Exam 3 Flashcards
four humors
(1) irritable and hostile choleric (yellow bile)
(2) pessimistic melancholic (black bile)
(3) overly optimistic and extraverted sanguine (blood)
(4) apathetic phlegmatic (phlegm)
clusters of personality disorders
A. odd eccentric (paranoid, schizoid, schizotypal)
B. dramatic, erratic (antisocial, borderline, histrionic, narcissistic)
C. anxious, fearful (avoidant, dependent, obsessive-compulsive)
*The Weird (A), The Wild (B), and The Willy (C)
schizoid and schizotypal
-schizoid is lesser degree of schizotypal
paranoid characterized by
pervasive, persistent, and inappropriate mistrust of others
**more common in MEN
1-4% in population
clinical picture paranoid
- on guard constantly (hypervigilant)
- trust no one
- tests honesty of others
- oversensitive
- insensitive to others feelings
- tends to misinterpret minute cues
- magnify and distort cues in environment
- does not accept responsibility for his/her own behavior
- attributes shortcomings to others
predisposing factors paranoid personality
-subject to early parental antagonism and harassment
schizoid personality disorder characterized by….
….primarily profound defect in ability to form personal relationships & failure to respond to others in meaningful emotional way
**more common in men
3-5% in population
clinical picture schizoid personality
- aloof and indifferent to others
- emotionally col
- no close friends (prefers being alone)
- appears shy, anxious, uneasy to others
- inappropriately serious about everything and difficulty acting in light-hearted manner
schizoid personality predisposing factors
- childhood characterized by:
- bleak
- cold
- unempathetic
- notably lacking in nurturing
schizotypal personality disorder characterized by
odd and eccentric but does not decompensate to level of schizophrenia
(graver form of less severe schizoid)
3% population
schizotypal clinical picture
- aloof and isolated
- behave in bland/apathetic manner
- bizarre speech pattern
- when under stress, can decompensate and demonstrate psychotic symptoms
- right on verge of psychosis (odd unusual behaviors)
- magical thinking
- ideas of reference
- illusions
- depersonalization
- superstitiousness
- withdrawal into self
predisposing factors
- physio (anatomic deficits or neurochem dysfxn)
- family dynamics (indifference, impassivity, formality)
- pattern of discomfort w/ personal affection and closeness
antisocial personality–behavior that is:
- socially irresponsible
- exploitative
- w/out remorse
- disregard for rights of others
*2-4% in men to about 1 percent in women
clinical picture of antisocial personality
- fails to sustain consistent employment or academic performance
- fails to conform to law
- fails to develop stable relationships (can’t form long-lasting monogamous relationship)
- can’t fxn as responsible parent
- belligerent and argumentative
- unable to delay gratification/impulsive/reckless
borderline personality disorder characterized by
- pattern of intense and chaotic relationships w/ affective instability (clients fall on border between neuroses and psychoses)
- fluctuating and extreme attitudes regarding other ppl
- highly impulsive
(1-2 percent of population and more common in women)
borderline clinical picture
- emotionally unstable
- directly/indirectly self-destructive (unstable self-image)
- lacks clear sense of identity
- chronic depression
- inability to be alone
histrionic personality disorder characterized by..
-colorful, dramatic, extroverted behavior in excitable and emotional people
2-3% (more common in women)
clinical picture of histrionic
- self-dramatizing
- ATTENTION-SEEKING
- overly gregarious
- seductive
- manipulative
- exhibitionistic
- EASILY influenced by others (follower)
- highly distractible
- difficulty forming close relationships
- strongly dependent
- somatic complaints common
- require constant approval and affirmation
predisposing factors histrionic personality
- link to noradrenergic and serotonergic systems
- biogenetically determined temperament
- learned behavior patterns
narcissistic personality disorder characterized by…
- exaggerated self-worth
- lack of empathy
- inalienable right to special consideration
*6% prevalence (more common in men)
narcissistic clinical picture
- exploits others to fulfill own desires
- mood (often grounded in GRANDIOSITY) is usually optimistic, relaxed, cheerful, and care-free
- mood can easily change if clients do not: meet self-expectations OR receive positive feedback that they expect
- criticism from others can cause them to respond with rage, shame, humiliation
predisposing factors personality
- as children, fears, failures, or dependency needs were responded to w/ criticism, disdain, or neglect
- narcissistic parents
- parents overindulged child/failed to set limits on inappropriate behavior
- parent lives vicariously thru child
avoidant personality disorder characterized by…
- extreme sensitivity to rejection
- social withdrawal
(1% and is equally common in men and women)
clinical picture avoidant personality disorder
- awkward and uncomfortable in social situations
- desire close relationships but avoid them because of fear of being rejected
- perceived as timid, withdrawn, or cold/strange
- view others as critical and betraying
predisposing factors personality disorder
NO CLEAR CAUSE
- combo of bio, genetic, and psychosocial
- primary psychosocial influence: parental rejection and censure (often reinforced by peers)
dependent personality disorder characterized by…
-pattern of relying on others for emotional support
relatively common, and more common in women and in youngest children of family
clinical picture of dependent personality
- have notable lack of self-confidence apparent in: Posture, Voice, Mannerisms
- overly generous and thoughtful while underplaying own attractiveness and achievements
- low self-worth and easily hurt by criticism and disapproval
- avoid positions of responsibility and become anxious when forced into them
- assume passive and submissive roles in relationships
predisposing factors dependent personality
from overprotective parents:
- stimulation and nurturance are experienced exclusively from one source
- singular attachment is made by infant to exclusion of all others
obsessive-compulsive personality disorder characterized by
- inflexibility about way in which things must be done and devotion to productivity at exclusion of personal pleasure
- relatively common and more common in men and most common in oldest children
obsessive-compulsive personality clinical picture
- esp. concerned w/ matters of organization and efficiency
- tend to be rigid and unbending
- socially polite and formal
- rank-conscious (ingratiating with authority figures and autocratic and condemnatory with subordinates)
- on surface, appear to be calm and controlled but underneath: ambivalence, conflict, hostility
- problems with decision-making
- thrive in chaos
predisposing factors
- overcontrol by parents
- notable parental lack of positive reinforcement for good behavior
- frequent punishment for undesirable behavior
who staff splits
-borderline personality disorder
patterns of interaction with borderline
- clinging and distancing behaviors
- splitting
- manipulation
- self-destructive behaviors (self-harm)
- impulsivity
psychosocial influences borderline
- childhood trauma & abuse
- fixed in rapprochment phase of development (16 to 24 mo)
- child fails to achieve task of autonomy
goals for client w/ borderline
- able to identify true source of anger
- relates to more than one staff member
- completes ADL’s independently
- express anger appropriately
antisocial personality disorder behaviors characterized by…
…reactive to perceived threats, control, and negative affect
psychopathy….
- low fear
- low empathy
- domination
- callous cruelty
- emotional insensitivity
predisposing factors antisocial personality
- disruptive behavior as child (ADHD/hyperactivity dx/conduct dx)
- hx severe physical abuse
- absent/inconsistent parental discipline
- extreme poverty
- removed from home
- growing up w/out parental figure of both sexes
- always being rescued when in trouble
DBT…
…antisocial personality tx
schizotypal tx
CBT not effective
antisocial
-do not tx w/ pharm
Freud and dissociation
-type of repression (active defense mechanism used to remove unacceptable mental contents from awareness)
**unexpressed emotions converted into physical symptoms
Richard Asher
-termed Munchausen Syndrome/Factitious Disorder
conversion dx epidemiological
- more in women
- more in adolescents and YA
- lower socioeconomic/less education/rural populations
- military personnel exposed to combat
DIDs epidemiology
*dissociative disorders
- more in women
- symptoms usually being in adolescence or early adulthood
single brief episodes of dissociation
- severe psychosocial stress
- sleep-deprived
- during travel to unfamiliar places
- intoxicated
somatic symptom dx basic definition
- chronic dx w/ symptoms beginning before age 30
- periods of remission and exacerbation
common complications of somatic symptom dx
-drug abuse
personality characteristics of somatic symptom disorder
- heightened emotionality
- strong dependency needs
- preocccupation with symptoms and oneself
illness anxiety dx
- preoccupation and fear of having serious dz
- anxiety and depression common and OC traits accompany dx
dissociative amnesia and dx
-difficult to dx in kids because mistaken for inattention or oppositional behavior
conversion dx
- loss or change in body fxn that cannot be explained by any known medical dx
- symptoms affect voluntary motor or sensory functioning suggestive of neurological disease
pseudocyesis
-false pregnancy
hereditary
- somatic symptom dx
- conversion dx
- illness anxiety dx
biochem in somatic symptoms dx
-decreased levels of serotonin and endorphins (may play role in pain)
defenses in psychodynamic theory of somatic symptom disorder (illness anxiety dx)
- ego defense mechanism
- physical complaints=expression of low-self esteem
*defense against guilt
conversion disorder psychodynamic theory
-emotions associated with traumatic event that are unacceptable to express
tertiary gain
-somatization brings some stability to fam and positive reinforcement to child
**dysfunctional fam
**shift focus away from family issue
primary gain
-may avoid obligations/be excused from unwanted duties w/ somatic complaints
secondary gain
-become prominent focus of attention because of illness
dissociative amnesia
-defined as inability to recall important personal info that is too extensive to be explained by ordinary forgetfulness (no substance use)
**onset follows severe psychosocial stress
most common types of dissociative amnesia
- localized amnesia (unable to recall incidents associated w/ stressful period)
- selective amnesia (can recall only certain incidents associated w/ stressful event for specific period after event)
- generalized type (amnesia for his/her identity and total life history)
dissociative fugue
**subtype of dissociative amnesia
-sudden, unexpected travel away from customary places or by bewildered wandering w/ inability to recall some or all of one’s past (sometimes assumes new identity)
termination of dissociative amnesia
-usually abrupt and followed by full recovery
**reoccurrences are unusual
dissociative identity disorder transition
-transition from one personality state to another may be sudden or gradual (sometimes quite dramatic)
parent in Munchausen
- depressed or anxious
- past hx of abuse
tx for Munchausen
- remove child from situation
- therapy for parent (sometimes lie in therapy tho)
depersonalization-derealization disorder
-temp change in quality of self-awareness, often taking on form of
1-feelings of unreality
2- changes in body image
3-feelings of detachment from environment
4-a sense of observing oneself from outside body
DID characteristics
-fragments of identity rather than separate personalities
DID symptoms
- voices in head
- sudden emotions have no control over
- constant change thru behavior, mem, perception, motor function
- gaps in mem
- thoughts suicide common trait
- depression & anxiety (from depersonalization and derealization)
depersonalization vs derealization
- depersonalization: disturbance in perception of oneself
- derealization: alteration in perception of external environment
s/s depersonlization-derealization disorder
- anxiety/depression
- fear of going insane
- obsessive thoughts
- somatic complaints
- disturbance in subjective sense of time
genetics and dissociative dx
-no evidence of genetic contribution
DID predisposing factors
- hx physical/sexual abuse (survival strategy for child in traumatic environment)
- depersonalizaton=evidenced w/ migraines and MJ use, responds to SSRIs (serotonergic involvement)
risk for suicide
DID
meds in somatic symptom dx
-not effective unless being used to tx underlying depression/anxiety
amobarbital
- retrieval lost mem in amnesia
- reveal historical info r/t trauma
abreaction
-recall past traumas in detail
“remembering w/ feeling”
tx w/ depersonlization-derealization
inconclusive
3 D’s in geriatric psychology
(1) delirium (reversible)
(2) dementia
(3) depression
s/s delirium
- difficulty sustaining/shifting attention
- disorganized thinking
- rambling speech (pressured/incoherent)
- disorientation to time and place
- impairment of recent mem
- misperceptions about environment (HALLUCINATIONS & DELUSIONS)
- disturbances in sleep/wake cycle/nightmares
- psychomotor activity that fluctuates between agitation and restlessness and vegetative state
autonomic manifestations of delirium
- tachy
- sweating
- flushed face
- dilated pupils
- elevated blood pressure
delirium due to medical condition
- systemic infections
- febrile illness
- metabolic disorders (electrolytes imbalances, hypoglycemia)
- hypoxia/COPD
- head trauma
- hepatic/renal failure
- migraine headaches
- seizures
- brain abscess/neoplasm
- stroke
- nutritional deficiency
- uncontrolled px
- burns
- heat stroke
- orthopedic and cardiac sx
- social isolation
precipitating factors for delirium for elderly (over 65)
- dementia
- depression
- falls
- elder abuse
med-induced delirium
- anticholinergics
- antihypertensives
- corticosteroids
- anticonvulsants
- cardiac glycosides
- analgesics anesthetics
- antineoplastic agents
- antiparkinson drugs
- H2 receptor antagonists (CIMETIDINE)
neurocognitive disorders defined as…
…cognitive fxns closely linked to particular areas of the brain
-impairment in cog fxn of thinking, reasoning, memory, learning and speaking
NCD (defined as MILD or MAJOR)
mild NCD
AKA mild cognitive impairment
early signs of dementia
major NCD
-progressive decline in cog ability in presence of clear consciousness
MANY cog deficits involved
reversible NCD
temporary dementia
- can occur as result of:
- stroke
- depression
- side effects of meds
- nutritional deficiencies (esp b12 or folate)
- metabolic disorders
- normal pressure hydrocephalus
- CNS infections
primary NCD
-ex: AD
**NCD itself is major sign of organic brain dz not directly r/t any other organic illness
secondary NCD
-ex: HIV, cerebral trauma
**caused by or r/t another dz or condition
cognition in NCDs
- abstract thinking impairment
- judgement impairment
- poor impulse control
behavior in NCDs
**conventional rules of social conduct often disregarded
-uninhibited and inappropriate behavior
language in NCDs
may or may not be affected
- trouble naming objects or language may seem vague and imprecise
- aphasia (in severe forms)
personality change in NCDs
common (accentuation or alteration of premorbid characteristics)
as dz progresses, symptoms may include:
- aphasia
- apraxia (inability to carry out motor activities despite intact motor fxn)
- irritability/moodiness/sudden outbursts
- inability to perform ADLs
- wandering away from home
- incontinence
stages of progressive symptoms of AD
- Stage 1: no apparent symptoms
- Stage 2: forgetfulness (losses in short term mem common)
- Stage 3: mild cog decline (pt. where we want to try to get tx started; interference w/ work performance which becomes noticeable to coworkers)
- Stage 4: mild-to-mod cog decline
- Stage 5: mod cog decline
- Stage 6: mod-to-severe cog decline
- Stage 7: severe cog decline
categories of etiology of NCDs
- NCD due to AD
- Vascular neurocognitive dx
- frontotemporal neurocognitive dx
- NCD due to TBI
- NCD due to Parkinson’s
- NCD due to Lewy body dementia
- NCD due to HIV infection
- substance-induced neurocognitive dx
- NCD due to Huntington’s
- NCD due to prion dz
- NCD due to another med condition
- NCD due to multiple etiologies
- unspecified NCD
NCD due to AD course of disorder
-progressive and deteriorating
predisposing factors to NCD due to AD
- neurotransmitter alterations (depression r/t alzheimer’s; acetylcholine reduction which reduces amount of NT that is released to cells in cortex and hippo)
- plaques and tangles (Tau’s)
- head trauma
- genetic factors (40% of AD pts have fam hx)
vascular NCD
- cerebrovascular dz (blood flow in brain impaired)
- more abrupt onset than seen in AD && course is more variable
**symptoms in STEPS rather than gradual deterioration (at times, symptoms tend to clear up)
etiology vascular NCD
- HTN
- cerebral emboli
- cerebral thrombosis
frontotemporal NCD
-result of shrinking of frontal and temporal anterior lobes of brain
(previously called PICK’s dz)
***predominantly main one
symptoms of frontotemporal NCD
*fall into two clinical patterns:
1-behavioral and personality changes
2-speech and language problems
NCD due to traumatic brain injury
-amnesia is the MOST COMMON neurobehavioral symptom following head trauma (posttraumtic amnesia)
- LOC
- disorientation/confusion
- neuro signs
- changes in speech, vision, personality
repeated head trauma
can result in dementia pugilistica
*syndrome characterized by:
- emotional lability
- dysarthria (slurred speech)
- ataxia
- impulsivity
NCD due to Lewy body dz
- similar to AD but progresses MORE RAPIDLY and early appearance of (1) hallucinations and (2) parkinsonian features
- depression and delusions also common
- Lewy bodies in cerebral cortex and brainstem
NCD cases and Lewy body
25% of all NCD cases
NCD due to Parkinson’s
*loss of nerve cells located in substantia nigra and decrease in dopamine activity
(cerebral changes in NCD from Park. resemble those of AD)
75% of parkinson’s clients
NCD due to HIV
-caused by brain infections w/ opportunistic organisms or by HIV-1 directly
- *symptoms:
- range from barely perceptible changes to acute delirium to profound cog impairment
substance-induced NCD
-substance rxns, overuse, or abuse (s/s persist beyond usual duration of intoxication and acute withdrawal)
- alc/sedative/hypnotic/anxiolytics/inhalants
- drugs causing anticholinergic effects
- toxins like lead/mercury
NCD due to Huntington’s
**more gene-related
- damage in basal ganglia and cerebral cortex
- declines into PROFOUND state of dementia and ataxia
NCD due to Prion dz
- insidious onset and rapid progression (dx to death in 2 yrs)
ex: infected meat products/Mad cow dz
manifestations of NCD due to prion dz
- probs w/ coordination
- other movement disturbances
- rapidly progressing dementia
development of NCD due to prion
-develop at any age but typically between 40 and 60 y/o
NCD due to another med condition
-hypothyroidism/hyperparathyroidism/ pituitary insufficiency -uremia -encephalitis -brain tumor -pernicious anemia (B12) or thiamine deficiency (B1) or pellagra (niacin deficiency) -MS -uncontrolled epilepsy -cardiopulm insufficiency -fluid/electrolyte imbalances -CNS and systemic infections -lupus
client hx/assessment for NCDs
(1) type, frequency, and severity of mood swings, personality/behavioral changes, and catastrophic emotional rxns
(2) cog changes (attn span, thinking process, prob-solving, mem)
(3) language difficulties
(4) orientation to person, place, time, situation
(5) appropriateness of social behaviors
most common mental illness in elderly
- depression (but is often misdiagnosed)
* cog symptoms of depression may mimic NCD and providers are too eager to make this dx
dx lab tests (blood and urine)
test for:
- infections
- hepatic/renal dysfxn
- DM or hypoglycemia
- electrolyte imbalance
- metabolic/endocrine dx
- nutritional deficiency
- toxic substances
janitor cells for amyloid beta
microglia
risk factors alz’s
- age
- genetics (DNA alone does not determine if we get Alz)
- sleep (glial cells work hard w/ deep sleep)
- cardio health (high BP, DM, obesity)
- **aerobic exercise decreases amyloid beta
neuroplasticity and cognitive reserve
*form more synapses (creating and strengthening new neural connections when we learn something new)
cognitive reserve=more functional synapses available
evaluation of client with NCD
- based on series of short-term goals rather than long-term goals
- Outcomes: measured in terms of slowing down process rather than stopping or curing
additional attention in delirium
- fluid/electrolyte status
- hypoxia
- anoxia
- DM probs
staff and client w/ delirium
-staff to remain w/ client at all times to monitor behavior and provide reorientation/assurance
meds for delirium
*some choose not to give meds to delirium clients as they may only compound syndrome of brain dysfxn
BUT if so:
-psychosis w/ agitation and aggression may require meds/restraint ((low-dose antipsychotics))
substance withdrawal
can use benzodiazepines for delirium w/ substance withdrawal
pharm agents for cognitive impairment
- Physostigmine (Antilirium)= cholinesterase inhibitor (mild to moderate AD)
- Tacrine (Cogex)=cholinesterase inhibitor
-Donepezil (Aricept)
-Revastigmine (Exelon)
-Galantamine (Razadyne)
^^all these are acetylcholine inhibitors
-Memantine (Namenda) =mod to severe tx
combo meds
- donepezil & memantine (Namzaric)
- aducanumab (Aduhelm) which is an ANTI-AMYLOID antibody IV admin/infusion
pharm agents for agitation, aggression, hallucination, thought disturbances, wandering
- risperidone (Risperdal)
- olanzapine (Zyprexa)
- quetiapine (Seroquel)
- ziprasidone (Geodon)
**these have fewer anticholinergic effects and EPS than do older antipsychotics
**black box warning that all atypical antipsychotics associated w/ increased risk of death in elderly pts w/ dementia
pimavancerin
*Nuplazid
-specifically for tx of hallucinations and delusions in Parkinson’s dz psychosis’
(serotonin agonist and antagonist activities)
anticholinergic effects
*many antipsychotics, antidepressants, and antihistaminic meds produce these
- confusion
- blurred vision
- constipation
- dry mouth
- dizzy
- difficulty urinating
**elderly specifically sensitive to these effects because of decreased cholinergic reserves
AD/depression comorbidity
40% with AD suffer from major depression
**difficult to distinguish from NCD
Tricyclic antidepressants
-avoided due to anticholinergic and cardiac side effects
Trazadone
*Desyrel
**good choice for clients with insomnia/depression (use at bedtime)
dopaminergic agents
-methylphenidate, amantadine, bromocriptine, bupropion
**may be helpful in tx of severe apathy
pharm agent for anxiety
**should not be used routinely for prolonged periods
**usually in early stages of NCD
-Librium (chlordiazepoxide), Xanax (alprazolam), Ativan (lorazepam), Serax (oxazepam), Valium (diazepam)
sleep disturbances
-among the problems that most frequently initiate need for client placement in long-term care facility
**intensify as NCD progresses
pharm therapy for sleep disturbances
**SHORT-TERM only
-Dalmane (flurazepam), Restoril (temazepam), Halcion (triazolam), Ambien (zolpidem), Sonata (zaleplon), Rozerem (ramelteon), Lunesta (eszopiclone), Desyrel (trazadone), Remeron (mirtazapine)
substance related disorders compromised of 2 groups
- substance-use disorders (addiction)
- substance-induced disorders (intoxication, withdrawal, delirium)
MAT
medication assisted therapy
*meds AND behavioral therapy
providers who are wavered
go thru federal certification training to prescribe these meds
**in TN, don’t allow advanced practice RN to prescribe, so they might go through training but still can’t prescribe
what makes ppl relapse
CRAVINGS
*MAT eliminates cravings and helps keep them comfortable while they withdraw
substance intoxication
REVERSIBLE SYNDROME of symptoms following excessive use of substance
**direct effect on CNS (disruption in physical and psychological fxn-ing)
**judgment is disturbed and social/occupational fxn-ing impaired
stimulants
caffeine and tobacco
biochem factors
-alcohol may produce morphine-like substances in brain that are responsible for alc addiction
certain personality traits that increase tendency toward addictive behavior
1-low self-esteem 2-frequent depression 3-passivity 4-inability to relax or defer gratification 5-inability to communicate effectively
dopamine
reward system
**creates cravings that encourage behaviors that help us survive
**pleasure stimulated by other NTs in hedonic hot spots in brain
dorsal striatum
-form habits (based on pleasurable things youve done)
prefrontal cortex
w/ help of glutamate, rich images of cravings are conjured
amygdala
dopamine causes neurons hear to be stimulated by learned emotional responses
cocaine
prevent removal of excess dopamine
methamphetamine
floods synapses with dopamine
heroin
blocks dopamine inhibitors
baclofen
-can tx alcohol dependency
electromagnetic stimulation
can tx cocaine cravings
cultural/ethnic influences of alcohol use
- increase in Native Americans and Irish
- decrease in Italians despite wine being part of meals
- Asians (genetic intolerance)
nations #1 health issue/factor in more than half of all homicides, suicides, and traffic accidents
-alcohol use disorder
Phase I and II patterns of use (alcohol)
Phase I: PREALCOHOLIC–characterized by use of alc to relieve everyday stress and tensions of life
Phase II: EARLY ALCOHOLIC– begins with BLACKOUTS (periods of amnesia); alcohol now required by the person
Phase III and IV patterns of use (alcohol)
Phase III: CRUCIAL– person lost control; physiological dependence is clearly evident
Phase IV: CHRONIC– emotional and physical disintegration; person intoxicated more than sober
peripheral neuropathy
**effect of alc on body
-associated to B1 (Thiamine) deficiency characterized by:
- peripheral nerve damage
- pain
- burning
- tingling
- prickly sensations of extremities
alcoholic myopathy
- thought to results from same B vitamin deficiency that contributes to peripheral neuropathy
- Acute: sudden onset muscle pain, swelling, and weakness; reddish tinge to urine; rapid rise in muscle enzymes in blood
- Chronic: gradual wasting and weakness in skeletal muscles
Wernicke’s encephalopathy
-most SERIOUS form of thiamine deficiency in alc patients
“Wet Brain”
- paralysis of ocular muscles
- ataxia
- somnolence/stupor
Korsakoff’s psychosis
**syndrome of confusion, loss of recent memory, and confabulation in alc patients
-frequently found in pts recovering from Wernicke’s encephalopathy
alcoholic cardiomyopathy
-effect of alc on heart is accumulation of lipids in myocardial cells, resulting in enlargement and weakened condition
**CHF or arrhythmia
esophagitis
-inflammation and pain in esophagus occurs because of toxic effects of alc on esophageal mucosa and also because of frequent vomiting associated w/ alc use
gastritis
**effects of alc on stomach: breaks down protective mucosal barrier which allows the hydrochloric acid to erode stomach wall
- epigastric distress
- n/v
- distention
normal serum amylase
23-85
*pancreatitis lab: above 200 U/L
acute pancreatitis
-occurs 1-2 days after binge of excessive alc consumption
s/s:
- constant, severe epigastric px
- n/v
- abd distention
chronic pancreatitis
-pancreatic insufficiency results in:
- steatorrhea
- malnutrition
- weight loss
- DM
alcoholic hepatitis labs
LFT’s
- elevated Bilirubin/Albumin
- elevated ALT (alanine transaminase)
- elevated AST (aspartate transaminase)
alcoholic hepatitis
s/s:
- enlarged, tender liver
- n/v
- lethargy
- anorexia
- elevated WBC
- fever
- jaundice
**ascites and weight loss in severe cases
cirrhosis
- end-stage of alcoholic liver disease
- widespread destruction of liver cells which are replaced by fibrous (scar) tissue
- same symptoms as alcoholic hepatitis plus blood coagulation abnormalities
4 complications of cirrhosis of the liver
1- portal hypertension
2-ascites
3-esophageal varices
4-hepatic encephalopathy
portal hypertension
-elevation of BP thru portal circulation results from defective blood flow thru cirrhotic liver
ascites
-excessive amount of serous fluid accumulates in abd cavity
**occurs in response to portal hypertension
esophageal varices
-veins in esophagus become distended from excessive pressure from defective blood flow through cirrhotic liver
RUPTURE=hemorrhage/death
hepatic encephalopathy
-response to inability of diseased liver to convert ammonia to urea for excretion
***continued rise in serum ammonia (can cross BBB) if allowed to progress can lead to coma and eventual death
leukopenia
**effect of alc on body
-impaired production, function, and movement of WBC
WBC normal range
(4,500-11,000)
thrombocytopenia
**effects of alc on body
-platelet production and survival are impaired as result of toxic effects of alcohol
platelet normal range
150,000-450,000
sexual dysfunction
**effects of alc on body
- short-term: enhanced libido and erectile dysfxn
- long-term: gynecomastia, sterility, impotence, decreased libido
FASDs
Fetal alcohol spectrum disorders
FAS
**problems w/ learning, memory, attention span, communication, vision, and hearing
characteristics of FAS
- abnormal facial features
- small head size
- shorter-than-average height
- low body weight
- poor coordination
- hyperactive behavior
- difficulty paying attention
- poor memory
- difficulty in school
- learning difficulties
- speech/language delays
- intellectual disability
- poor reasoning skills
- sleep/sucking problems as baby
- vision/hearing problems
- problems w/ heart, kidneys, or bones
alcohol intoxication occurs at…
…BAL between 100-200 (TN legal limit is .08%)
alcohol withdrawal occurs w/in
-4-12 hrs of cessation of or reduction in heavy/prolonged alcohol use
sedative/hypnotic substance use disorder
- barbiturates
- non-barbiturate hypnotics
- antianxiety agents
- club drugs
sedative/hypnotic use disorder effects on body
- effects on sleep/dreaming (less time spent dreaming; upon withdrawal–intense dreams)
- respiratory depression
- cardiovascular effects (hypotension, cardiovasc. collapse)
- renal fxn (oliguria in high doses)
- hepatic effects (stimulate production of liver enzymes which inhibits metabolism of other drugs)
- body temp
- sexual fxn-ing (biphasic response: initial increase in libido, then impaired sexual pleasure)
- pupil constriction
half-lives and withdrawal
- short-acting (short half lives) sedative hypnotics (like lorazepam)
- long half lives (diazepam, phenobarbital, chlordiazepoxide)
severe withdrawal from CNS depressants
can be life-threatening
stimulant use disorder drugs
- amphetamines
- synthetic stimulants
- non-amphetamine stimulants
- cocaine
- caffeine
- nicotine
cocaine and cardio
can result in severe vasoconstriction and MI
pulmonary effects stimulants
-smooth muscle relaxation of bronchioles
GI and renal effects stimulants
- usually urine retention
- GI decrease in motility (constipation)
amphetamine and cocaine intoxication
- euphoria
- pupil dilation
- impaired judgment/confusion
- vital sign changes (coma/death poss.)
caffeine intoxication
**usually consumption of 250mg or over
-restlessness & insomnia most common symptoms
amphetamine and cocaine withdrawal
- dysphoria
- fatigue
- sleep disturbances
- increased appetite
withdrawal from caffeine
- HA
- fatigue/drowsiness
- irritability
- muscle pain/stiffness
- n/v
withdrawal from nicotine
- dysphoria
- anxiety
- difficulty concentrating
- irritability
- restlessness
- increased appetite
inhalant use disorder (profile of substance)
- aliphatic and aromatic hydrocarbons found in substances such as:
- fuels, solvents, adhesives, aerosol propellants, paint thinners
CNS effects inhalants
up then down (excitement then extreme drowsiness)
respiratory effects inhalant use dx
-increased airway resistance from inflammation in passages
GI effects inhalant use dx
-abd px, n/v
renal effects inhalant use dx
- acute/chronic renal failure
* renal toxicity from toluene exposure
symptoms of inhalant intoxication
- dizziness
- ataxia, muscle weakness
- euphoria/excitation/disinhibition
- slurred speech
- nystagmus
- blurred/double vision
- dilated pupils
- psychomotor retardation/ hypoactive reflexes
- stupor/coma
opioids of natural origin
- morphine
- codeine
opioid derivative
- heroin
- oxycodone
synthetic opiate-like drugs
- methadone
- fentanyl
opioids and cardio
- at high doses
- hypotension
opioids and sexual fxn
decreased sexual fxn/libido
s/s opioid intoxication
- euphoria followed by apathy
- dysphoria
- pupil constriction
- psychomotor agitation or retardation and impaired judgment
short-acting opioids and withdrawal
- heroin
- s/s occur w/in 6-8 hrs, peak w/in 1-3 days, gradually subside in 5-10 days
long-acting opioids and withdrawal
- methadone
- s/s occur w/in 1-3 days, peak at 4-6 days, subside in 14-21 days
ultra-short-acting opioids and withdrawal
- Demerol
- s/s begin quickly, peak in 8-12 hrs, subside in 4-5 days
symptoms of opioid withdrawal
- dysphoria
- muscle aches
- n/v
- lacrimation or rhinorrhea
- pupillary dilation
- sweating
- abd cramping, diarrhea
- yawning
- fever
- insomnia
naturally-occurring hallucinogens
- Mescaline-Peyote Cactus
- Psilocybin mushrooms
synthetic compounds (hallucinogens)
- angel dust
- LSD
- PCP
s/s of hallucinogen intoxication
- perceptual alteration
- depersonalization
- derealization
- tachycardia
- palpitations
- pupil dilation
symptoms of PCP intoxication
- belligerence and assaultiveness
- may proceed to seizures or coma
**pts can be VERY dangerous =
hallucinogen physiological effects on body
- n/v
- chills
- pupil dilation
- increased BP and pulse
- loss of appetite
- insomnia
- elevated blood sugar
- decreased respirations
hallucinogen psychological effects on body
- heightened response to color/sounds
- distorted vision
- sense of slowed time
- magnification of feelings
- paranoia, panic
- euphoria, peace
- depersonalization/derealization
- increased libido
cardio effects cannabis
- tachy
- decrease in BP (orthostatic hypotension)
respiratory effects cannabis
-bronchodilation initially
reproductive effects cannabis
- men have decrease in sperm count
- women, suppression of ovulation and disruption in menstrual cycles
CNS
“high” equivalent to alcohol
- euphoria/decreased inhibitions
- depersonalization/derealization
toxicity of MJ
-paranoia
sexual fxn cannabis
-increase sexual pleasure
pupils in cannabis use
dilated pupils
s/s cannabis intoxication
-impaired motor coordination (impairment of motor skills lasts for 8-12 hrs)
- euphoria
- anxiety
- sensation of slowed time
- impaired judgment
physical symptoms cannabis intoxication
- conjunctival injection
- increased appetite
- dry mouth
- tachy
s/s of withdrawal in cannabis dx
*s/s occur w/in week following cessation of use
- irritability
- anger/aggression
- anxiety
- sleep disturbances
- decreased appetite
- depressed mood
- stomach px
- tremors
- sweating
- fever/chills
- HA
assessment tools for substance abuse
- CIWA (clinical institute withdrawal assessment of alcohol scale)
- MAST (Michigan Alcoholism Screening Test)
- CAGE questionnaire
- COWS (Clinical Opiate Withdrawal Scale)
CAGE questionnaire
- have you ever felt you should CUT down on drinking?
- have ppl ANNOYED you by criticism?
- have you felt bad or GUILTY about drinking?
- have you ever had drink first thing in morning? (EYE-opener)
management of illness education
(1) activities to substitute for substance in times of stress
(2) relaxation techniques (progressive relaxation, tense and relax, deep breathing, autogenics)
(3) problem-solving skills
(4) essentials of good nutrition
nurses suffering from dz of chemical dependency
10-15%
-alcohol most widely abused, followed by narcotics
signs chemically impaired nurse
- poor concentration
- difficulty meeting deadlines
- inappropriate responses
- poor memory/recall
- probs w/ relationships
- irritability, tend to isolate, elaborate excuses for behaviors
- unkempt appearance, impaired motor coordination, slurred speech, flushed face
- pt complaints of inadequate pain control, discrepancies in documentation
during suspension period
- completion of inpatient/outpatient/individual counseling tx
- evidence of regular attendance at nurse support groups or 12-step program
- random negative drug screens
- employment or volunteer activities
peer assistance programs
-serve to assist impaired nurses to:
- recognize their impairment
- obtain necessary tx
- regain accountability w/in profession
TnPAP (Tennessee Professional Assistance Program)
codependency traits
- sacrifice their own needs for fulfillment of others to achieve sense of control
- derive self-worth from others and feels responsible for happiness of others
- denies problems exist
- keep feelings in control, and often releases anxiety in form of stress-related illnesses or compulsive behaviors (eating, spending, working, use of substances)
predisposing factors codependency
- experienced abuse or emotional neglect as child
- outwardly focused on other and know very little about how to direct their lives own sense of self *** (BIG part of codependency)
tx of codependency
**Cermak (1986)
(1) survival stage (let go of denial)
(2) re-identification stage (able to take responsibility for their own dysfunctional behavior and can tell themselves they are codependent)
(3) core issues stage (detach from willful efforts to control things out of their control; realize relationships cannot be managed by force of will)
(4) reintegration stage (reclaim personal power of their own lives; relinquish power over others that wasnt theirs)
AA based on concept of
- peer support
- acceptance
- understanding from others who have experienced same prob
only cure for alcohlism
- total abstinence
* person can never safely return to social drinking
disulfiram
(Antabuse)
**pharm for alcoholism
-client must have abstained from alcohol for at least 12 hrs before administering (and after d/c-ing, sensitivity may last for up to 2 weeks)
disulfiram
**avoid alcohol-containing substances
- cold medicines
- aftershave
- cologne
- mouthwash
- nail polish remover
- vanilla extract
other meds for alcholism
- ReVia (naltrexone)
- Revex (nalmefene)
- SSRIs
- Campral (acamprosate)
pharm for substance intoxication/substance withdrawal
ALCOHOL
- benzodiazepines
- anticonvulsants
- multivitamin therapy
- thiamine
pharm for intoxication/withdrawal
OPIOIDS
-narcotic antagonists (Narcan-naloxone, Revia/Vivitrol-naltrexone, Revex-nalmefene)
- Methadone
- Buprenorphine
- Clonidine
pharm for intoxication/withdrawal
DEPRESSANTS
(barbiturates, alcohol)
- phenobarbital (Luminal)
- long-acting benzos
pharm for intoxication/withdrawal
STIMULANTS
- minor or major tranquilizers
- anticonvulsants
- antidepressants
pharm for intoxication/withdrawal
HALLUCINOGENS & CANNABINOLS
- benzodiazepines
- antipsychotics
psychosocial influences gambling disorder
- loss of parent before age 15
- inappropriate parental discipline
- exposure to gambling as adolescent
- family emphasis on material and financial symbols
- lack of family emphasis on saving/planning/budgeting
pharm for gambling
- SSRIs
- clomipramine
- lithium
- carbamazepine
- naltrexone
vivitrol dose
-380 mg (4mL injection)
vivitrol injection site rxn
-induration, swelling, erythema
14 days after vivitrol dosing
concentrations slowly decline
vivitrol admin and opioid-free
*must be opioid free for minimum of 7-10 days before admin to avoid precipitation of withdrawal that may be severe enough for hospitalization
onset of schizophrenia
-late adolescence into early adulthood
schizophrenia characterized by:
-disturbance of thought processes, perception, affect
s/s schizo.
-severe deterioration of social and occupation fxn-ing
Phase I schizo development
(Premorbid)
- social withdrawal
- irritability
- antagonistic behavior
- poor relationships and school performance
- display antisocial behavior
Phase II schizo development
(Prodromal Phase)
**SEE CARDINAL s/s
- last 2-5 yrs but can be as short as month
- negative & positive symptoms
negative s/s
- poor sleep and ADLs
- increased anxiety, irritation and depression
- decreased concentration
- fatigue
- intentional peer avoidance leading to isolation
- ANHEDONIA
- FLAT AFFECT
- WAXY FLEXIBILITY
positive s/s
- stimuli (hallucinations)
- magical thinking and delusional thought and ideas of reference
*hypervigilance emerges in latter stage of this phase (sets stage for onset of stage III)
Phase III schizo
(Schizophrenia)
*active phase where POSITIVE symptoms are prominent (persists for more than 6 mo)
Expect to See:
- delusions/hallucinations
- disorganized speech
- bizarre behaviors
negative symptoms in phase III
-decreased functioning in work/relationships/ADLs/academic performance
w/ positive symptoms, you must FIRST r/o:
- schizoaffective DO
- depressive DO’s
- bipolar DO’s that include psychotic features
Phase IV schizo
(Residual Phase)
- periods of remission and exacerbation
- no longer see acute stage s/sx (specifically the + symptoms)
- negative symptoms may continue (flat affect and role fxn-ing impairment still)
more positive prognosis associate w/
- later onset of 1st psychotic break
- being female (poor prognosis for men)
- abrupt symptom onset (gradual, poorer prognosis)
- rapid resolution of active phase
biochem of schiz
- dopamine (excess)
- glutamate (when very high, hippocampus begins to atrophy and hippo shrinkage strongly associated w/ schiz)
viral hypothesis schiz
-increased risk if mother suffers exposure to influenza after after reaching prenatal state (histological changes in fetal hippocampus
enlarged ventricles
correlates w. negative symptoms, poor tx response, & cog. impariment
downward drift hypothesis
-typical symptoms associated w/ schiz inhibit these individuals from remianing employed leading to DRIFT DOWN into lower socioeconomic level
stress and schiz
NO scientific evidence to support stress as causative factor of schiz
-stress may contribute to severity and course of illness which may include increased rates of relapse
delusional disorder
- hallucinations not prominent and no bizarre behavior
* if delusional content is bizarre, then needs to be categorized
categorize delusions
- erotomaniac (belief famous person is in love with them)
- grandiose (their own worth, talent, knowledge, power is enormously greater than reality of situation; may voice SPECIAL RELATIONSHIP w/ famous person sometimes assuming identity of that person)
- jealous (belief person’s sexual partner is unfaithful, person may attack imagined lover)
- persecutory (MOST COMMON TYPE*****)
- somatic (have medical condition that they don’t really have)
- mixed (no single theme is dominant)
substances causing active psychosis
- alcohol
- amphetamines
- THC
- cocaine
- hallucinogens
- opioids
psychotic d/o due to another med condition
- acute intermittent porphyria
- deafness
- electrolyte imbalance
- hypo-hyper thyroidism
- hypoglycemia
- migraine HA
- B12 deficiency
schizoaffective disorder
- combo of psychotic symptoms coupled w/ mood d/o
- 2-week period of hallucinations/delusions occurring w/out major mood or mania episode (prominent mood d/o must be evident for majority of time)
positive symptoms
- better tx response to meds
* ex: delusion, paranoia, circumstantiality
negative symptoms
- more difficult to treat, less responsive to antipsychotic med tx
- more destructive in tat they are associated w/ anergia and avolition
**ex: alogia (poverty of speech), waxy flexibility/catetonia/ pacing/rocking, anergia, decreased abstract thinkingn
delusion of religiosity
**don’t discourage if it provides comfort
MAGICAL THINKING
thoughts have control over specific situations or ppl (common in kids)
associative looseness
-pt unaware that comments are not connected
concrete thinking
literal interpretation of environment
mutism
-unable or unwilling to speak
POSITIVE symptom
perseveration (speech)
-persistently repeats same word/idea in response to diff questions
echolalia
-repeats words they hear
**attempt to identify w. person they are speaking to
hallucination vs illusion
-illusion is misinterpretation of REAL external stimuli
formication
(tactile hallucination)
-something crawling on or under skin
echopraxia
-pt. purposelessly imitates movement made by others
lack of interpersonal interaction skills
*negative symptom
3 types:
1-cling to others
2-ambivalent toward everyone
3-withdrawn altogether (asociality)
anosognosia
1 predictor of nonadherence to tx and predict higher relapse rate
**lack of insight (negative symptom)
-no awareness of their affliction
waxy flexibility considered…
…negative symptom
posturing
*another negative symptom
anhedonia
-compels some to attempt suicide (very distressing symptom)
regression
- another negative symptom
- retreat to earlier developmental level (defense mechanism to decrease anxiety)
***(FOUNDATION for many of the behaviors r/t schizophrenia)
typical antipsychotic
dopaminergic blockers in hypothalamus and limbic systems
atypical antipsychotics
- weak dopamine antagonists
- potent 5HT2a antagonists
FGAs
- thorazine
- haldol
SGAs
- zyprexa
- risperidone
- geodon
(may help to also tx negative symptoms)
gold standard for schizophrenia tx
clorazil (SGA)
Alpha-1 (adrenergic blockers)
- dizziness
- orthostatic hypotension
side effects antipsychotics
- rash
- orthostatic hypotension
- photosensitivity
- ECG changes
- increased risk of mortality in elderly clients with dementia
- reduction in seizure threshold
- agranulocytosis (typicals AND atypical clonazepine)
- hypersalivation
- decreased libido
antipsychotics and elderly
-increased risk for suicide with dementia-related psychosis
contraindications SGAs
- DM
- prolonged QT interval hx
- hypotension
- pregnant/children
top 3 typical antipsychotics
- Thorazine (chlorpromazine
- Prolixin (fluphanazine)
- Haldol
top 5 atypical antipsychotics
- Clozaril (clozapine)
- Zyprexa (olanzapine)m
- Seroquel (quetiapine)
- Risperidal (risperidone)
- Geodon (ziprasidone)
EPS
- pseudoparkinsonism (shuffle gait, drooling, rigidity)
- akinesia (muscle weakness)
- akathisia (restlessness/fidget, sense of doom; more common in women)
- dystonia (involuntary muscular movements/spasms of Face/Neck, Arms/Legs; more often in men and clients younger than 25)
- oculogyric crisis (uncontrolled rolling back of eyes)
dystonia and oculogyric crisis
txx as EMERGENCY situation
tx for acute EPS
- Cogentine
- Trihexyphenidyl (Artane)
- Benadryl
TD
- bizarre facial/tongue movements
- stiff neck
- difficulty swallowing
**potentially irreversible symptoms
NMS nursing intervention
-frequent temp checks w/ parkinsonian symptom observation
NMS symptoms
- severe Parkin. muscle rigidity
- VERY HIGH FEVER
- tachycardia/tachypnea
- BP fluctuations
- diaphoresis
- rapid deterioration of mental status to stupor and coma
DM/hyperglycemia
- can result from atypical antipsychotics
- obtain fasting BS before 1st admin
lab draw weekly
w/ clozapine tx
prolactin
FGA/SGA tx
-decrease dopamine, which increases prolactin release, increases lactation
