STUDY GUIDE 3 (NSG 150)

Schizophrenia & other psychotic conditions 3.1 EOs

1.1 key terms
1.2 theories of the etiology of schizophrenia
Genetics
60% inherited
6-17% chance if one parent or sibling has it
identical twin rises to 40-65%
non-identical twin 17%
Toxin (environmental)
toxin exposure as a result of breathing (pollutants), eating, drinking, & smoking
pollution
infections
viral exposure
malnutrition
being born in winter
being born in a city
childhood brain injury
Neurotransmitter alterations
dopamine- regulates both movement and emotions
dopamine hypothesis- persons w/ schizophrenia have an increased level of dopamine in certain areas of the brain
such as the nigrostriaganglia & some critical functions.
Excessive dopamine causes symptoms of psychosis (e.g., hallucinations, delusions) b/c it disrupts cognition &
thought.
66% increase in the # of dopamine receptors in persons w/ schizophrenia.
Serotonin, acetylcholine, norepinephrine, cholecystokinin. Glutamate, & GABA
Neuro anatomical
enlargement of cerebral ventricles
3rd ventricle dilation
ventricle asymmetry
abnormal lobes some atrophy as seen in MRI & PET scans
changes in blood flow
Viral (immunological)
Exposure to influenza during pregnancy is a risk factor for development of schizophrenia in later life.
Polio, measles, varicella-zoster, rubella, & herpes simplex virus type 2 during childhood.
Few immunologic studies of schizophrenia
Stress-trauma
substance abuse
nicotine common addiction in these p/ts
socio-economic
Psychological & psychosocial theories
Persons vulnerability interacts w/ stressful environmental influences to produce the symptoms of schizophrenia.
Psychosocial stressors include stressful life events such as interpersonal losses, sociocultural stresses (poverty or
homelessness) or stressful emotion situation where the p/t lives.
Psychosocial rehabilitative interventions have been shown to improve the quality of life in p/ts w/ schizophrenia.
1.3 epidemiological factors
males earlier onset (15-25), poorer outcome
females later onset (25-35), better outcome
new dx of schizophrenia occur in b/t 0.3 & 0.6 individuals per 1000 persons per year in the US
1% of the US population has schizophrenia
paranoid-type schizophrenia occurs earlier in males than in females
disorganized-type schizophrenia occurs earlier in females than in males
prevalence is equal for males & females
childhood onset is rare
oldest of age-of-onset group is after the age of 60

a female fetus who is exposed to influenza has a higher risk for shizophrenia than a male fetus
males show significantly more structural brain abnormalities from perinatal or early childhood trauma than females
do
1.4 onset and course of disease
rare onset in children
persons who have later onset have better outcomes in all areas
approx 80% of people w/ schizophrenia had an early onset, whereas 20% have a late onset (after 40) or very late
onset (after 60).
Course of illness
premorbid: social, motor, cognitive changes
Prodromal: 1 month to 1 year before dx/S&S of this phase include
mood symptoms (anxiety, irritability, dysphoria, anguish)
cognitive symptoms (distractibility, concentration, difficulties, disorganized thinking)
obsessive behaviors
social withdrawal & role functioning deterioration
sleep disturbances
attenuated (weaker) positive symptoms (illusions, ideas of reference, magical thinking, superstitiousness)
Psychotic: acute, recovery/maintenance, stable phases
acute- florid positive symptoms (delusions, hallucinations) negative symptoms (apathy, withdrawal,
avolition). Unable to perform self-care activities, brief hospitalization required.
Recovery/maintenance- 6-18 mo. After acute treatment. Less severe symptoms. Able to take care of
themselves w/ some supervision.
Stable- symptoms are in remission. Residual symptoms (milder forms of symptoms). May live
independently in the community.
1.5 subtypes & related disorders of schizophrenia
Paranoid
Better prognosis/less cognitive & neurological impairments
respond better to meds
in acute phase more a danger to self or others
suspicious of others
touch & personal space should be considered
must meet 2 of the symptoms in criterion A: also listed on pg 270
presence of delusions & hallucinations.
The other diagnostic criteria (I.e disorganized speech, behavior, & other negative symptoms) are not
prominent.
Disorganized (formerly called hebephrenic)
severe disorganization in speech, odd behaviors
socially withdrawn
poor grooming
prognosis is poor
word salad (communication that includes both real & imaginary words in no logical order)
Catatonic
psychomotor disturbances catalepsy (waxy flexibility)
catatonic stupor (psychomotor retardation) or excitement (psychomotor excitation)
require the most nursing care due to chronic vegetative state can see & hear physical care
to meet the criteria, p/t must show two of the following behaviors:
motor immobility
excessive motor activity
extreme negativism (resistance to all instructions & attempts to be moved)
peculiar voluntary movements (grimacing. Sterotypic movements, posturing)
echopraxia (imitating the movement of others) OR echolalia (repeating what was said by another)
Undifferentiated
prognosis poor & chronic
does not fit other types
extreme delusions & odd behavior

Residual
free of prominent symptoms but still some negative
may continue for years w/ or w/o exacerbation
dx criteria:
absence of prominent delusions, hallucinations, disorganized speech, disorganized or catatonic behaviors.
Continuing evidence of the presence of negative symptoms or reduced positive symptoms
Related disorders
Schizoaffective: a condition in which a person experiences a combination of schizophrenia symptoms such as
hallucinations & delusions & of mood disorder symptoms such as mania & depression
later onset
severe mood swings
some psychotic symptoms
better prognosis
treatment is based on presenting symptoms
depressed phase like major depression
manic phase like bipolar manic
psychotic more like schizophrenia
diagnosis: Bleuler's fundamental signs
affect (feeling)
associative looseness (speech)
autism (thinking)
ambivalence (behavior)
Schizophreniform
Defining characteristics same as those of schizophrenia w/ 2 exceptions: duration (at least 1 mo. But less than 6
mo.) & impairment function.
Prognosis: functional capacity is high.
Delusional
fixed false belief is not bizarre, that it may seem plausible, & that it lasts more than a month w/ causing obvious
impairment in functioning.
Stalking behaviors
jealousy w/ evidence
sadness, grief, irritability, legal problems
Brief psychotic
lasts less than a month
may have delusions, hallucinations, incoherent speech, grossly disorganized & confusing dysfunctional behaviors.
Symptoms not r/t to substance abuse or meds
associated w/ stressors
young adults who are high risk for suicide
care must focus on saftey & attention to the basic needs of nutrition & hygiene.
Shared psychotic (Folie a Deux)
a person may share the same delusions w/ another person.
If primary person is a parent, affect children may literally grow up w/ the delusions.
Psychotic D. due to a general medical condition
high fever caused by a kidney infection may induce hallucinations, confusion, disorganization, aggressive or
bizarre behavior.
Strokes, fluid & electrolyte imbalances, SLE, hypoxia, encephalitis, hypoglycemia.
Best approach is to assume that psychosis is a manifestation of an underlying & undiagnosed medical problem
until it is proven otherwise
Substance-induced Psychotic D.
tactile hallucinations (insects crawling over the skin) are characteristic of alcohol & drug abuse.
Symptoms usually resolve within a month.
Persons of psychosis may use drugs & alcohol as a method of self-medicating.
Psychotic disorder not otherwise specified
etiology of psychotic behaviors is unclear
1.6 positive & negative symptoms

Negative
interfere w/ the ability to initiate or maintain relationships, conversations, hold a job, make decisions, & maintain
ADLs.
Not as obvious
more insidious onset
more debilitating
contributes to social/occupational functioning
blunted or flat affect
Anhedonia- lack of pleasure
anergia- lack of energy
avolition- lack of motivation
depression, hopeless (risk for suicide)
social isolation
decreased spontaneity
poor response to 1st generation antipsychotics (may actually worsen)
Positive
delusions, persecutory or grandiose
delusions of being controlled
mind-reading or thought-insertion ideas
perceptual: hallucinations, auditory or other sensory modes
bizarre dress & behavior
thought disorganization & tangential (superficial) speech
aggressive & agitated behavior
pressured speech
presence of suicidal ideation
ideas of reference
respond well to treatement & reduced stressors
1.7 nursing process
Assess
what problems have you been having recently
do you now or have you ever used alcohol or drugs
have you heard (sounds, voices, or messages) seen (lights, figures) smelled (strange, bad, good odors) tasted
(strange, bad, or good tastes) or felt (touching, warm , or cold sensations) anything that others who were
present did not
what are the voices like that you hear
it sounds like you're very scared right now
I don't hear any other voices but yours & mine
what helps to make the voices go away or get quieter
let's see if doing something (walking , crafts, singing etc.) helps with the hallucinations.
Nursing dx
based on the assessment of positive or negative symptoms
risk for suicide, risk for self-directed & other directed violence
disturbed sensory perception & thought processes
self-care deficit
outcomes
safety always priority
vary w/ phase of illness & c/t
measurable, behavioral & realistic
demonstrate an absence of suicidal behaviors or violent behaviors toward others
demonstrate an absence of self-mutilating behaviors
nursing interventions
specific to the symptom
aimed at lowering anxiety
decreasing defensive patterns
encouraging participation

raising self-esteem
agitated c/ts
SAFETY
reduce stimulation
brief , concise , not abstract statements
what are the stressors/triggers
redirect come walk w/ me, tell me what is going on
prevent aggression c/ts always give signs, just look
acute phase
crisis intervention
stabilization
safety
limit setting
maintenance/stable phase
teach symptoms management
small amounts of info, can't tolerate lots of detail, use pictures
prevent relapse
1.8 shift to community treatment
assertive community treatment teams
designed specifically for the individuals strengths & deficits.
Deliver care 24/7
help w/ ADLs & job seeking skills & placement & offering support

family interventions, supported employment, CBT, social skills training, early intervention programs
group therapy, group homes.
therapeutic methods to prevent violence psychopharmacology, somatic therapy, milieu therapy, behavior modification
1.9 psychopharmological management
typical/conventional antipsychotic/1st generation
work by blocking the D2 dopamine receptors in the limbic region of the brain
Phenothiazines: Chlorpromazine (Thorazine) (first drug to treat psychosis in the 50s), Thioridazine (Mellaril),
Trifluoperazine (stelazine) & Fluphenazine (Prolixin)
most effective for treating positive psychotic symptoms only
has many side effects which causes clients to stop taking them
blocks dopamine in the motor centers (Extrapyramidal Nerve tract) causes movement disorders or
EPSincluding Tardive dyskinesia (a neurologic syndrome that consists of abnormal, involuntary,
irregular choreoathetoid movements of the muscles, the head, the limbs and trunk)
choreoathetosis is the occurrence of involuntary movements in a combination of chorea (irregular
migrating contractions) & athetosis (twisting & writhing)
-manifested by tongue protrusion, puffing of the cheeks, chewing or puckering of the mouth
-occurs rarely, but may be irreversible
AIM scale (autonomic involuntary movement scale)- performed not less than every 6 months when a p/t
is taking either typical or aytypical antipsychotics
then came Butyrophenons: Haloperidol (haldol)
others: Thiothixene (Navane)
Extrapyramidal symptoms: serious reactions that appear r/t to high dose of neuroleptic meds
Akathisia- subjective feeling of muscular discomfort that causes the p/t to become agitated, pace, alternately sit &
stand & feel a lack of control
Parkinsonian- muscle stiffness, cogwheel, rigidity, shuffling gate, perioral tremor, hypersalvation, & mask like
expression
acute dystonias-spasmodic movements caused by slow, sustained, involuntary muscle contractions such as:
torticollis (abnormal, asymmetrical head or neck position)
opisthotonos ( body is rigid & arches the back, w/ the head thrown backward)
oculogyric crisis ( prolonged involuntary upward deviation of the eyes)
EPS can involve the neck, jaw, tongue or entire body

Drugs of treatment:
Antiparkinson drug Benztropine (cogentin), trihexyphenidyl (Artane)
Acute emergencies Acute dystonic reactions, NMS (neuroleptic malignant syndrome)
Tardive dyskinesia life-threatening irreversible sweating, fever, unstable bp, stupor, muscle rigidity,
autonomic dysfunction, elevated CPK, excessive salvation, occurs in 1% but 10% die
other side effects of typicals:
anticholinergic (dry mouth, blurred vision, urinary retention, nasal congestion, constipation, ejaculatory
inhibition)
sedation (most common during early stage of treatment, need to avoid alcohol, antihistamines, & sleeping
aids)
postural hypotension
arrhythmias, palpitations, & prolonged QT intervals
lowered seizure threshold
weight gain increased risk for type II diabetes
photosensitivity & skin changes
poikilothermia loss of ability to regulate internal body temp. watch older adults in hot weather
galactorrhea & gynecomastia breast enlargement or tenderness
cholestatic jaundice
Atypicals- Clozoril (clozapine) was the first in the 90s
1st to effectively treat both + & - symptoms of schziophrenia
not used as a first resort due to risk for agranulocytosis ( bone marrow does not make enough of a certain type
of mature white blood cells (neutrophils)- regular & frequent serum lab testing required
used for refractory schizophrenia
other atypicals:
Seroquel (quetiapine)
Risperdal (risperidone)
Geodone (ziprasidone) problem prolonged QT interval
Zyprexa (olanzapine) similar to clozapine w/o the risks of agranulocytosis, does have high risk for
seizures- common side effect is gain weight
both serotonin + dopamine antagonists
work on + & - symptoms
fewer EPS side effects, but there still may be
less risk for tardive dyskinesia
cost more
elderly w/ dementia r/t to psychosis increased risk for death when taking these meds
black box warning contraindicated
mostly death r/t to cardiac failure/sudden death or infection (pneumonia)
3.2 Substance abuse disorders
1.1 key terns
1.2 definitions of SUD
addiction- compulsive drug seeking or use.
Substance misuse- use of psychoactive substance (drug or alcohol) for a purpose other than that for which it was
intended & that causes physical, social , & psychologic harm.
Polysubstance abuse dependency abuse
1.3 USDEA categories
schedule 1 (high potential for abuse, no accepted medical use in treatment in the U.S ex. Heroin, mescaline)
schedule II (high potential for abuse but has currently accepted medical use w/ severe restrictions, may lead to
psychologic or physical dependence ex. Morphine, cocaine, codeine)
schedule III (potential for abuse less than for schedules I & II , currently accepted in medical practice, moderatelow dependence ex. Anabolic steriods, ketamine, thiopental)
schedule IV (low potential for abuse, current medical use, abuse may lead to limited dependence ex
benzodiazepines, ambien, sonata, meridia)
schedule V (only contains cough preparation w/ codeine up to 200 mg/100ml

so basically just know that the lower the number the higher the strictness/regulation of these substances/drugs and the higher
the risk for dependency.
1.4 neurobiological basis of addiction
drugs of dependence are categorized as depressants, stimulants, opiatesm hallucinogens, inhalants, & nicotine.
All drugs of abuse evoke a rapid release of neurochemicals that is followed by a reduced-from-baseline level of
neurotransmitter when the effect of the drug wears off creating a reward threshold & biologic need for craving
for more drug.
Drug serves as a reinforcer that increases the probability of a repeat behavior & the use of that substance.
Two sides of addiction:
light side (beginning use): the feel good neurotransmitters dopamine, serotonin, opiod peptides, & other
neurochemicals predominate.
Dark side (end use/withdrawal): neurotransmitters norepinephrine & corticotropin-releasing factor (CRF) as
well as the stress circuits are activated, which results in withdrawal symptoms. The individual then uses the
substance not to feel good but to prevent the physical & psychologic stress & discomfort.
Individuals w/ genetically greater neuroplastic potential for glutamate & dopamine production & activation
may be more prone to addiction
4 circuits:
reward: involves nucleus accumbens & ventral palladium (dopamine I.e light side)
Memory & learning: involve the amygdala & hippocampus
cognitive control: located in the prefrontal cortex & dorsal anterior cingulated cortex
motivation, drive, salience: orbital frontal cortex
all of these contribute to the initiation & continuation of substance use.
1 way path from amygdala to the frontal cortex frontal cortex does not have reciprocally direct communication
w/ the amygdala this frontal cortex (prioritization, organization, decision making) is unable to tell the amygdala
to stop.
1.5 epidemiological issues
50% for men whose father was an alcohol dependent
women are at higher risk than men for problems r/t to alcohol use, including organ damage & other problems.
Women begin problem drinking later in life than men develop physical & psychosocial problems in a faster,
often during child bearing years telescoping
native Americans have a high rate of alcoholism; Asians have low rate
the liver metabolizes alcohol by converting alcohol into acetaldehyde then into acetate & finally into carbon &
water. The enzyme responsible is ADH, alcohol dehydrogenase
Japanese, Chinese, & Koreans are missing this enzyme or have an inactive form. This is protective as
acetaldehyde increases in the blood quickly resulting in flushing, nausea, dizziness, & rapid HR. REMEMBER
this when we talk about Antabuse (disulfiram)
Co-morbid
people w/ mental illness have a greater risk of addiction & abuse PTSD, bipolar, anxiety, depression
medical comorbidites associated w/ drug & route of choice
vehicular accidents due to DUI & associated medical complications due to substance ingested.
1.6 substance abuse among special populations
women are more vulnerable to domestic violence & suicide
traditional programs do not address women's issues
binge drinking or frequent drinking problem in pregnant women
drinking in pregnancy is the leading known cause of preventable birth defects & learning difficulties
Fetal alcohol syndrome growth retardation, central nervous system involvement that results in mental
retardation & other learning difficulties, facial & other abnormalities occurs in 1 to 3 per 1000 live births.
Health
care professionals
10-20 % of nurses & 9% physicians are identified as having substance abuse problems
Older adults
at risk population for substance abuse
statistics do not reflect true extent of the population
70% of those 60 or older hospitalized for medical problems or accidents was r/t to alcohol
use to manage pain & loneliness
always look for it: falls, cognitive changes, assaults, & suicides may be correlated w/ alcohol abuse

Adolescents
p/t- family teaching guidelines: signs & prevention
bloodshot, red eyes, droopy eyelids
wearing sunglasses at inappropriate times
changes in sleep patterns (napping, insomnia)
unexplained periods of moodiness, depression, anxiety, or irritability
decreased interaction & communication w/ family
loss of interest in previous hobbies, sports & so on
change in friends; will not introduce new friends
decline in academic performance, drop in grades
loss of motivation & interest in school activities
change in peer group
disappearance of money or items of value
use of eye drops & mouthwash
unfamiliar containers or locked boxes
money missing from the house
prevention
ensure positive role modeling by parents & adults
reinforce the dangers of SU & teach positive behaviors
reinforce positive coping
establish limits & structure
anticipate pressures
provide life skills training
monitor media use
1.7 dual dx
Concurrent mental illness & drug abuse or dependence. Occur at the same time, or one follows the other,
eventually it becomes difficult to know which came first.
Antisocial personality disorder, bipolar, & schizophrenia highest w/ substance abuse.
Depression + bipolar disorder also have increased rates of substance abuse
HIV, HBV, HCV, TB sharing/reusing needles, syringes exposes risk.
1.8 alcohol use on American population
most widely used & abused substance
effects on the neurologic system
assess alcohol use in all cases of rapidly developing confusion.
Liver damage fatty liver
GI ulcers & inflammation
cardio high bp, LDL, triglycerides myocardial infarction & thrombosis wasting of heart muscle
immune system lowers white blood cells prone to infection
sleep fall asleep more quickly but depressed levels of REM & less stage 4 sleep glutamate increases causing
inability to sleep hangover symptoms
hormonal changes menstrual irregularity, decreased sperm production & motility, decreased ejaculate volume,
testosterone production & impotence.
Accidents DUI
1.9 intoxication, overdose , & withdrawal from:
CNS depressants: Alcohol, prescription opiates, anxiolytic drugs
Alcohol: significant psychologic/maladaptive changes that occur during or shortly after the ingestion of
alcohol.
Slurred speech, lack of coordination, unsteady gait, nystagmus, the breath smell of alcohol, impaired
attention & memory, coma or stupor.
Withdrawal symptoms: irritability, anxiety, agitation, insomnia, tremors, diaphoresis, delirium alcohol
DTs, seizures, possible death, begins 12-24 hrs after last ingestion
Prescription opiates: pain relievers, tranquilizers, stimulants, & sedatives
cognitive impairment + physical instability
Anxiolytic
drowsy, calming, & sedating effects to help w/ sleep disorders & symptoms of anxiety (common in all

CNS depressants)
lethal in overdose situations
when used as drug abuse, people often take them to reduce subjective unpleasant anxiety or to manage
withdrawal symptoms from other drugs (alcohol, cannabis, heroin, methadone, cocaine, amphetamines)
GHB illegal CNS depressant that relaxes/sedates the user often used in combination w/ alcohol
involved in date rapes, poisonings, overdoses, deaths.
Overdose in GHB Nausea, vomiting, headache, loss of consciousness & reflexes
overdose in benzodiazepines chlordiazepoxide (librium), diazepam (valium), lorazepam (Ativan),
clonazepam (klonopin), Alprazolam (xanax) disturb sleep patterns & cause changes in affect
withdrawal is lengthy, rapid discontinuation after habitual use of large amounts often causes seizures.
Live support measures: Naloxone (Narcan), lavage or dialysis, control of withdrawal seizures phenobarbital
tapering
Symptoms of CNS depressants withdrawal:
begins 12-16hrs after last dose
cravings
Abdominal cramps
diarrhea
Nausea & vomiting
bone & muscle pain
muscle spasm
tremor, chills, diaphoresis
treatment of CNS withdrawal: opioid substitution
methadone (dolophine) opioid agonist
buprenorphine (subutex) opioid agonist
naltrexone (re-via) blocks opioid receptors (antagonist) used for alcohol & opiate maintenance
decreases the craving & blocks the high or the effects of heroin & other opioids during
rehabilitation or overdose
**P/t's need to be wear alert bracelet **
revia is the oral form
vivitrol depot is the injection (last 1 month)
naltrexone implant is good for 2 months
suboxone (buprenorphine) in combination w/ naltrexone used for maintenance
treatment of alcohol acute intoxication or overdose
ABCs
Thiamine/high protein diet
nutrional support IV glucose
Clonidine (catapress) for tx of withdrawal symptoms
benzodiazepines such as ativan or librium (detox) (cross-tolerance)
Stimulants: cocaine, crack coaine, nicotine, caffeine, ephedrine, propanolamine, amphetamines, amphetamine-like
substances. Substances similar in action but diff. Chemical structure (diet pills).
Popular drugs of abuse b/c of their effects on brain
people get addicted to the sense of high energy, alertness, & well-being produced by them
effect the CNS mechanism HR & RESP.
raise bp & temp.
aggressive or violent behavior occurs w/ high dose use anxiety, paranoia, & psychotic episodes occur w/ the
abuse of & dependence on stimulants
cocaine most potent inhibits the uptake of dopamine in the brain & increases the dopamine receptors in
the brain reward system rapid dependency as it magnifies the pleasure sites of the brain increases
norepinephrine which causes vasoconstriction & cardiovascular stimulation.
Intoxication: Euphoria, feelings of impending doom, agitation/combativeness, hallucinations paranoia
confusion, seizures
withdrawal: headache, anxiety, restlessness, dreaming, cravings, depression (in cocaine high risk suicide),
decreased Bp, psychomotor retardation
nicotine has same intoxication, tolerance, withdrawal symptoms as other CNS stimulants
Steroids: anabolic androgenic steroid (r/t to male sex hormones)

anabolic (muscle building) androgenic (increased masculine characteristics)

higher risk for heart attacks, strokes, liver problems
physical changes: breast development, genital shrinking in men, increased risk for prostate cancer, infertility,
reduced sperm count. Women masculinzation of their bodies growth of facial hair, male pattern
baldness, changes in menstrual cycle, enlargement of the clitoris, deepened voice.
Drug abuse Extreme mood swings occur, violent behaviors, depression, paranoid jealousy, delusions, &
impaired judgment
Hallucinogens
alter perception, cognition & mood.
LSD famous derivative of peyote or mescaline (flashbacks)
clinical symptoms: delirium, psychosis, confusion, paranoia, hallucinations, & violent outbursts. Act as
stimulants.
Emergencies hypertension, hyperexcitability, & hyperthermia
long-term use does not result in withdrawal symptoms
little tolerance or dependency
risk for suicide, may trigger psychiatric disorders
Cannabis
ranks 4th as most commonly used drug after caffeine, nicotine, & alcohol
active ingredient is THC (creates most of the effects that lead to continued use)
euphoria, grandiosity, distorted sensory perception, lethargy, distortions of time
dilated pupils, high HR, cravings, dry mouth & eyes, impaired ovulation & sperm count
long-term users performed poorly on memory, attention, & info testing
medical use: control nausea & vomiting from chemotherapy; stimulate appetite in c/ts w/ aids
Inhalants
cheap/ readily accessible in home
solvents (paint thinners, gasoline, glue)
gases (spray paints, hair, deodorant sprays)
Nitrites
slight stimulation, decreased inhibition, loss of consciousness sniffing high amounts causes heart failure,
suffocation, death
irreversible effects hearing loss, peripheral neuropathies/limb spasms, CNS damage, bone marrow damage.
Reversible effects liver, kidney impairment, blood oxygen depletion
OTC
Club drugs/designer drugs
MDMA, GHB, Rohypnol, Ketamine, methamphetamine, LSD
potential lethal effects or produce long lasting or permanent brain or other physical damage.
Uncertainties about drug sources, chemicals used, possible contaminants make it difficult if not impossible to
determine the symptoms, toxicity, & consequences of the use of these club drugs.
1.10 assessment
awareness of what the p/t does not say as well as what the p/t says
nurse makes decisions about when to ask, what questions to ask, when to seek more info from those who know p/t.
Under-estimate vs over-estimate
age of first use
patterns of use
binges, blackouts, DTs, seizures
treatment successes or failures
MSE
DAST 28 self-reported items
CAGE 2 out of 4 positive responses potential problem w/ alcoholism
have you ever felt that you out to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or t o get rid of a hangover (an Eyeopener)?
Blood tests useful for determining light or heavy alcohol or drug use quantitative measures. Elevated liver

enzymes & macrocytic anemia, carbohydrate-deficient transferrin (CDT). Urine drug screens within a
specified time frame qualitative.
1.11 plan of care nursing dx, goals & outcome, interventions
nursing dx
address orientation, level of anxiety, limitations in function (mental or physical) as a result of substance use,
social limitations, & dx r/t to altered family relationships.
The at risk for nursing dx relate to withdrawal, trauma, & relapse.
Be aware of difficulties w/ the 4 Ls love, livelihood, liver (health), & legal (problems)
outcome & goals
direct outcomes toward short or long-term changes in behaviors & lifestyles.
Maintain: safety & health, sobriety, his/her vital signs within normal range, normal fluid hydration.
Interventions
nurse focuses on treating & supporting the p/t through the drug withdrawal process detoxification. Focus on
education during stages of recovery.
FYI : cross-tolerance used to prevent withdrawal effects of drugs or alcohol. Ex. Ativan has a crosstolerance w/ alcohol b/c both affect the GABA receptors in the brain. It is used & gradually decreased to
manage withdrawal symptoms.
1.12 pharmacological agents used for withdrawal, detox, & maintenance
benzodiazepines used for alcohol withdrawal, detox & maintenance:
oxazepam (Serax), Lorazepam (ativan) for p/ts w/ severe liver failure
chlordizepoxide (Librium) long-acting for severe withdrawal symptoms
Acamprosate (campral) treats cravings that occur during early sobriety
Naltrexone (ReVia) used in conjunction w/ antidepressants it is an opioid antagonist
disulfiram (Antabuse) deterrent to alcohol use & abuse
thiamine (vitamin B1) for p/t's w/ severe alcohol withdrawal symptoms b/c of inadequate dietary intake
& malabsorption
Opioids
Methadone morphine & heroin addicts long acting used to treat withdrawal symptoms
L- -acetylmethadol (LAAM) longer acting opioid withdrawal
all these are used to suppress withdrawal symptoms.
Naltrexone opioid antagonist blocks opioids from reaching receptors in the brain.
Buprenorphine/naloxone (suboxone) naloxone (opioid antagonist) helps prevent abuse. Buprenorphine
helps w/ withdrawal symptoms & cravings
Buprenorphine (subutex) partial opioid agonist
Nicotine
varenicline (Chantix), bupropion (Zyban or Wellbutrin) reduce cravings
1.13 other treatment modalities
psychotherapy
active involvement in a recovery program in addition to participating in individual or group therapies.
Addresses p/t's addiction as well as any comorbid disorders or life threatining behaviors.
Relapse prevention
help p/ts avoud or take control of situations in which relapse is possible.
Practices what to do if relapse occurs & develops a comphrenisive plan to follow.
Harm reduction
techniques that help a person to change patterns of use to decrease the risk of harm & to adapt to a healthier
life-style.
Opiate replacements, needle-exchange programs
residential, half way house
provide living situations for c/ts who will need to totally reshape their lives, friends, social network, reconnect
w/ family & friends.
Outpatient care
teach the p/t to change & adjust to life w/o drugs while living in a real-life situation.
Community & faith based organizations
after-school programs, mentoring activities, sports
spirituality important to recovery for many individuals

Personality disorders 3.3 EOs

1.1 define key terms
1.2 distinguish what makes personality traits adaptive or maladaptive
Personality traits- behaviors & patterns of perceiving, relating to others, & thinking about the environment &
oneself that are exhibited in a wide range of social & personal contexts.
Adaptive or maladaptive depending on whether the trait is inflexible or cause significant functional impairment or
subjective distress.
When a person demonstrates inflexible & maladaptive methods of problem solving & relating to others that cause
difficulty w/ functioning, this individual can be described as having a personality disorder.
Long story short: if your behaviors & patterns cause problems to your ability to function then that is considered
maladaptive. If they do not not cause problems to your ability to function then they are considered adaptive.
1.3 Examine the DSMIV-TR criteria for the dx of a personality disorders
an enduring pattern of inner experience & behavior that deviates markedly from the expectations of the individuals
culture. This pattern is manifested in 2 (or more) of the following areas:
cognition (i.e., ways of perceiving & interpreting self, other people, & events)
affectivity (i.e., the range, intensity, lability & appropriateness of emotional response)
interpersonal functioning
impulse control
The enduring pattern is inflexible & pervasive across a broad range of personal & social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
The pattern is stable & of long duration, & its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
The enduring pattern is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition (e.g., head trauma).
1.4 discuss theoretical perspectives of the development of personality disorders
Psychoanalytic Mr. Freud
oral stage: met is to try to relate to others w/o excessive dependency or jealously. You build trust, selfreliance. Not met leads one to have lack of trust, become self-centered, dependent, & jealous. Paranoid,
borderline or a histrionic PD.
Anal stage: met Manage uncertainty by making decisions w/o shame or self-doubt. Sense of self-autonomy
& independence. Not met unable to make decisions, withholds friendships or cannot share w/ others, is full
of rage, stubborn, may have sadomasochistic tendencies (desire to hurt others or be hurt by others). Antisocial,
borderline, histrionic, dependent PD.
Phallic stage: met to master ones internal processes & impulses & gain beginning sense of relating to other
people. Not met issues managing internal impulses, relating to others, & sexual identity. Antisocial,
borderline, histrionic, Narcissistic PD. (risk for psychotic disorders).
Latency stage: met inner control over instinctive drives & emotions, learning & industry, exploration of the
environment & play. Not met lack inner control, difficulty relating to others, interactions & problemsolving abilities disturbed. OCD, borderline PD.
Genital stage: met work & learn, establish goals & values within the context of ones own unique personal
identities. Not met compromised sense of self & ones ability to relate to others. Unable to attain identified
goals or to form values. Difficulty identifying ones strengths & weaknesses, likes & dislikes, other skills. All
PDs.
Object relations theory:
studied ability of individuals to relate to each other
observed development of personality structure & relatedness.
Mahler theorized about the relationship of the separation-individuation phase, of development to PDs ( b/t
3-25 months)
Separation- child's developing self, distinct, & separate from the mother.
Individuation- infants attempts to form a distinct identity.
4 stages of separation-individuation:
differentiation (3-8 mo.)- differentiates own image from significant nurturer.
Practicing (8-15 mo.)- explores world on his/her own (walking)
rapprochement (15-22 mo.)- conflict b/t dependence & independence (terrible twos)

object constancy (25 mo.)- ability to maintain a relationship regardless of frustration & changes in the
relationship (can comfort self even w/o mother present-use of representation-blanket).
Kernberg
tasks for ego development- distinguish b/t self & others. Integration of good & bad (self images, objectsother person 's image)
Splitting: inability to synthesize + & - aspects of self & others.
Idealization: idealizes person when needs are met.
Devaluation: devalues person when needs are unmet.
Lack of object constancy: inability to maintain the object (memory of good/bad characteristics) in one's
memory- leads to feelings of abandonment.
Projective identification-primitive type of projection
person projects an impulse on to another person (e.g., anger projected on to mother)
person continues to experience the impulse that they have projected to another (e.g, anger)
person fears the other person b/c they believe they have an impulse (e.g., anger)
person needs to control the other person
Borderline PD exhibit these issues.
1.5 biological factors r/t to the etiology of personality disorders
genetic twin studies- strong biological relationship b/t genetics & personality organization.
Focus on biological similarities b/t schizotypal PD & people w/ schizophrenia (similar symptoms/not as severe)
inability to correctly interpret environmental information- eye tracking behavior & backward maskingsuggests neurointegrative functioning deficits in the frontal lobes-associated w/ deficit traits of schizophreniasocial integrative functioning, isolation, detachment & inability to r/t to others.
Some biomarkers of neurochemical measures are evident w/ schizotypal borderline & antisocial PD
1.6 identify characteristics of p/ts in each of the 3 personality clusters A, B, C & unspecified personality disorders & 1.7

Cluster A
Paranoid, schizoid & Schizotypal make up the odd or eccentric cluster. These diagnosis are more likely to cooccur in an individual w/ a psychotic disorder.
Clinical symptoms:
interpret all experiences from the perspective that they have done damage by others.
Avoid relationships
reluctant to share info, guarded, suspicious, odd, detached
hypervigilant
Paranoid PD
distrustful & suspicious
difficulty adjusting to change
overly sensitive & argumentative
feelings of irreversible injury by others often w/ evidence
anxiety w/ difficulty relaxing
short temper
difficulty w/ problem-solving
unwilling to forgive even minor events
jealousy of significant other, often w/ evidence
Epidemiology: males more often than females; family members diagnosed w/ paranoid PD are at increased
risk; SUD common.
Schizoid PD
brief psychotic episodes in response to stress
lack of desire to socialize, enjoys solitude
lack of strong emotions
detached & self-absorbed affect
lack of trust in others
difficulty expressing anger
passive reactions to crisis
Epidemiology: males slightly more than females; increased prevalence w/ family members who have
schizophrenia or shizotypal PD.

Schizotypal PD
incorrect interpretation of external events/believes all things refer to self
superstitious w/ preoccupation w/ paranormal phenomena
belief in possession of magical control over others
constricted or inappropriate affect
anxiety in social situations
Epidemiology: generally seek treatment for anxiety or depression-not generally for PD;1st degree relatives of
persons w/ schizophrenia at increased risk; males slightly more than females.
Cluster B
Antisocial, borderline, Histrionic, & narcissistic PD constitute the dramatic & emotional cluster. Great deal of
co-morbidity w/ axis 1 disorders: substance abuse, mood & anxiety disorders.
Clinical symptoms
these disorders share dramatic, erratic, or flamboyant behavior
they share a high degree of overlap of symptoms
Co-morbidiy
substance abuse, mood disorders, depression, eating disorders, & anxiety disorders.
Antisocial PD
irresponsible
failure to honor financial obligations, plan ahead or provide children w/ basic needs.
Involvement in illegal activities
lack of guilt
difficulty learning from mistakes
initial charm dissolves in coldness, manipulation, & blaming others
lack of empathy
irritability
abuse of substance
Epidemiology: APD usually diagnosed before 18 yrs, Hx, conduct disorder before 15 years; males
(characteristics in early childhood) more than females (characteristics evident by puberty); Many in SUD
programs or prison; incidence higher among lower socioeconomic populations; impulsive behavior common;
approx. 1% of U.S population 18 yrs or older.
Borderline PD
recurrent suicidal &/or self-mutilating behaviors
poor impulse control & engage in impulsive acts (gambling, binging, spending money, reckless driving, unsafe
sex).
Negative or angry affect
feeling emptiness or boredom
difficulty being alone or feelings of abandonment
difficulty identifying self
perception of people all good or bad
intense & stormy relationship
Epidemiology: condition diagnosed in 1.6% of population 18+ yrs; often hx of physical or sexual abuse,
neglect, hostile or conflictual experiences, & early parental loss or separation; more females than males.
Histrionic PD
use of suicidal gestures & threats when feeling abandoned
fluctuation in emotion
attention-seeking & self-centered attitude
sexual seduction & flamboyance
attentiveness to own physiologic appearance
dramatic & impressionistic speech style
vague logic; a lack of conviction in arguments, often switching sides
shallow emotional expression
craving for immediate satisfaction
complaints of physical illness; somatization
Epidemiology: females more than males
Narcissistic PD

 grandiose view of self

lack of empathy towards others
need for admiration
preoccupation w/ fantasies of success, brilliance, beauty & ideal love
Epidemiology: males more often than females
Cluster C
Avoidant, dependent, & Obessive-Compulsive PD compose the anxious & fearful cluster. These dx are often
associated w/ anxiety disorders.
Clinical symptoms:
experiences high levels of anxiety & outward signs of fear
exhibits social inhibitions like shyness & awkwardness esp. w/ opposite sex
usually afraid to express irritation or anger even when its justified
tend to internalize blame for frustrations in their lives
Avoidant PD
fearful of criticism, disapproval, or rejection
avoidance of social interactions
tendency to withhold thoughts or feelings
negative sense of self-esteem & low self-esteem
Epidemiology: 5.2% of population 18+ yrs in US; males 2x as often as females.
Dependent PD
submissiveness & tendency to cling
inability to make decisions independently
inability to express negative emotions
difficulty following through on tasks
Epidemiology: more females than males; symptoms are demonstrated early in life; children or adolescents w/
chronic physical illness or separation anxiety disorder may be predisposed to this condition.
Obsessive-compulsive PD
preoccupation w/ perfection, organization, structure & control
procrastination
abandonment of projects due to dissatisfaction
excessive devotion to work
difficulty relaxing
rule-conscious behavior
self-critisim & ability to forgive own errors
reluctant to delegate
inability to discard anything
insistence on others conforming to own methods
rejection of praise
reflectance to spend money
background of stiff & formal relationships
preoccupation w/ logic & intellect.
Epidemiology: males 2x females
unspecified PD
individuals whose personality patterns meets the general criteria for a PD but not the criteria for any specific
PD.
Also for individuals whose personality pattern meets the general criteria for a PD; however, the person has a
PD that is not in the current classification, such as passive-aggressive PD.
1.8 examine the prognosis & expectations for improvement for persons w/ dx of a PD
prognosis is guarded as a result of ingrained & prevasive nature of these disorders
relaistic outcomes person will commit to explore & evaluate their thoughts & behaviors, esp. when under stress.
1.9 Discuss the assessment of a p/t w/ a personality disorder
place needs to be comfortable, quiet, private, & safe.
No interruptions during the assessment
do not be judgmental or confrontational during the interview.
There is a physical, emotional, cognitive, social & spirtual domain to the assessment

 Look at nursing assessment box on page 307

1.10 nursing dx
Cluster A (schizoid, schizotypal, paranoid)
anxiety social isolation ineffective coping disturbed thought processes
Cluster B (borderline, histrionic, narcissistic)
risk for suicide risk for self-mutilation risk for self & other directed violence ineffective coping chronic low
self-esteem impaired social interactions disturbed personal identity complicated grieving
Cluster C (Avoidant, dependent, obsessive compulsive PD)
anxiety ineffective coping chronic low self-esteem impaired social interaction
1.11 measurable outcomes
demonstrate absence of active suicide ideation
stop having thoughts of harming others
refrain from self-mutilation
1.12 nursing interventions
Histrionic PD
realize seduction is a response to stress
keep interactions & communications professional
never respond to p/t in a flirtatious or misleading manner
teach assertive behaviors in lieu of seductive ones
Narcissistic PD
always remain neutral despite behaviors
avoid power struggles over control
avoid becoming defensive
show unassuming self confidence when providing care
Obsessive Compulsive PD
do not engage in power struggles, the person's need for control is very high
treatment is geared towards psychotherapy. Supportive or insight orientated therapy, cognitive-behavioral therapy
& group therapy.
1.13 specific modes for treatment
Dialectic Behavioral therapy (DBT)
useful for people w/ borderline PD, eating disorders, & chronically depressed older adults
helps the individual build skills that involve mindfulness, mediation, to reduce emotional dysregulation, & to
increase validating & dialectic strategies (balance change w/ acceptance).
DBT is combined w/ individual & group therapy & telephone support
Goal of treatment increase tolerance, regulate their emotions, & learn to adopt more effective behavioral
responses
first therapy that has been experimentally demonstrated to be generally effective in treating borderline PD.
Uses journaling to recognize emotions; dialogue to rework destructive ways to deal w/ crisis; teaches there are
choices to decrease suicidal thoughts & emotionally reactive patterns; clients learn new patterns of thinking &
behaving.
Milieu therapy
a planned treatment environment in which everyday events & interactions are therapeutically designed for the
purpose of enhancing social skills & building confidence.
Valuable in treating PD & behavioral problems
encourages person to take responsibility for themselves
allows interactions w/ other c/ts & problem solving
1.14 discharge
inpatient dependent on safety & risk factors (e.g., suicidal thinking/behaviors)
P/t's w/ PD often have multiple dx & complex issues follow-up w/ outpatient care & medication (when
appropriate) is important