WEEK 13
PART 1: CARE OF CLIENT W/
SUBSTANCE RELATED DISORDERS
SUBSTANCE USE
− 12 to 17 years have an alcohol use disorder
− alcohol related death is the third leading preventable
cause of death in the United States
− defined as using a drug in a way that is inconsistent
with medical or social norms and despite negative
consequences.
SUBSTANCE ABUSE VS. SUBSTANCE
DEPENDENCE
Substance abuse = using a drug in a way that is
inconsistent with medical or social norms and despite
negative consequences
Substance dependence = problems associated with
addiction such as tolerance, withdrawal, and unsuccessful
attempts to stop using the substance.
Polysubstance abuse
Abuse of more than one substance
Intoxication
use of a substance that results in maladaptive behavior
Withdrawal syndrome
refers to the negative psychological and physical reactions
that occur when use of a substance ceases or dramatically
decreases.
Detoxification
is the process of safely withdrawing from a substance.
ONSET
the early course of alcoholism typically begins much earlier,
with the first episode of intoxication = between ages of 12
and 14 years
Episodes of “sipping” alcohol may occur as early as 8 years
A pattern of more severe difficulties for people with
alcoholism begins to emerge in the mid-20s to mid-30s;
Blackout, which is an episode during which the person
continues to function but has no conscious awareness of his
or her behavior at the time or any later memory of the
behavior
As the person continues to drink, he or she often develops a
tolerance for alcohol; that is, he or she needs more alcohol
to produce the same effect. After continued heavy drinking,
the person experiences a tolerance break, which means
that very small amounts of alcohol intoxicate the person
spontaneous remission or natural recovery, people with
alcohol-related problems can modify or quit drinking on their
own without a treatment program
RELATED DISORDER
Gambling disorder
attempts to quit or cut down result in restless, anxious, and
irritable behavior.
substance-induced anxiety, substance-induced
psychosis
substances can induce symptoms that are similar to other
mental illness diagnoses, such as anxiety, psychosis, or
mood disorders
symptoms = subside once substance is eliminated from the
body
methamphetamine = can cause substance-induced
psychosis, but the psychotic symptoms may persist due to
damage to the brain.
N/C: similar to caring for client w/ delusion & hallucination
RISK FACTORS
❑ Children of alcoholic parents – higher risk for
developing alcoholism & drug dependence (env.
factor)
❑ growing up in an alcoholic home
Alcohol consumption increases in areas where availability
increases and decreases in areas where costs of alcohol are
higher because of increased taxation.
In U.S., they classifies marijuana as a Schedule 1 drug
Urban areas where cocaine and opioids are readily available
also have high crime rates, high unemployment, and
substandard school systems that contribute to high rates of
cocaine and opioid use, and low rates of recovery.
COMMON ABUSED SUBSTANCE
A. CNS DEPRESSANTS
1. ALCOHOL
Alcohol is absorbed rapidly into the bloodstream. the effects
are relaxation and loss of inhibitions.
Intoxication: there is slurred speech, unsteady gait, lack of
coordination, and impaired attention, concentration, memory,
and judgment. Some people become aggressive or display
inappropriate sexual behavior when intoxicated
An overdose: in a short period, can result in vomiting,
unconsciousness, and respiratory depression. This
combination can cause aspiration pneumonia or
pulmonary obstruction.
Alcohol-induced hypotension can lead to cardiovascular
shock and death.
Treatment: gastric lavage or dialysis, support of respiratory
and cardiovascular functioning
Administration of CNS stimulants = contraindicated

WITHDRAWAL & DETOXIFICATION
4 to 12 hours after cessation alcohol intake = Sx of
withdrawal usually begin; coarse hand tremors, sweating,
elevated pulse and blood pressure, insomnia, anxiety, and
N/V.
Severe/ untreated withdrawal = progress to transient
hallucinations, seizures, or delirium (delirium tremens).
Alcohol withdrawal usually peaks on the second day and is
over in about 5 days.
Detoxification (mild) – treated at home
If severe – 3 to 5 days admission
Safe withdrawal administration of; benzodiazepines, such as
lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam
(Valium), to suppress the withdrawal symptoms.
Withdrawal can be accomplished by fixed-schedule dosing
known as tapering, or symptom triggered dosing --
severity of symptoms depends on amount of medication
needed
2. SEDATIVES-HYPNOTICS &
ANXIOLYTICS
Class of drugs: barbiturates, nonbarbiturate hypnotics,
anxiolytics, benzodiazepines
Benzodiazepines (rarely fatal) and barbiturates (lethal) –
most frequently abused drugs
Sx of intoxication, and withdrawal symptoms are similar to
those of alcohol.
Intoxication symptoms: slurred speech, lack of coordination,
unsteady gait, labile mood, impaired attention or memory,
and even stupor and coma.
Treatment: gastric lavage followed by ingestion of activated
charcoal and a saline cathartic; dialysis – if severe sx,
WITHDRAWAL & DETOXIFICATION
Withdrawal syndrome is characterized by symptoms that are
the opposite of the acute effects of the drug—autonomic
hyperactivity (increased PR, BP, RR, and Temp), hand
tremor, insomnia, anxiety, nausea, and psychomotor
agitation.
Detoxification: often medically managed by tapering
(decreasing doses of a medication) the amount of the drug
the client receives over a period of days or weeks,
depending on the drug and the amount the client had been
using.
Tapering = essential with barbiturates to prevent coma and
death that occur if drug is stopped abruptly.
3. OPIOID
A popular drug of abuse; desensitize the user to both
physiological and psychological pain and induce sense of
euphoria and well being.
Opioid compounds include both potent prescription
analgesics such as morphine, meperidine (Demerol),
codeine, hydromorphone, oxycodone, methadone,
oxymorphone, hydrocodone, and propoxyphene as well as
illegal substances such as heroin, illicitly produced fentanyl,
and normethadone.
Fentanyl (Duragesic, Actiq) – synthetic opioid used for
anesthesia. It is 50 to 100 times more potent than morphine.
INTOXICATION
Opioid intoxication develops soon after the initial euphoric
feeling
Symptoms: apathy, lethargy, listlessness, impaired judgment,
psychomotor retardation or agitation, constricted pupils,
drowsiness, slurred speech, and impaired attention and
memory.
Severe intoxication or opioid overdose: can lead to coma,
respiratory depression, pupillary constriction,
unconsciousness, and death. A
Administration of naloxone (Narcan), an opioid antagonist,
is the treatment of choice, it reverses all signs of opioid
toxicity. Given every few hours until opioid level drops to
nontoxic
WITHDRAWAL & DETOXIFICATION
Withdrawal: develops when drug intake ceases or decreases
or can be precipitated by administration of opioid antagonist.
Initial symptoms: anxiety, restlessness, aching back and
legs, and cravings for more opioids.
Symptoms that develop as withdrawal progresses include
N/V, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea,
yawning, fever, and insomnia.
Methadone can be used as a replacement for opioids, and
the dosage is then decreased over 2 weeks. Substitution of
methadone during detoxification reduces symptoms to no
worse than a mild case of flu. Withdrawal symptoms: anxiety,
insomnia, dysphoria, anhedonia, and drug craving may
persist for weeks or months
B. CNS STIMULANTS
▪ CAFFEINE
▪ NICOTINE (MHGAP)
▪ AMPHETAMINE & COCAINE
Stimulants are drugs that stimulate or excite CNS and have
limited clinical use, high potential for abuse.
Amphetamine (uppers) – used by people who wanted to
lose weight quickly or stay awake
Cocaine – no clinical use; highly addictive and popular
because of the intense and immediate feeling of euphoria it
produces.
Methamphetamine – dangerous; highly addictive and
causes psychotic behavior. Brain damage related to its use
is frequent, primarily because of the substances used to
make it—that is, liquid agricultural fertilizer
INTOXICATION
Intoxication from stimulants develops rapidly;
high or euphoric feeling, hyperactivity, hypervigilance,
talkativeness, anxiety, grandiosity, hallucinations, stereotypic
or repetitive behavior, anger, fighting, and impaired
judgment.
Physiological effects: tachycardia, elevated blood pressure,
dilated pupils, perspiration/ chills, nausea, chest pain,
confusion, and cardiac dysrhythmias.
Overdoses can result in: seizures and coma; deaths are
rare.
Treatment: Chlorpromazine (Thorazine), an antipsychotic,
controls hallucinations, lowers blood pressure, and relieves
nausea
WITHDRAWAL & DETOXIFICATION
Withdrawal: occurs within few hours to several days after
cessation of drug and is not life-threatening.
Marked dysphoria – primary symptom and accompanied by
fatigue, vivid and unpleasant dreams, insomnia or
hypersomnia, increased appetite, and psychomotor
retardation or agitation.
Marked withdrawal symptoms “crashing” – person may
experience depressive symptoms, including suicidal
ideation, for several days.
C. HALLUCINOGENS
Substances that distort the user’s perception of reality and
produce symptoms similar to psychosis, including
hallucinations (usually visual) and depersonalization.
Hallucinogens also cause increased pulse, blood pressure,
and temperature; dilated pupils; and hyperreflexia.
Ex. mescaline, psilocybin, lysergic acid diethylamide, and
“designer drugs” – ecstasy. Phencyclidine (PCP) =
anesthetic, acts similarly to hallucinogens
INTOXICATION
Intoxication: maladaptive behavioral or psychological
changes: anxiety, depression, paranoid ideation, ideas of
reference, fear of losing one’s mind, and potentially
dangerous behaviors such as jumping out a window in the
belief that one can fly.
Physiological symptoms: sweating, tachycardia, palpitations,
blurred vision, tremors, and lack of coordination.
Toxic reactions to hallucinogens are primarily psychological;
overdoses as such do not occur. These drugs are not a
direct cause of death, though fatalities have occurred from
related accidents, aggression, and suicide.
Treatment of toxic reactions is supportive. Psychotic
reactions are managed best by isolation from external
stimuli; physical restraints may be necessary for the safety of
the client and others.
WITHDRAWAL & DETOXIFICATION
No withdrawal syndrome has been identified, though some
people have reported a craving for the drug. Hallucinogens
can produce flashbacks. These episodes occur even after all
traces of the hallucinogen are gone and may persist for a
few months up to 5 years.
D. CANNABIS
Cannabis sativa, hemp plant that is widely cultivated for its
fiber used to make rope and cloth and for oil from its seeds.
It has become widely known for its psychoactive resin.
Marijuana refers to the upper leaves, flowering tops, and
stems of the plant; hashish is the dried resinous exudate
from the leaves of the female plant. Cannabis is often
smoked in cigarettes (joints), and it can also be eaten
States may have legalized medical marijuana use,
recreational use, both, or neither. Has short-term effects of
lowering intraocular pressure, but not approved for the
treatment of glaucoma.
Is effective in relieving N/V associated with cancer
chemotherapy and the anorexia and weight loss of AIDS.
Currently, two cannabinoids, dronabinol (Marinol) and
nabilone (Cesamet), have been approved for treating N/V
from cancer chemotherapy. Cannabis-related drugs have
shown promise in the control of seizures in people who do
not experience seizure control from other medications
INTOXICATION & OVERDOSE
Cannabis begins to act less than 1 minute after inhalation.
Peak effects: 20 to 30 min. & last 2 to 3 hours.
Symptoms of intoxication: impaired motor coordination,
inappropriate laughter, impaired judgment and short-term
memory, and distortions of time and perception. Anxiety,
dysphoria, and social withdrawal may occur in some users.
Physiological effects: conjunctival injection (bloodshot eyes),
dry mouth, hypotension, and tachycardia.
Excessive use: may produce delirium or rarely, cannabis-
induced psychotic disorder, both of which are treated
symptomatically. Overdoses of cannabis do not occur
E. INHALANTS
Inhalants are a diverse group of drugs that include
anesthetics, nitrates, and organic solvents that are inhaled
for their effects.
Most common substances: aliphatic and aromatic
hydrocarbons found in gasoline, glue, paint thinner, and
spray paint. Less frequently used halogenated hydrocarbons
include cleaners, correction fluid, spray can propellants, and
other compounds containing esters, ketones, and glycols.
 Most of the vapors are inhaled from a rag soaked with the
compound, from a paper or plastic bag, or directly from the
container.
Inhalants can cause:
▪ brain damage
▪ peripheral nervous system damage
▪ liver disease
INTOXICATION
Intoxication: dizziness, nystagmus, lack of coordination,
slurred speech, unsteady gait, tremor, muscle weakness,
and blurred vision. Stupor and coma can occur.
Significant behavioral symptoms: belligerence, aggression,
apathy, impaired judgment, and inability to function.
Acute toxicity causes anoxia, respiratory depression, vagal
stimulation, and dysrhythmias. Death may occur from
bronchospasm, cardiac arrest, suffocation, or aspiration of
the compound or vomitus
Treatment: supporting respiratory and cardiac functioning.
There are no antidotes or specific medications to treat
inhalant toxicity.
WITHDRAWAL & DETOXIFICATION
There are no withdrawal symptoms or detoxification
procedures for inhalants as such, though frequent users
report psychological cravings.
Abusing inhalants – suffer from persistent dementia or
inhalant-induced disorders, such as psychosis, anxiety, or
mood disorders even if the inhalant abuse ceases.
ASSESSMENT DATA
▪ Denial or minimization of alcohol use or dependence
▪ Blaming others for problems
▪ Reluctance to discuss self or problems
▪ Lack of insight
▪ Failure to accept responsibility for behavior
▪ Viewing self as different from others
▪ Rationalization of problems
▪ Intellectualization
TREATMENT
✓ Detoxification
✓ Alcoholics Anonymous (AA) founded in 1930s by
alcoholics.
self-help group developed 12-step program model for
recovery wc is based on the philosophy that total abstinence
is essential and that alcoholics need the help and support of
others to maintain sobriety.
People who are early in recovery are encouraged to have a
sponsor to help them progress through the 12 steps of AA.
Once sober, a member can be a sponsor for another person.
The 12-step concept of recovery has been used for other
drugs as well. Such groups include:
▪ Narcotics Anonymous
▪ Al-Anon, a support group for spouses, partners, and
friends of alcoholics
▪ and AlaTeen, a group for children of parents with
substance problems.
This same model has been used in self-help groups for
people with gambling problems and eating disorders
PHARMACOLOGIC TREATMENT
two main purposes:
(1) to permit safe withdrawal from alcohol, sedative–
hypnotics, and benzodiazepines and
(2) to prevent relapse.
Vitamin B1 (thiamine) – often prescribed to prevent or to
treat Wernicke Korsakoff syndrome—neurologic conditions
that can result from heavy alcohol use.
for clients whose primary substance is alcohol:
Cyanocobalamin (vitamin B12) and folic acid – for
nutritional deficiencies;
Avoidance of all psychoactive drugs
Dual Diagnosis
client with both substance abuse and another psychiatric
illness. Dual diagnosis clients who have schizophrenia,
schizoaffective disorder, or bipolar disorder present the
greatest challenge to health care professionals. It is
estimated that 50% of people with a substance abuse
disorder also have mental health diagnoses
The use of alcohol and other drugs can precipitate psychotic
behavior; this makes it difficult for professionals to identify
whether symptoms are the result of active mental illness or
substance abuse.
N.I
For Substance Abuse:
✓ Health teaching for the client and family
✓ Dispel myths surrounding substance abuse
✓ Decrease codependent behaviors among family
members
✓ Make appropriate referrals for family members
✓ Promote coping skills
✓ Role-play potentially difficult situations
✓ Focus on the here-and-now with clients
✓ Set realistic goals such as staying sober today
PART 2: CARE FOR CLIENTS W/
PARAPHILIC DISORDERS
Sexual Masochistic Disorder
sexual urge or behaviors involving the act of being
humiliated, beaten, bound, or otherwise made to suffer.
Some individuals act on masochistic urges by themselves,
others with a partner.
Sexual Sadistic Disorder
sexual urges or behaviors involving acts in which the
psychological/physical suffering of victim is sexually arousing
to the person.
Victims may be consenting (those with sexual masochism) or
nonconsenting
Ex. domination (caging the victim or forcing victim to crawl,
beg, plead), restraint, spanking, beating, electrical shock,
rape, cutting, and, in severe cases, torture and death.
Exhibitionist Disorder
exposure of the genitals to a stranger, sometimes involving
masturbation; usually occurs before age 18 and is less
severe after age 40
Fetishistic Disorder
Use of nonliving objects (the fetish) to obtain sexual
excitement and/or achieve orgasm. It begins by adolescence
and tends to be chronic
Common fetishes: women’s underwear, bras, lingerie, shoes,
or other apparel. The person might masturbate while holding
or rubbing the object.
Frotteuristic Disorder
Touching and rubbing against a nonconsenting person,
usually in a crowded place from which the person with
frotteurism can make a quick escape, such as public
transportation, a shopping mall, or a crowded sidewalk.
Individual rubs his genitals against victim’s thighs and
buttocks or fondles breasts or genitalia with hands.
Age 15 to 25 – acts of frottage occur most often
Pedophilic
Sexual activity with a prepubescent child (generally 13 years
or younger) by someone at least 16 y/o and 5 years older
than the child.
Transvestic Disorder
recurrent, intense sexual arousal from cross-dressing
(wearing clothing often associated w/ opposite gender)
Voyeuristic Disorder
act of observing person who is naked or engaging in sexual
activity. During this behavior, it may involve masturbation
It is chronic and usually begins before age 15.
PART 3: CARE OF CLIENT W/ SEXUAL
PROBLEM
MALE SEXUAL DISORDER
Delayed Ejaculation
“Male orgasmic disorder”
delay in, or absence of, orgasm following a normal sexual
excitement phase
Premature Ejaculation
persistent or recurrent onset of orgasm and ejaculation w/
minimal sexual stimulation before, on, or shortly after
penetration and before the person wishes it
Erectile Disorder
Persistent or recurrent inability to attain or maintain, until
completion of the sexual activity, an adequate erection
Male Hypoactive Sexual Disorder
deficiency or absence of sexual fantasies and a lack of
desire for sexual activity
FEMALE SEXUAL DISORDER
Female Orgasmic Disorder
Persistent or recurrent delay in, or absence of, orgasm
following a normal sexual excitement phase
Female Sexual Interest Disorder
have little or no interest in sex and do not respond
subjectively or physically to sexual stimulation.
Genito-pelvic pain/ Penetration Disorder
“dyspareunia”
Genital pain associated with sexual intercourse, making
sexual intercourse painful or impossible
PART 4: CARE OF CLIENT W/ GENDER
DYSPHORIA
Gender Dysphoria
diagnosed when an individual has a strong and persistent
sense of incongruence between experienced or expressed
gender and the gender assigned at birth, usually anatomical
and called natal.
The incongruence is accompanied by the persistent
discomfort of his or her assigned sex or a sense of
inappropriateness in the gender role of that assigned sex.
The person experiences clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
In boys, there is a preoccupation with traditionally feminine
activities, a preference for dressing in girls’ or women’s
clothing, and an expressed desire to be a girl or grow up to
be a woman.

Girls may resist parental attempts to have them wear

dresses or other feminine attire, wear boys’ clothing, have
short hair, ask to be called by a boy’s name, and express the
desire to grow a penis and grow up to be a man.