerate anxiety, and must promote consistency of intervention
What are some goals for patients with eating disorders?
- Patient will identify cognitive distortions about food, weight, body shape
- Develop nutritionally balanced menus
- Accurately describe body dimensions
- Exercise moderately only when nutritionally, medically stable
What are some cognitive distortions of clients with eating disorders?
- Magnification – overestimating the significance of undesirable events, stimuli are embellished with meaning not supported by objective. “I gained 2 lbs so I can’t wear shorts anymore.”
- Superstitious thinking – believing in the cause and effect relationship of non-contingent events. “If I eat a candy, it will instantly turn to fat.”
- Dichotomous or all-or-nothing thinking – thinking in extreme or absolute terms. “If I gain 1 lb., I will go on to gain 100 lbs.
- Overgeneralization – extracting a rule on the basis of one event and applying it to other dissimilar situations. “I used to be of normal weight and I wasn’t happy. So I know gaining weight is not going to make me feel better.”
- Selective abstraction – basing a conclusion on isolated details while ignoring contradictory and more important evidence. “The only way I can be in control is through eating.”
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Personalization and self-reference – egocentric interpretation of impersonal events or over-interpretation of events related to the self. “They whispered to each other as I walked by. They were probably saying how ugly I looked after gaining 5 lbs.”
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What are some common coping mechanisms for patients with eating disorders?
- Denial
- Control issues – Especially A.N.
- Isolation of affect
- Avoidance – of feelings
- Intellectualization – Will use intellect to reason for not eating
What are some treatment interventions for patients with eating disorders?
- Nutritional stabilization
- Types of exercise
- Cognitive behavioral approaches
- Body image interventions
- Family involvement
- Group therapies
- Medications
What are some treatment options for patients with eating disorders?
- Getting patient with anorexia to gain weight is difficult
- Nurse-patient contracts can be effective
- May set goal of gaining 1 pound/week
- If fails to gain 4 pounds in 1 month, contract would stipulate that patient would agree to enter hospital, or day treatment program
- No drugs have been found to be effective in AN. The role of antidepressants is usually best assessed following weight gain when the psych effects of malnutrition are resolving.
- Antidepressants maybe helpful in comorbid depression, mood swings, or obsessions about food and fat.
Antidepressants have a therapeutic effect on many pt. w/ BN. Med benefits include decreases in frequency of binge eating and weight regulatory behaviors such as vomiting. Meds are most effective when used with other psychotherapeutic interventions
Describe the nurse patient contract with a patient anorexia?
Getting a patient with anorexia to gain weight is an even more difficult task. Nurse-patient contracts can be effective tools in working with these patients because their need for control of food is so great. For example, the nurse and patient may set a realistic goal of gaining 1 pound (0.45 kg) per week. The contract would stipulate that if the patient fails to gain 4 pounds (1.8 kg) in 1 month, the patient agrees to enter a hospital, day treatment program, or some other more intensive type of care.
