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247 Cards in this Set
- Front
- Back
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The Nursing Process
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assess
plan implement evaluate |
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Nursing Diagnosis
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based on assessment
occurs before plan of care formed based on diagnosis, appropriate care can be planned |
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Evaluation
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decide if interventions were effective and appropriate
strategizes for an even better process next time in a similar situation |
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Assessment
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collect a valid database
establish a sound engagement of the pt in the therapeutic alliance develop an evolving and compassionate understanding of the pt decrease pt's anxiety and instill hope |
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Patient History
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pt history is a good predictor of the future
may need to obtain from prior providers, family, friends (in an ethical and appropriately confidential manner) rule out physical causation before assigning psych causation (bio-psycho-social model) |
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Interview Process and Data Gathering,
components of |
identifying information
presenting problem/chief complaint appearance history mental status exam medical assessment social assessment |
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Identifying Info
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name, age, sex, race/ethnicity, marital status, religion, language spoken
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Presenting Problem/Chief Complaint
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patient or family member's subjective statement of reason for being there
WHY NOW? |
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Appearance
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description of indiv - ht, wt, grooming
unusual behaviors ie: tremors, tics, speech abnormalities, somnolence, hyperactivity, intoxication, avoids eye contact, etc |
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Psych History
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prior hosp, when and why
other treatments, what worked, what didn't work diagnosis given past psych meds, what worked, side effects and adverse reactions to meds; assess for TD if pt has been or is on neuroleptics Current psych meds, exact doses prescribed and what the pt is actually taking date and result of last blood level if on LITHIUM, CARBAMAZEPINE OR VALPROIC ACID |
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Substance Abuse DO and treatment
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evidence of intoxication (postpone interview if possible if pt intoxicated)
drug tox screen if possible has pt been treated in a substance abuse program family hx of alcoholism or drug abuse attendance at 12 step meetings current usage alcohol and drugs - last drink, drinking pattern - how often do you drink, drink to intoxication; what drug and last use, what substances used and how often, IV use do you think your alcohol or drug use is a problem? potential for withdrawal syndrome family hx: genogram, sexual abuse, physical abuse or neglect, mental illness or alcoholism in the family |
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Mental Status Exam
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attitude toward examiner
speech mood affect suicidal/homicidal potential perception thought content thought process OCD screening cognitive screening |
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Attitude
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cooperative
hostile guarded |
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Speech
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poverty of speech
poverty of content pressured/rapid slurred |
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Mood
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depressed - incr or decr sleep/weight, fatigue, energy level, anhedonia, interest concentration
manic or hypomanic - hyperverbal, grandiose, sleeplessness, hypersexual, poor financial decisions, euphoric, irritable anxious - panic attacks irritable angry |
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Affect (presentation)
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inappropriate
flat constricted labile normal - full range of appropriate emotional expression |
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Suicidal/Homicidal potential
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current suicidal ideation/plans
past suicide attempts and details - method, lethality, when, what interventions were taken at the time current homicidal ideas/plans - be aware of Tarasoff law past incidents of harming others/spouse/children (outside of combat) history of destroying property |
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Perception: specify content
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hallucinations - visual often has organic cause; auditory more common in psych illness
command hallucinations |
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Thought content: specify content
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delusions
general suspiciousness or paranoia depersonalization apart from under the influence of substances dissociation |
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Thought process: specify content
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tangential
circumstantial flight of thought thought blocking |
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OCD screening
esp for pt with sx of anxiety |
Obsessions - repeated thoughts can't get out of head
Compulsions - feel compelled to do certain things over and over for no reason, emotional release after performing ritualistic behavior how much does this behavior interfere with daily functioning |
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Cognitive screening
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intermediate term memory
orientation attention concentration calculation verbal abstraction general information |
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Judgment and Insight
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inferred from history and observations
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Intermediate Memory test
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recalls 3 of 4 words after 3-5 minutes of interviewing
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Orientation
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person, place, time
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Attention eval
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able to repeat 4 digits forward
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Concentration eval
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able to repeat 4 digits backwards
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Calculations eval
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calculate 5 x 13, or if unable 19 + 8
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Verbal abstraction eval
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"how are an orange and a banana alike?" (fruit, food)
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General Information eval
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how many weeks in a year
where does the sun rise |
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Medical Assessment
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current medical problems
past major medical problems treatment providers, past and present surgeries hx of head trauma sleep patterns seizures last physical exam current meds allergies and adverse reactions |
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Social Assessment
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living situation
social support system - family, friends, church income, financial resources legal considerations - conservatorship/payee, arrests including DUI and drug/ETOH, jail/prison history, current legal issues - parole, probation, charges pending, upcoming court dates education employment - current, past, job skills marital hx, children military hx - branch of service, dates, job, rank, type of disch, service connected disabilities, past combat and wounds, sexual harassment or assault, evidence of PTSD, tx for PTSD |
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Assessment and Screening tools
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Beck Depression Inventory
Abnormal Involuntary Movement Scale Exam medical testing Psychological testing |
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DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, published by American Psychiatric Assoc in 2000. |
classification of mental disorders with incidence, symptomatology and gender differences
purpose: provide clear descriptions of diagnostic categories to enable clinicians and investigators to diagnose, communicate about, study and treat individuals with mental illness focuses on clinical work, research and education codes and terms fully compatible with codes and terms of ICD 10 |
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Culture Specific
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the DSM-IV-TR texts contains a culture-specific section, a glossary of culture bound syndromes, and the provision of an outline for cultural formulation
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Multiaxial Assessment
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provides format for organizing and communicating clinical information
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Axis I
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clinical disorders
other conditions that may be a focus of clinical attention if more than one axis I disorder present, the principal dx or reason for the visit should be listed first |
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Axis II
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personality disorders
mental retardation prominent maladaptive personality features that do not meet the threshold for a Personality DO habitual use of maladaptive defense mechanisms may also be indicated |
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Axis III
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general medical conditions
current general medical conditions that are potentially relevant to understanding or management of the indiv mental disorder WHEN A MENTAL DO IS JUDGED A DIRECT PHYSIOLOGICAL CONSEQUENCE OF THE GENERAL MEDICAL CONDITION, a Mental DO due to a General Medical Condition should be dx on axis I and the general medical condition should be recorded on both axis I and axis III |
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Axis IV
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psychosocial and environmental problems
describes the stressors causing psychosocial and environ problems that may affect the dx, tx and prognosis of mental DO that are listed on axes I and II Problems with Primary Support Group Problems r/t the Social Environ Education problems Occupational problems Housing problems Economic problems Health Care Issues Legal problems Other psychosocial and environ problems |
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Axis V
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global assessment of functioning
scale used to report the overall functioning of the patient |
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Global Assessment of Functioning (GAF) Scale
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100 = superior functioning, no sx
90 = absent or minimal sx, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems 80 = if sx present they are transient and expectable reactions to psychosocial stressors, mo more than slight impairment in social, occupational or school functioning 70 = some mild sx OR some difficulty in social, occupational or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships 60 = moderate sx (flat affect, panic attacks) OR moderate difficulty in social, occupational, or school functioning (few friends, conflicts with peers) 50 = serious sx (suicidal ideation, severe obsessional rituals) OR serious impairment in social, occupational or school functioning (no friends, unable to keep a job) 40 = some impairment in reality testing or communication OR major impairment in several areas such as work, school, family relations, judgment, thinking, mood 30 = behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas 20 = some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication 10 = persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death 0 = inadequate information |
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Not Otherwise Specified
four situations in which a NOS dx may be appropriate |
presentation conforms to general guidelines for a mental DO but the symptomatic picture does not meet the criteria for any of the specific DO
presentation conforms to a sx pattern that has not been included int the DSM-IV-TR classification but that causes clinically significant distress or impairment there is uncertainty about etiology - the DO may be due to a general medical condition, substance induced, or may be primary there is insufficient opportunity for complete data collection |
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Frequently Used Criteria:
It is freq necessary to include exclusion criteria to establish boundaries between DO and to clarify differential dx. |
examples: criteria have never been met for
criteria are not met for does not occur exclusively during the course of not due to the direct physiological effects of a substance or a general medical condition |
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Schizophrenia
Diagnostic Categories and Tx Issues |
a disturbance that lasts for at least six months and includes at least one month of active-phase sx
demonstrates 2 or more characteristic sx - delusions, hallucinations, disorganized speech, grossly disordered or catatonic behavior |
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Criterion I or Positive Sx Schizophrenia
Note: only 1 criterion I symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the indiv behavior or thought or 2 or more voices conversing with each other |
delusions
hallucinations disorganized speech grossly disorganized or catatonic behavior |
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Negative Sx Schizophrenia
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affect flattening
alogia avolition |
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Social/occupational dysfunction
Schizophrenia |
for a significant portion of the time since the onset of the disturbance one or more major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset
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Duration
Schizophrenia |
continuous signs of the disturbance persist for at least 6 months
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Schizoaffective and mood disorder exclusion
Schizophrenia |
schizoaffective DO and mood DO with psychotic features have been ruled out because either:
no major depr, manic or mixed episodes have occurred concurrently withactive-phase sx if mood episodes have occurred during active-phase sx their total duration has been brief relative to the duration of the active and residual periods |
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Substance/general medical condition exclusion
Schizophrenia |
the disturbance is not due to the direct physiological effects of a substance or a general medical condition
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Relationship to a pervasive developmental disorder
Schizophrenia |
if there is a hx of autistic DO or another pervasive developmental DO, the additional dx of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated)
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Schizophrenia Subtypes: defined by the predominant symptomatology at the time of evaluation
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catatonic
disorganized paranoid undifferentiated residual |
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Catatonic type Schizophrenia
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characterized by extreme psychomotor disruption, either reduced movement and negativism or active but purposeless movements not influenced by surroundings
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Disorganized type Schizophrenia
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characterized by disorganized speech and behavior and flat or inappropriate affect
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Paranoid type Schizophrenia
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assosciated with preoccupation with delusions or frequent hallucinations
hallucinations and delusions are persecutory or grandiose |
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Undifferentiated type Schizophrenia
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assigned when a pt presents with prominent active phase sx not meeting critiera for the catatonic, disorganized or paranoid type
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Residual type Schizophrenia
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is for presentations in which there is continuing evidence of the disturbance but the criteria for the active-phase sx are no longer met.
Negative sx like flat affect and inability to work are present |
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Schizophreniform DO
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essential features identical to those of schizophrenia (criterion 1) except for 2 differences:
total duration of the illness is at least 1 mo but less than 6 mo and impaired social or occupational functioning during some part of the illness is not required may be prodromal to schizophrenia or schizoaffective illness |
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Schizoaffective DO
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essential feature: uninterrupted period of illness during which, at some time, there is either a major depr episode, a manic episode, or a mixed episode concurrent with sx that meet criterion I for schizophrenia
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Other Psychotic DO
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delusional DO
brief psychotic DO shared psychotic DO psychotic DO due to a general medical condition substance-induced psychotic DO psychotic DO NOS |
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Treatments for Schizophrenia and other psychotic DO
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psychopharmacology - antipsychotics
case management social skills training promoting family understanding and involvement promoting community contacts |
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Mood Disorders
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disorders that have a disturbance in mood as the predominant feature
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Major Depressive DO
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the essential feature of a major depressive episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities
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Criteria for Major Depr Episode:
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five or more sx have been present during the same 2 wk period AND represent a change from previous functioning; at least one of the sx is either depressed mood or loss of interest or pleasure.
the sx do not meet criteria for a mixed episode. the sx cause clinically significant distress or impairment in social, occupational or other important areas of functioning. the sx are not due to the direct physiological effects of a substance or a gen medical cond. the sx are not better accounted for by bereavement. |
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Manic Episode
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a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 wk (or any duration if hosp is necessary).
during the period of mood disturbance 3 or more sx have persisted (4 if the mood is only irritable) and have been present to a significant degree. the sx do not meet the criteria for a mixed episode. the mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or usual soc activities or relationships or to necessitate hosp to prevent harm to self or others or there are psychotic features. the sx are not due to the direct physiological effects of a substance or a gen med condition |
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Symptoms of Major Depressive Episode
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depr mood most of the day, nearly every day either subjective report or observation made by others (in child/adoles can be irritable mood)
markedly diminished interest or ploeasure in all or almost all activities most of the day nearly every day significant wt loss when not dieting or wt gain, or decr or incr in appetite nearly every day insomnia or hypersomnia nearly every day psychomotor agitation or retardation nearly every day that is observable by others, not subjective fatigue or loss of energy nearly every day feelings of worthlessness or excessive or inappropriate guilt nearly every day diminished ability to think or concentrate or indecisiveness nearly every day recurrent thoughts of death, recurrent suicidal ideation w/o a specific plan or a suicide attempt or a specific plan for committing suicide |
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Manic Symptoms
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inflated self-esteem or grandiosity
decreased need for sleep (rested after 3 hr, etc) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (attention too easily drawn to unimportant or irrelevant external stimuli) increase in goal-directed activity (socially, work, school, sex) or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences (unrestrained buying sprees, sexual indiscretions, etc) |
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Mixed Episode
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a period of time (lasting at least 1 wk) in which the criteria are met both for a manic episode and for a major depressive episode nearly every day
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Hypomanic Episode
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a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood that lasts at least 4 days.
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Dysthymic DO
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a chronically depressed mood that occurs for most of the day, more days than not for at least 2 years.
it may be intermittent with period of feeling normal. these periods of relief last for no more than 2 months. |
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Cyclothymic DO
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characterized by chronic, fluctuating mood disturbances involving numerous periods of hypomanic sx and numerous periods of depressive sx.
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Bipolar I Disorder
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a clinical course that is characterized by the occurrence of 1 or more manic episodes OR mixed episodes AND episodes of major depression.
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Bipolar II Disorder
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a clinical course that is characterized by the occurrence of one or more major depressive episodes accompanied by at least one HYPOMANIC episode.
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Frequent complication in ALL affective disorders
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substance abuse
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TX for Bipolar Disorders
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hospitalization
suicide prevention biological treatments - antidepressants, mood stabilizers, antipsychotics, ECT, individual psycho therapy, group therapy, cognitive-behavioral therapy |
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Cognitive Disorders
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delirium
dementia dementia of the Alzheimer's type vascular dementia other dementias |
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Delirium:
due to a general medical condition substance-induced delirium due to multiple etiologies NOS |
cognitive DO characterized by global cognitive impairment of ABRUPT onset and relatively BRIEF duration in which perception, thinking and memory are all disrupted.
common in adults, usually caused by underlying systemic illness. pt are capable of returning to previous levels of functioning. |
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Dementia
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marked by a loss of intellectual abilities of sufficient severity to interfere with social and occupational functioning.
involves PROGRESSIVE intellectual, behavioral, and physiological deterioration. |
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Alzheimer's Disease, four phases
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early - forgetfulness
more advanced phases - disorientation, diminished concentration terminal phases - severe agitation, disorientation, psychosis, complete helplessness |
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Alzheimer's Disease treatments
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acetylcholinesterase inhibitors
(donepexil - Aricept) used to slow the cognitive decline |
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Other Dementias
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Dementia due to: HIV disease
head trauma Parkinson's disease Huntington's disease Pick's disease Creutzfeldt-Jakob disease other general medical conditions: substance induced multiple etiologies NOS |
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Anxiety Disorders
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characterized by either recurrent or persistent psychological and physical sx that interfere with normal functioning,
continue in the absence of obvious external stress, OR are excessive responses to these stresses. |
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Anxiety DO include:
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panic DO
phobias - agoraphobia, specific phobia, social phobia. generalized anxiety DO obsessive compulsive DO acute stress DO PTSD |
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Panic DO
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essential feature of panic DO is the presence of recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about having another panic attack
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Panic Attack
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discrete period of intense fear or discomfort in which 4 or more sx develop abruptly and reach a peak w/in 10 minutes
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Panic Attack Symptoms
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palpitations, pounding heart, accelerated heart rate.
sweating trembling or shaking. sensations of shortness of breath or smothering. feeling of choking. chest pain or discomfort. nausea or abdominal distress. feeling dizzy, unsteady, lightheaded or faint. derealization (feelings of unreality) or depersonalization (being detached from oneself). fear of losing control or going crazy. fear of dying. paresthesias (numbness or tingling sensations). chills or hot flushes. |
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Panic DO without Agoraphobia
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recurrent unexpected panic attacks about which there is persistent concern.
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Panic DO with Agoraphobia
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both recurrent unexpected panic attacks and agoraphobia.
agoraphobia in this context means anxiety about or avoidance of, places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having a panic attack or panic-like sx. |
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Agoraphobia in Panic DO
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agoraphobia in this context means anxiety about or avoidance of, places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having a panic attack or panic-like sx.
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Treatment of Panic DO
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Pharmacological: IMIPRAMINE can prevent a high % of panic attacks.
PROPRANOLOL a beta-adrenergic blocker is particularly effective against somatic signs of anxiety. MAOIs can be effective for some cases of panic DO esp with agoraphobia. Behavioral Modification |
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Agoraphobia
Phobic Disorders |
fear of being alone or in public places from which escape might be difficult or help might not be available.
usually accompanied by panic attacks. |
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Specific Phobia
Phobic Disorders |
characterized by clinically significant anxiety provoked by a specific feared object or situation.
often leads to avoidance behavior. |
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Social Phobia
Phobic Disorders |
clinically significant anxiety provoked by exposure to certain types of social or performance situations where the individual may be scrutinized.
often leads to avoidance behavior. |
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Treatments of Phobias
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behavior modification
systematic desensitization |
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Anxiety Disorders
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GAD
OCD acute stress DO PTSD |
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Generalized Anxiety DO - GAD
Diagnostic Criteria: |
pervasive and persistent anxiety of at least 6 months duration w/o phobias, panic attacks, or obsessions and compulsions.
associated with mild depressive sx. predisposed to the abuse of alcohol or other drugs. |
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Treatment of GAD
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behavioral therapy
individual therapy |
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Obsessive Compulsive DO - OCD
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characterized by obsessions (which cause marked anxiety or distress) and/or by compulsions (which serve to neutralize anxiety).
in obsession the recurring thought cannot be dismissed from consciousness. in compulsion there is an uncontrollable, persistent urge to perform certain acts or behaviors to relieve an otherwise unbearable tension. |
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Treatment of OCD
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Pharmacological - ANAFRANIL (clomipramine) tricyclic antidepressant; PROZAC (fluoxetine) SSRI at high doses.
Behavioral therapy. |
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Acute Stress DO
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the development of anxiety AND dissociative sx occurring w/in 1 month of an extremely traumatic event.
precipitating stressors are similar to thos of PTSD. exposure to a traumatic event in which the indiv experienced or witnessed events that involved actual or threatened injury or death. a response involving helplessness, fear, or horror. dissociative sx and avoidance of specific stimuli. sx of hyperarousal. |
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Treatment of Acute Stress DO
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critical incident debriefing
short term use of anxiolytics trauma victim support group individual therapy |
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PTSD types
post traumatic stress DO |
Acute: if duration of sx less than 3 months
Chronic: if duration of sx is 3 mo or more With Delayed Onset: if onset of sx is at least 6 months after the stressor |
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PTSD
Diagnostic Criteria See further elaboration under specific flashcards |
the indiv has been exposed to a traumatic event.
the traumatic event is persistently re-experienced. individual is engaged in persistent avoidance of stimuli associated with the trauma. persistent sx of increased arousal. duration of the disturbance is more than 1 month. disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. |
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PTSD diagnostic criteria:
Ways of being exposed to traumatic event |
the indiv has been exposed to a traumatic event in which he witnessed an event that involved actual threatened death or serious injury.
AND the indiv response involved intense fear, helplessness, or horror. |
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PTSD diagnostic criteria:
traumatic event is persistently re-experienced in the following ways: |
intrusive thoughts of the traumatic event
recurrent dreams of the traumatic event feeling or acting as if the traumatic event were recurring intense distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event. |
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PTSD diagnostic criteria:
individual is engaged in persistent avoidance of stimuli associated with the trauma with numbing of general responsiveness as indicated by: |
efforts to avoid thoughts, feelings, or conversations assoc with the trauma.
efforts to avoid activities, places, or individuals that arouse recollections of the trauma. inability to recall an important aspect of the trauma. markedly diminished interest or participation in significant activities. restricted range of affect. sense of foreshortened future. |
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PTSD diagnostic criteria
persistent sx of increased AROUSAL are indicated by 2 or more of the following: |
difficulty falling or staying asleep.
irritability or outbursts of anger. difficulty concentrating. hypervigilance. exaggerated startle response. |
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Causes of PTSD
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sexual assault
child abuse combat criminal assault natural disasters medical illnesses serious accidents |
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Prevalence of PTSD
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8% lifetime prevalence, 10% women, 5% men
2:1 women to men 60-80% of individuals will experience a traumatic during their lifetime. 9% of women will be raped in their lifetime. rape victims have a 50% incidence of PTSD. Vietnam veterans: 30% of men and 27% of women who served have PTSD. |
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Co-Morbid Conditions
PTSD |
major depr DO 50%
substance related DO panic DO agoraphobia OCD social phobia dissociative DO |
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Treatments for PTSD
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address possibility of suicidal behavior.
address substance abuse. group therapy individual therapy education group Psychopharmacology: SSRIs to treat anxiety and depression. sleep issues: use TRAZODONE in combination with SSRIs. |
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Personality Disorders:
10 types |
paranoid
schizoid schizotypal antisocial borderline histrionic narcissistic avoidant dependent obsessive-compulsive |
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Personality DO: definition
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an enduring, inflexible, pervasive pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture.
onset is during adolescence or early adulthood, continues over time, and leads to impairment and/or distress in social areas of functioning |
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Personality DO NOS
2 situations in which this is used: |
personality pattern meets the general criteria for a personality DO and traits of several different personality disorders are present, but the criteria for a specific personality DO are not met.
OR personality pattern meets the general criteria for a personality DO but the individual is considered to have a personality DO that is not included in the classification (passive-aggressive personality DO). |
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Personality DO: 3 clusters based on descriptive similarities (American Psychiatric Assoc, 2000)
individuals frequently present with co-occurring personality DO from different clusters |
Cluster A: individuals may appear odd or eccentric:
paranoid schizoid schizotypal. Cluster B: individuals often appear very dramatic, emotional or erratic: antisocial borderline histrionic narcissistic. Cluster C: individuals often appear anxious or fearful: avoidant dependent obsessive-compulsive NOS |
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Shea 1998 defined 3 broad groups of personality DO that differ slightly from DSM-IV-TR clustering system:
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anxiety prone disorders - obsessive compulsive, dependent, avoidant
poorly empathic disorders - schizoid, antisocial, histrionic, narcissistic psychotic prone personality disorders - borderline, schizotypal, paranoid |
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Cluster B personality disorders
antisocial, borderline, histrionic, narcissistic. theories and info |
are thought to have a genetic base by some researchers.
there is a strong association between histrionic personality DO and somatization DO. antisocial personality DO is associated with alcohol use disorders. slow-wave activity on EEGs is found most commonly in antisocial and borderline types. cluster B DO are associated with high levels of father educational involvement, father psychological maladjustment, high number of family stressors, low levels of maternal physical abuse, childhood sexual abuse, and poor parental decision-making style. |
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Cluster C personality disorders
avoidant, dependent, obsessive-compulsive, NOS theories and info |
may have a genetic base.
individuals with avoidant personality DO often have high anxiety levels. patients with OCD often show sx assoc with depr. |
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theories and info about personality disorders
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indiv who exhibit impulsive traits will often show incr levels of testosterone, 17-estradiol and estrone.
androgens in nonhuman primates increase the likelihood of aggression and sexual behavior. low levels of MAO (monoamine oxidase) have been associated with college students spending more time in social activities than students with high levels of MAO. decreased serotonin causes depressive sx. increase in dopamine causes euphoria. some personality DO may arise from poor parental fit (poor match between temperament and child-rearing practices). |
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Personality Traits
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individual's enduring patterns of perceiving, relating to, and thinking of what is happening in their world and experience.
ONLY when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. |
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A patient with a personality disorder has an impairment in functioning or subjective distress in at least 2 of the following areas: (Criterion A-F)
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Criterion A: cognition
affectivity interpersonal functioning impulse control Criterion B: the pattern is inflexible and pervasive across a variety of different situations. Criterion C: this intense inner distress leads to a significant distress or impairment in social, occupational, or other important areas of functioning. Criterion D: the pattern is stable and of long duration. onset can be traced back to adolescence or early adulthood. Criterion E: the pattern is not accounted for as a manifestation or consequence of another mental disorder. Criterion F: it is not due to the direct physiological effects of a substance or a medical condition. |
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Cognition
Impairments personality DO |
impairment in memory
decreased concentration |
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Affectivity
Impairments personality DO |
emotional dysregulation
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Interpersonal functioning
Impairments personality DO |
inability to maintain friendships.
inability to maintain coworker relationships causes individual to get fired from job. |
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Impulse control
Impairments personality DO |
spending sprees
binge drinking binge eating |
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Documentation
Personality disorders |
code on Axis II
DSM-IV-TR suggests listing the defensive mechanisms the client uses. list all relevant personality DO in order of importance. |
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Anxiety Prone Personality DO
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OCD personality DO
dependent personality DO avoidant personality DO |
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OCD Diagnostic Criteria:
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a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
begins in early adulthood and is present in a variety of situations, as indicated by 4 or more sx |
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Characteristic traits OCD
American Psychiatric Assoc, 2000 |
preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
shows perfectionism that interferes with task completion. is excessively devoted to work and productivity to the exclusion of leisure activities and friendship. is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). is unable to discard worn-out or worthless objects even when thy have no sentimental value (e.g. saves labels from water bottles). is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. shows rigidity and stubbornness. |
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Prevalence of OCD personality DO
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affects 1% of individuals in community sample.
affects 3-10% of indiv presenting to mental health clinics. |
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Treatment of OCD personality DO
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group psychotherapy
behavior therapy SSRIs (fluoxetine usually at dosages of 60-80mg). |
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Differential Dx OCD personality DO
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OCD: key is HOARDING in extreme OCD
Narcissistic vs OCD - OCD is usually self-critical Schizoid vs OCD - schizoid has lack of capacity for intimacy. personality change due to general medical condition. sx that may develop in assoc with chronic substance use. |
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Dependent Personality DO
diagnostic criteria: |
a pervasive and excessive need to be cared for that leads to clinging and submissive behavior with fears of separation.
begins in early adult hood and presents in a variety of contexts (5 or more) |
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Dependent Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
has difficulty making everyday decisions w/o an excessive amt of advice and reassurance from others.
needs others to assume responsibilty for most major areas of his/her life. has difficulty expressing disagreement with others because of fear of loss of support or approval. has difficulty initiating projects or doing things on his/her own (due to lack of self confidence in judgment or ability rather than a lack of motivation or energy). goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for him/herself. urgently seeks another relationship as a source of care and support when a close relationship ends. is unrealistically preoccupied with fears of being left to take care of him/herself. |
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Dependent Personality DO
Prevalence |
is among the most frequently reported personality DO in mental health clinics
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Differential Dx Dependent Personality DO
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dependency arising as a consequence of Axis I DO and as a result of a general medical condition.
dependent personality DO has an early onset, chronic course, and a pattern of behavior that does not occur exclusively during an Axis I or Axis II disorder. Borderline Personality DO - indiv with dependent personality DO will react with increasing appeasement and submissiveness. Avoidant Personality DO - will have a strong fear of humiliation and rejection so they withdraw until they are certain they will be accepted. |
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Treatment Strategies for Dependent Personality DO
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individual psychotherapy
behavioral therapy assertiveness training family therapy group therapy Pharmacotherapy: SSRIs to treat sx of anxiety and depr. |
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Avoidant Personality DO
Diagnostic Criteria |
a pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts 4 or more)
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Avoidant Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
avoidance of occupational activities that require significant interpersonal contact due to fears of criticism, rejection, or disapproval.
unwillingness to get involved with individuals unless certain of being liked. shows restraint within intimate relationships because of the fear of being shamed or ridiculed. is preoccupied with being criticized or rejected in social situations. inhibition in new interpersonal situations because of feelings of inadequacy. views self as inferior to others, personally unappealing, and socially inept. reluctant to take personal risks or to engage in new activities because they may prove embarrassing. |
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Differential Diagnosis Avoidant Personality DO
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there is a great amt of overlap between avoidant personality DO and social phobia generalized type.
avoidant personality DO and panic DO with agoraphobia often co-occur. |
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Treatment of Avoidant Personality DO
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individual psychotherapy
social skills therapy behavior therapy (assertiveness training) Pharmacotherapy: atenolol (beta blocker to manage autonomic nervous system hyperactivity) SSRIs may help their rejection sensitivity. |
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Poorly Empathic Personality Disorders
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schizoid
antisocial histrionic narcissistic |
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Schizoid Personality DO
diagnostic criteria: |
a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early adulthood and present in a variety of contexts (4 or more)
DOES NOT OCCUR EXCLUSIVELY DURING THE COURSE OF SCHIZOPHRENIA, A MOOD DISORDER WITH PSYCHOTIC FEATURES, ANOTHER PSYCHOTIC DISORDER, OR A PERVASIVE DEVELOPMENTAL DISORDER AND IS NOT DUE TO THE DIRECT PHYSIOLOGICAL EFFECTS OF A GENERAL MEDICAL CONDITION. |
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Schizoid Personality DO
diagnostic criteria: contexts of behavior |
neither desires nor enjoys close relationships, including being part of a family.
almost always chooses solitary activities. has little if any interest in having sexual experiences with another individual. experiences pleasure in few if any activities. lacks close friends or confidantes other than first-degree relatives. appears indifferent to the praise or criticism of others. shows emotional coldness, detachment, or flattened activity. |
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Schizoid Personality DO
Differential Diagnosis |
delusional DO
schizophrenia mood DO with psychotic features autistic disorders personality change due to a general medical condition. sx that may develop in assoc with chronic substance use. |
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Treatment of Schizoid Personality DO
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group therapy: work on issues of trust.
pharmacotherapy: small dosages of antipsychotics to clear thinking. antidepressants to treat depression and anxiety. SSRIs may make pt less sensitive to rejection. |
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Antisocial Personality DO
Prevalence |
3% in males, and about 1% in females
varies between 3-30% in clinical settings. higher prevalence rate assoc with substance abuse tx settings and prison or forensic settings. environmental and genetic factors contribute to the risk of this group. |
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Antisocial Personality DO
diagnostic criteria: American Psych Assoc, 2000 |
pervasive pattern of disregard for and violation of the rights of others occurring since age 15 yrs, (3 or more of context of behavior).
the individual is at least 18 yr of age. onset of conduct disorder is evident before age 15 yr of age. antisocial behavior does not occur exclusively during the course of schizophrenia or a manic episode. |
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Antisocial Personality DO
diagnostic criteria: context of behavior |
failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. impulsivity and aggressiveness, as indicated by repeated physical fights or assaults. reckless disregard for safety of self or others. consistent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. lack of remorse as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another. |
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Treatment of Antisocial Personality DO
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psychotherapy: establish firm limits.
separate control from punishment. separate help and confrontation from social isolation and retribution. pharmacotherapy: psychostimulants (RITALIN) or WELLBUTRIN for co-existing ADHD. DEPAKOTE to control impulsive behavior.` |
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Histrionic personality DO
Prevalence |
more frequently in females.
prevalent in about 2-3% of the general population. noted in inpt and outpt health settings in 10-15% of the population. noted with a tendency for somatization. |
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Histrionic Personality DO
diagnostic criteria: |
a pervasive pattern of excessive emotionality and attention seeking, beginning by early adult hood and present in a variety of contexts (5 or more).
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Histrionic Personality DO
diagnostic criteria: contexts of behavior Amer Psych Assoc 2000 |
is uncomfortable in situations when he/she is not the center of attention.
interaction is often characterized by inappropriate sexually seductive or provocative behavior. displays a rapidly shifting and shallow expression of emotions. consistently uses physical appearance to draw attention to self. has a style of speech that is excessively impressionistic and lacking in detail. shows self-dramatization, theatricality, and exaggerated expression of emotion. is suggestible, easily influenced by others or circumstances. considers relationships to be more intimate than they actually are. |
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Treatment of Histrionic Personality DO
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psychotherapy: psychoanalytically-oriented therapy is the treatment of choice.
pharmacotherapy: antidepressants for depr and somatic complaints. antianxiety agents for anxiety. antipsychotics for derealization and illusions. |
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Narcissistic Personality DO
Prevalence |
narcissistic traits are particularly common in adolescents.
indiv may have difficulties adjusting to the onset and physical and occupational limitations that are inherent in the aging process. 50-75% of these diagnosed with this DO are male. Prevalence ranges from 2-16% in the clinical population, less than 1% in the general population. |
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Narcissistic Personality DO
diagnostic criteria: |
a pervasive patter of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts (5 or more).
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Narcissistic Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
has a grandiose sense of self-importance (exaggerates achievement and talents and expects to be recognized as superior w/o commensurate achievements).
is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. believes that he/she is special and unique and can only be understood by or should associate with other special high-status individuals or institutions. requires excessive admiration. has a sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with his/her expectations). is interpersonally exploitive (takes advantage of others to achieve his/her own ends). lacks empathy, is unwilling to recognize or identify with the feelings and needs of others. Is often envious of others or believes that others are envious of him/her. shows arrogant, haughty behaviors or attitudes. |
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Treatment of Narcissistic Personality DO
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psychotherapy: psychoanalytic therapy approach
pharmacotherapy: mood stabilizers for mood swings. SSRIs for those prone to depression. |
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Psychotic Prone Personality disorders
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borderline personality DO
schizotypal personality DO paranoid personality DO |
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Borderline Personality DO
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defensive structure is delayed developmentally and includes magical thinking, preoccupation with internal fantasy worlds, and tendencies to act impulsively or out of rage.
when pressured may experience micropsychotic episodes lasting from minutes to a few hours. BORDERS between neurotic and psychotic, and copes with and experiences life as if there were no inner self. feels empty and hollow unless filled with the presence of others. experiences intense feelings of self-loathing. is highly unpredictable and exhibits repetitive self-destructive acts. may seek stimulation using drugs, sex, eating to satisfy feelings of emptiness and to avoid painful feelings. |
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Borderline Personality DO
Prevalence |
most closely assoc with paternal psychiatric maladjustments and sexual abuse, more strongly r/t paternal rather than maternal factors.
often co-occurs with mood disorders. is distinguished from histrionic personality DO by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. |
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Borderline Personality DO
diagnostic criteria: American Psych Assoc 2000 |
a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts (5 or more).
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Borderline Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
frantic efforts to avoid real or imagined abandonment.
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. identity disturbance: markedly and persistently unstable self-image or sense of self. impulsivity in at least 2 areas that are potentially self-damaging - spending, sex, substance abuse, reckless driving, binge eating. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting for a few hours and only rarely more than a few days). chronic feelings of emptiness. inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fignts). transient, stress-related paranoid ideation or severe dissociative sx. |
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Treatment of Borderline Personality DO
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psychotherapy: treatment of choice is
DIALECTICAL BEHAVIOR THERAPY (DBT) focusing on 4 groups of skills: core mindfulness skills interpersonal effectiveness skills emotion modulation skills distress tolerance skills. pharmacotherapy: antipsychotics to control anger, hostility, and brief psychotic episodes. antidepressants to improve mood. MAOIs can modulate impulsive behaviors. anticonvulsants (TEGRETOL) may improve global functioning for some patients. |
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Schizotypal Personality DO
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sx include internal blandness, vivid fantasy, and psychoses.
internal world is filled with clairvoyant messages, ghost-like apearances and magical hunches. sensitive to rejection and retreat from life. want to make contact but are unable to know how to do it. |
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Schizotypal Personality DO
Prevalence |
associated with paternal emotional abuse and paternal psychological maladjustment.
occurs in 3% of the general population. stable course, only a small group going on to develop schizophrenia or another psychotic DO. is more prevalent among the first-degree biological relatives of indiv with schizophrenia. |
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Schizotypal Personality DO
diagnostic criteria: American Psych Assoc 2000 |
Criterion A: a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and decreased capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior beginning by early adulthood and present in a variety of contexts (5 or more).
Criterion B: does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder. |
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Schizotypal Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
ideas of reference (excluding delusions of reference).
odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (superstitiousness, belief in clairvoyance, telepathy or 6th sense; in children and adolescents bizarre fantasies or preoccupation). unusual perceptual experiences, including bodily illusions. odd thinking and speech (vague, circumstantial, metaphorical, over-elaborate, or stereotyped). suspiciousness or paranoid ideation. inappropriate or constricted affect. behavior or appearance that is odd, eccentric, or peculiar. lack of close friends or confidants other than first-degree relatives. excessive social anxiety that does not diminish with familiarity and tends to be assoc with paranoid fears rather than negative judgments of self. |
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Schizotypal personality DO
Differential Diagnosis |
30-50% have a concurrent dx of MDD when admitted to a clinical setting.
there is considerable co-occurrance with schizoid, paranoid, avoidant, and borderline personality disorder. |
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Treatment of Schizotypal Personality DO
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psychotherapy
pharmacotherapy: antipsychotics to deal with ideas of reference, illusions, and other psychotic sx. |
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Paranoid Personality DO
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deep rooted sense of inferiority.
see the world as a hostile environment. see all new faces as potential enemies rather than as potential friends. may appear cold and lacking of tender feelings. are often hostile stubborn, and have sarcastic expressions. labile range of affect and are predisposed to more severe disorders on Axis I. |
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Paranoid Personality DO
Prevalence |
0.5-2.5% in the general population.
10-30% among those in inpt psych settings. 2-10% among those in outpt mental health clinics. familial pattern in relatives with chronic schizophrenia and a more specific familial relationship with delusional DO, persecutory type. |
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Paranoid Personality DO
diagnostic criteria: American Psych Assoc 2000 |
a pervasive suspiciousness and distrust of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts (4 or more).
the personality DO must have been present before the onset of psychotic sx and must persist when the psychotic sx are in remission. needs to be distinguished from personality change due to a general medical condition. |
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Paranoid Personality DO
diagnostic criteria: contexts of behavior American Psych Assoc 2000 |
suspects w/o sufficient basis that others are exploiting, harming, or deceiving him/her.
is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. is reluctant to confide in others because of unwarranted fear that the info will be maliciously used against him/her. reads hidden demeaning or threatening meanings into benign remarks or events. persistently bears grudges (unforgiving of insults, injuries or slights). perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. has recurrent suspicions w/o justification regarding fidelity of spouse or sexual partner. |
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Paranoid Personality DO
differential diagnosis: |
delusional DO, persecutory type.
schizophrenia, paranoid type. mood DO with psychotic features. |
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Treatment of Paranoid Personality DO
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psychotherapy is the treatment of choice
pharmacotherapy antipsychotics are useful in dealing with agitation and anxiety |
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Personality DO NOS
definition |
category used for disorders of personality functioning that do not meet the criteria for any specific personality DO.
features from more than one personality DO may cause significant distress or impairment in one or more important areas of functioning. |
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Addiction:
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a substitute satisfaction for essential unmet needs.
dependency upon a substance, drug or object characterized by chronic, obsessive thoughts about the substance, drug or object and accompanying psychological and/or physiological cravings and urges for and compulsive behavior utilized in obtaining the substance, drug or object. |
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Craving:
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an intense psychological desire for a substance.
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Tolerance:
in substance related disorders |
repeated administration of a drug result in a need for larger doses of the drug to achieve the same effect or less effect with the same dose.
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Cross-tolerance:
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a client who is tolerant to a drug/substance is also physically/psychologically addicted to other drugs w/in a similar class.
ie: alcohol and benzodiazepines |
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Drug/Substance Abuse:
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use of a substance that is not culturally acceptable.
there is impairment in roles, family, occupation, legal, social, interpersonal, or medical complications as a result. |
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Drug/Substance Dependence:
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continuing usage of a substance despite negative consequences.
loss of control and time spent consuming the substance/s continue despite physical/psychological problems. |
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Psychological Dependence:
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an internal belief that one needs the drug/substance in order to survive.
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Physiological Dependence:
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when the body displays sx of withdrawal when the indiv abstains from the drug/substance.
addiction = dependence. when there is a physiological dependency there is also a psychological dependency. |
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Withdrawal:
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a substance-specific syndrome when the drug is stopped or decreased.
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Detoxification:
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use of a drug from the same substance classification to treat objective withdrawal signs.
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Intoxication:
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a specific set of substance-specific sx displayed after heavy usage of a drug/substance.
at very high levels of the substance/drug it can be lethal. |
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Relapse:
substance related disorders |
recurrence of the disease state after a period of abstinence.
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Co-morbidity:
substance related disorders |
the presence of one or more additional psychiatric dx in an indiv who has a dx of an alcohol-related disorder.
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Dual Diagnosis:
substance related disorders |
presence of a psychiatric dx in an individual who has a dx of a substance related disorder.
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Substance Abuse per DSM-IV-TR
Criteria for Diagnosis |
a maladaptive substance use pattern causing clinically significant distress or impairment, as evidenced by one or more criteria/behaviors w/in a 12 month period.
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Substance Abuse
criteria/behaviors per DSM-IV-TR |
persistent substance abuse with the outcome of failure in fulfilling major role responsibilities at home, work or school.
persistent substance use in situations in which it is physically dangerous. persistent legal problems r/t substance use. substance use continues regardless of continuous social and interpersonal problems created or exacerbated by the substance effects. |
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Substance Intoxication
per DSM-IV-TR |
a substance-specific syndrome caused by recent ingestion of a mood-altering substance.
maladaptive psychological and behavioral changes experienced are caused by substances that have an effect on the central nervous system which develop during or shortly after use of the substance. sx that are not caused by a general medical condition or by another mental disorder. |
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Substance Withdrawal
per DSM-IV-TR |
a substance-specific syndrome that develops due to the reduction of or cessation of heavy and prolonged substance use.
evidenced by clinically significant impairment or distress in occupational, social or other significant areas of functioning caused by the substance-specific syndrome. not caused by a general medical condition or other medical disorder. |
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CAGE Questionaire
4 questions to assess drinking habits and patterns |
C: have you ever felt you should Cut down on your alcohol intake?
A: have individuals Annoyed you by criticizing your alcohol intake? G: have you ever felt Guilty about your alcohol intake? E: have you ever needed alcohol for an Eye-opener (morning consumption)? An affirmative answer to 2 or more indicates probable alcoholism. A single affirmative answer requires further nursing assessment of the client's alcohol consumption. |
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Withdrawal from Substances
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defined as the sx seen when a mood-altering substance is discontinued.
LARGELY dependent upon the half-life of the substance. treatment of the withdrawal sx depends upon the type of drug taken, needs to be managed medically. |
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Calculating Potential for Withdrawal:
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note: duration
amount date time of the last usage of the substance half-life of the substance TO CALCULATE THE POTENTIAL FOR WITHDRAWAL. withdrawal sx will occur if the indiv is physiologically dependent upon the substance. withdrawal will begin anywhere between the numbers indicated as the half life of the drug. |
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Calculating How Long to Observe Someone for Withdrawal Symptoms
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multiply the half-life of the drug/substance by 5.
if no withdrawal sx are seen w/in that period, the pt is no longer at risk for withdrawal from that substance. |
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Alcohol Withdrawal:
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withdrawal will occur anywhere between 8 and 12 hr.
some articles report alcohol withdrawal as early as 4 hr. it may continue up to 5 days. |
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Sedatives/Hypnotics:
Categories of Drugs/Substances |
alcohol
benzodiazepines (minor tranquilizers) barbiturates (major tranquilizers) antihistamines sedatives |
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Benzodiazepines: minor tranquilizers
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Librium - chlordiazepoxide HCL
Tranxene - chlorazepate Serax - oxazepam Klonopin - clonazepam Ativan - lorazepam Valium - diazepam Restoril - temazepam Limbitrol - chlordiazepoxide-amitriptyline Xanax - alprazolam Dalmane - flurazepam Halcion - triazolam |
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Barbiturates: major tranzuilizers
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Phenobarbital
Tuinal - amobarbital NA & secobarbital NA Seconal - secobarbital NA Luminal - phenobarbital Pentothal - thiopental NA Butisol - butabarbital Fiorinal - butalbital & caffeine Amytal - amobarbital Nembutal - pentobarbital Brevital - methohexital NA |
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Antihistamines:
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Benadryl - diphenhydramine
Phenergan - promethazine HCL Vistaril - hydroxyzine HCL |
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Sedatives:
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chloral hydrate -
Somnol - flurazepam (same as dalmane) Equanil - meprobamate Noctec - chloral hydrate paraldehyde - (Paral, Paracetaldehyde) |
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Sedative Hypnotic
Signs of intoxication: |
due to CNS depression.
decreased pulse, respiration, BP. dry, flushed skin. drowsiness, slurred speech. GI tract slowing. slowed thought processes. slowed reflexes. |
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Sedative Hypnotic
Signs of Withdrawal: |
due to CNS hyperactivity.
elevated pulse, respiration, BP. diaphoresis, pallor. hyperreflexia. insomnia, anxiety, restlessness. hyperactive thought processes. GI tract hyperactivity, nausea, vomiting, anorexia. |
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Medical Consequences of Alcohol
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brain atrophy: Wernicke-Korsakoff's syndrome - due to thiamine deficiency.
chronic subdural hematoma. Gastritis. pancreatitis. diarrhea. fatty liver. alcoholic hepatitis. ascites. alcoholic cirrhosis. esophageal varices. portal hypertension. cardiac arrhythmias. CAD. Alcoholic cardiomyopathy. peripheral neuropathy. diminished sexual desire and potency. gynecomastia. fetal alcohol syndrome. sleep disturbances. |
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Wernicke-Korsakoff's syndrome
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Wernicke: sudden marked confusion, unsteady gait, double vision, uncoordinated movement. REQUIRES PROMPT TX WITH LARGE AMTS OF THIAMINE W/IN THE FIRST FEW HOURS TO FIRST FEW DAYS TO AVOID DEATH OR DEVELOPMENT OF KORSAKOFF'S SYNDROME.
Korsakoff syndrome: marked impairment of memory, disorientation to person, place, date and time; an inability to retain memory of ongoing events, and short-term memory loss. will most likely have peripheral neuropathy. |
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Alcoholic Cirrhosis, S/S
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jaundice
palmar erythema - reddening of the palms of the hands |
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Portal hypertension:
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occurs when blood is blocked in the liver, cannot flow freely through the liver, and requires finding another route to the heart.
this causes undue pressure on the vein systems that are already vulnerable, the esophagus and stomach. PORTAL HYPERTENSION IS NOT ASSOCIATED WITH HIGH BLOOD PRESSURE. |
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Cardiac arrhythmias:
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drinking alcohol along with caffeinated beverages will predispose an indiv to developing an arrhythmia.
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Fetal Alcohol Syndrome: FAS
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associated with maternal alcohol consumption during pregnancy.
Defects assoc with FAS: small head, low birth wt, short body length, slow growth after birth. narrow eye slits, underdeveloped facial structure, flattened cheek bones, abnormally thin upper lip. mental retardation, delayed development. |
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Sleep disturbances
Alcohol related |
during the sobering-up period there is an incr in rapid eye movements.
client may c/o restlessness during sleep, vivid dreams, and/or nightmares. during the wks to months after alcohol cessation, sleep may be restless with frequent yet unremembered awakenings. |
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Treatment for Withdrawal - Sedative Hypnotics
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VS every 2-4 hr and medicate per institution protocol.
administer benzodiazepine per detox protocol, taper dosages per protocol, do not miss/skip doses due to seizure risk (esp with benzo dependency). MONITOR FOR SEIZURES. no strenuous exercise until after post-withdrawal monitoring complete DUE TO benzos stored in fat cells and exercise would cause the benzo to be released more quickly and WITHDRAWAL SX COULD WORSEN AND POSSIBLY LEAD TO SEIZURE ACTIVITY. thiamine 100mg tid for alcohol withdrawal. increase fluid intake. comfort measures. patient teaching re: withdrawal process, breathing and relaxation, need to report sx accurately so best care can be provided. |
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Opioid type/Narcotic Drugs:
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morphine - morphine sulfate
Dilaudid - hydromorphone HCL Methadone, Dolophine - methodone HCL Darvocet - propoxyphene HCL & acetaminophen Lomotil - diphenoxylate HCL & atropine sulfate codeine - Hycodan - hydrocodone bitartrate Demerol - meperidine HCL Stadol - butorphanol tartrate heroin - Percodan - oxycodone & ASA Darvon - propoxyphene HCL Talwin - pentazocine HCL |
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Opiate Intoxication:
symptoms |
analgesia, apathy, drowsiness, drooling, euphoria, nodding,slowed speech.
flushed skin, itching, peripheral vasodilation, spontaneous orgasm. respiratiory depression. OVERDOSE: shallow breathing, tachycardia, hypotension, depressed levels of consciousness, clammy skin, convulsions, papillary dilation, unconsciousness, coma and death. |
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Opiate Withdrawal Symptoms:
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abdominal spasms, muscle cramps.
anorexia, vomiting, diarrhea, dehydration, weight loss. chills, elevated temperature and pulse, flushed skin, gooseflesh, rhinorrhea, sneezing, yawning, lacrimation. depression, irritability. Sx subside w/in 5-7 days. |
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Antidote for Opioid/Narcotic Overdose:
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Narcan
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Treatment for Opiate Withdrawal
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comfort measures and symptom management.
Catapres (clonidine) to prevent or alleviate withdrawal sx. sleep hygiene. anti-diarrheal medication prn. enc adequate hydration. deep breathing techniques. interventions to alleviate N/V. |
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Stimulants:
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Cocaine
Amphetamines: Ritalin - methylphenidate Methamphetamine - Cylert - pemoline Dexedrine - dextroamphetamine sulfate Adderall - amphetamine sulfate Crank - Crystal methamphetamine - Speed - D - Amphetamine - dextroamphetamine Benzedrine - ? Melfiat - ? Phendiet - ? Preludin - ? Focalin - dexmethylphenidate Ionamin - ? Tepanil - ? Methadrine - ? Didrex - benzphetamine HCL Paredrine - hydroxyamphetamine HBr |
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Medical Consequences Amphetamines
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hepatitis, endocarditis, lung abscesses, HIV; sexual dysfunction with long term use and high doses
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Psychostimulant Intoxication: signs
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sense of increased alertness
anxiety decreased appetite delayed orgasm drowsiness in chronic users elevated mood enhanced physical strength enhanced mental capacity irritability suspiciousness psychosis hallucinations hypertension elevated pulse preoccupation diarrhea decreased skin temperature repressed stomach contractions sleep disturbances |
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Psychostimulant Withdrawal: signs
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agitation
cravings decreased concentration dullness drowsiness GI disturbances labile emotions decreased psychomotor performance fatigue depression prolonged sleep seizures may occur from IV cocaine withdrawal |
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Psychostimulant Overdose: signs
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arrhythmias
assaultiveness chills convulsions psychosis hallucinations coma diarrhea flushing confusion restlessness respiratory depression respiratory collapse sweating tremors labile blood pressure circulatory collapse |
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Management of Psychostimulant Withdrawal
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withdrawal sx generally subside over 2 -4 days after drug abstinence
no specific tx for stimulant withdrawal symptom management Cocaine abusers commonly take alcohol, marijuana, or heroin with cocaine to reduce the irritability caused by high-dose stimulant abuse; withdrawal may be in response to a combination of drugs |
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Hallucinogenic Drugs
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LSD
STP PCP - phencyclidine peyote - a cactus psilocybin - a mushroom hashoil ecstasy - methylenedioxymethamphetamine. mescaline - alkaloid derivative of the peyote cactus. psilocin hashish - resin from the cannibis indica plant contains high THC content. MDA - methelenedioxyamphetamine. |
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Medical Consequences Hallucinogens
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unique to each individual
mild or severe depression convulsions flashbacks death from toxic drug levels, suicide or driving under the influence. |
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Hallucinogen Intoxication: signs
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unpredictable alterations in thought, mood perceptions.
enhanced self-awareness. heightened sensitivity to faces, gestures. feelings are magnified. heightened body awareness. distortions of all senses occurring from excitement to terror. combination of sensory experiences - what is seen is also heard. episodes can last from minutes to days. effects can last from hours to weeks. Other signs: anorexia, anxiety, dizziness, hallucinations, hyperthermia, HTN, nausea, vomiting, paresthesia, dilated pupils, suspiciousness, tachycardia, tremor. |
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Hallucinogen Overdose: signs
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delirium
grand mal seizures hyperthermia paresthesia psychosis tachycardia HTN abdominal cramps dilated pupils |
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Hallucinogen Withdrawal:
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not much is known about hallucinogen withdrawal.
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Cannabis (Marijuana and Hashish) and tetrahydrocannabinol (oral)
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most commonly used illicit substance in the U.S.
often used with alcohol or stimulants such as cocaine and nicotine. urine drug tests may be positive for up to 7 - 10 days; with heavy users 2 -4 weeks. |
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Cannabis Medical Consequences:
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many reports indicate long-term use of cannabis is associated with cerebral atrophy, susceptibility to seizures, birth defects, chromosomal damage, alterations in concentrations of testosterone, disruption in the menstrual cycle, and am impaired immune system.
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Cannabis Intoxication: signs
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euphoria
relaxed inhibitions impaired memory and attention impaired motor skills increased appetite heightened sensitivity to external stimuli. |
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American Psychiatric Assoc (2000)
Cannabis intoxication |
recent ingestion of cannabis.
psychological and behavioral changes of clinical significance that develop during or shortly after use of cannabis. Two or More of the following sx develop w/in 2 hr after cannabis use: conjunctival injection, increased appetite, dry mouth, tachycardia. The sx are not caused by a gen med condition or by another mental illness. |
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Cannabis Withdrawal: signs
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anxiety
decreased appetite hyperactivity insomnia |
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Cannabis Toxic Reaction: signs
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fatigue
panic reactions paranoid ideation psychosis |
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PCP - phencyclidine intoxication: signs
other names: crystal, angel dust, rocket fuel, dust, peace pill |
agitation
floating sensation lethargy increased blood pressure slowed reflexes altered body image altered perceptions of time and space catatonic immobility bizarre behavior stupor violent behavior Symptoms last from 30 min to 6 hr. |
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PCP - phencyclidine: major symptoms/patterns seen with this drug and are possibly dose related:
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acute brain syndrome
catatonic syndrome coma - mild, moderate or severe toxic psychosis |
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Acute Brain Syndrome sx:
PCP |
disorientation
confusion loss of recent memory labile inappropriate behavior violence |
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Catatonic Syndrome sx:
PCP |
mutism
negativism posturing possible violence rigidity stupor |
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Toxic Psychosis sx:
PCP |
delusions
hallucinations onset of these sx may not be exhibited for up to 7 days after ingestion of PCP. duration of sx is 1 - 30 days, the average is 3 - 4 days. |
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Dual Diagnosis and Co-Morbid Conditions: definitition
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Co-morbidity is the presence of an additional psychiatric diagnosis in an individual with a diagnosis of a substance- related disorder. This is often referred to as dual diagnosis.
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common psych dx accompanying substance-related disorders
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polysubstance abuse
antisocial personality disorder bipolar illness major depressive disorder cyclothymic disorder anxiety disorders PTSD |
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Relapse Prevention:
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Relapse: term used to describe when an individual begins to behave in a dysfunctional /unhelpful manner after a period of abstinence, recovery, or sobriety.
Relapse occurs long before the actual "slip" of chemical/drug/ETOH use. It is a period of time leading to a relapse. Identifying relapse triggers is important. |
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Treatment Issues, Chemically Dependent Client:
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assessment for and treatment of co-morbid psychiatric illnesses.
participation in a 12- step recovery program. spirituality. anger management. stress management, anxiety reduction. attachment/avoidance issues. reality orientation. |
