Personal Interaction

Chemical Dependency
Personality Disorders
PTSD
Trauma Disorders
 Chemical Dependency

• Chemical dependency is the result of a complex

interaction of biologic vulnerability, environmental
factors such as childhood experiences and parental
attitudes, social policies and culture
Overview of Substance Use

Marijuana use has increased since 2007

Most people use drugs for the first time when they are teenagers. 
Drug use is increasing among people in their fifties and early sixties. 
 In 2013, there were 19.8 million current users—about 7.5 percent
of people aged 12 or older
• At least 14 million people in America use illicit drugs
• Drugs are stronger, reformulated
• Self medicating society

www.drugabuse.gov
Cycle of Abuse

Cycle of Abuse

Cycle
of
Abuse
 Etiology

Biological
• Genetic predisposition 40% risk
Psychological
• Risk takers, impulse control difficulties
• Rebellious/critical
• Lack self esteem
• Low frustration tolerance
Sociocultural
• Social pressures
• Culture of drug use in family
• Lack of protective factors
• History of trauma
Brain and Substance Use

Impact of Substance Use & Addictive Behaviors causes:

• Limbic system circuitry changes
• Chronic changes to receptors
• Decreased glucose metabolism
 Terms/Definitions
• Substance Abuse: repeated use/misuse of a substance with adverse consequences
from that use. Patient may spend excess time obtaining drugs, have impairment in social
or occupational functioning or recreational activities, continue substance use despite
negative consequences
• Dependence: continued use of a substance despite severe life problems (divorce, loss
of a job, homelessness) and includes the following symptoms occurring over a 12 month
period
• Tolerance: needing increased amounts of a substance to achieve desired effect and eventually no
longer produces
• Euphoria
• Positive effects
• Substance Withdrawal: uncomfortable physiological and/or cognitive/behavioral
changes that are a result of reducing or stopping the heavy and regular use of a
substance
• Detoxification: The controlled withdrawal from an abusive substance in a medically
prescribed program using gradually tapered sedation, a controlled environment, and
nutritional supplements
 DSM V Criteria
Substance Abuse:
at least one of the following symptoms occurring consistently for 12
months: inability to fulfill their daily roles, recurrent legal or personal
problems, continued substance use despite problems, or hazardous risk
taking.
Substance Dependence/Addiction:
at least one of the following symptoms for over 12 months: presence of
tolerance and withdrawal over ingestion of a substance, decreased ability
to meet and complete responsibilities, unsuccessful at reducing the use
of the substance, increased time spent is spent with the
substance and continued use despite problems
 CNS Depressant
Alcohol

• Alcohol is the most widely misused and abused

substance with 2/3 of adults consuming it regularly
• Third leading cause of death
• Need to assess amount and time of last drink
• Assess for family history
• Legal limit is .08g/dl
A Standard Drink
 Assessment
• Blood Alcohol Level (BAL) / Blood Alcohol Content/Concentration (BAC)
• Family History genetically predisposed to crave alcohol
• Malnutrition
• Verification when possible with family/significant others
• Use of CIWA-AR (Clinical Institute Withdrawal Assessment Alcohol Revised)

CAGE ASSESSMENT
• C Have you ever felt you should cut down on your drinking?
• A Have people annoyed you by criticizing your drinking?
• G Have you ever felt bad or guilty about your drinking?
• E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves
or to get rid of a hangover?
Two positive responses are considered a positive test and indicate further assessment
is warranted
 Assessment:
Which Defense Mechanisms?
• Rationalization –making logical excuses or explanation to
justify behavior

• Projection- attributing to the impulse behavior to someone

else
• Denial- ignoring the existence of the problem
• a way to deal with painful experiences
Blood Alcohol Levels
Alcohol Use

Intended Effect
◦ Relaxation
◦ Decreased social anxiety ◦ Stress reduction
Medical Complications
◦ Toxic to Entire Body
• Gastritis
• Cirrhosis
• Intoxication/Overdose/Poisoning
• Withdrawal/Detoxification
• Wernicke-Korsakoff Syndrome
Hangover: Mild alcohol withdrawal

• Dehydration
• Hypoglycemia
• Buildup of lactic acid and acetaldehyde in blood
• 4-6 hours after drinking
• GI disturbances
• Headache
• Fatigue
• Sweating, thirsty
• Restless, irritable
• May be “shaky
Alcohol Withdrawal Syndrome

Can include Hangover symptoms or any of the following

symptoms
• Alcoholic hallucinosis: auditory hallucinations 12-48
hours
• Generalized seizures 6-36 hours
• Delirium tremens (DTs)

Symptoms may begin in as early as 6-8 hours to 2-3 days

and may go on for up to 5 days
Delirium Tremens (DT’s)

• Medical Emergency
• Within 48-96 hours of last drink
Hallucinations Tactile & Visual
• Tachycardia, fever, diaphoresis
• Delirium
• Convulsions
• Death
• High Mortality Rate
 Alcohol Long Term Complications
Wernicke’s Syndrome (alcoholic encephalopathy) treat with
thiamine large doses, in acute early stage
Korsakoff’s Syndrome Alcohol-induced persisting amnestic
disorder, can be reversed if early treatment with thiamine.
Once established is chronic
Blackouts are a loss of memory of the activity, but it is not a
loss of consciousness
Fetal Alcohol Syndrome symptoms can include: low birth
weight, abnormal facial features, delayed development,
learning problems and/or mental retardation, heart defects,
and hyperactivity/behavioral problems
Risk for Gastritis, Esophageal Varices, Cirrhosis
 Alcohol Withdrawal/ Detox

• Will be on Benzodiazepine taper (Usually Librium)

• Check BP and Pulse to assess for withdrawal symptoms
• Keep patient hydrated
• Magnesium sulfate for seizure prevention
• Vitamins, especially thiamine (B1)
• Dilantin if needed
• May use CIWA-AR to evaluate

• http://ireta.org/sites/ireta.sitesquad.net/files/CIWA-Ar.pdf
Interventions: Pharmacology Alcoholism

Long Term medications

• Naltrexone (Revia) blocks the craving for alcohol, IM
Injection once Every 4 weeks , works With Opioids as Well
• Acamprosate Stimulates GABA receptors, reduces cravings,
restores chemical balance in the brain, help maintain
abstinence from ETOH, reduces insomnia, anxiety,
restlessness and depression
• Disulfiram (Antabuse) used to discourage ETOH use. Causes
n/v, palpitations, flushing when combined with ETOH
Recovery From Alcoholism: Inpatient
Milieu
• Firm, consistent, supportive
• Confront with reality
• Emphasize consequences of continued use
• Tremendous denial
• Countertransference
Discuss relapse and common triggers
• Being dishonest with self or others
• Feeling impatient/sorry/ frustrated with others
• Believing they are the victim
• Believing it’s easy to change behaviors,
• Being complacent
• Setting unrealistic goals
 Co-Dependency

• Co-dependency:
• Enabling
• Family or friend of substance abuser
• Focused on rescuing
• Making excuses
• Reducing consequences
• Up to half of all nurses
• Breaking out of enabling
 Cannabis (Marijuana)
Pot, Weed, Hash THC, Cannabinoids (CBD)
Most used drug, after alcohol and tobacco (in US)
Can eat, smoke, pill form
Used for psychoactive effects

Immediate Effects
•Distorted perception
•Difficulty with problem-solving
•Euphoria, Increased appetite
•Intoxication
• impaired motor control, impaired judgment
•Delirium, cannabis-induced psychotic disorder
•No overdose
Medical Application: (Marinol), Nabilone (Cesamet),
• Produces a Sense of Well Being , increases appetite, decreases nausea

No clinically significant withdrawal syndrome

•Possible symptoms of insomnia, muscle aches, sweating, anxiety, tremors
 Opioids

Heroin, Morphine, synthetic opioids (Oxycontin, Demerol, Codeine, Methadone),

Fentanyl
• Analgesic
• Some produce euphoria
• Sedation
• PO, snort, IV
• IV use increases risk of infection of
• HIV
• Hep C
• Endocarditis
• Abscesses
Intoxication Effects : apathy, lethargy, listlessness, impaired judgment, psychomotor
retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired
attention and memory
Overdose: coma, respiratory depression, pupil constriction, unconsciousness, death

Narcan: IV narcotic antagonist…..antidote

Opioid withdrawal

• Nausea, vomiting, dysphoria, lacrimation, rhinorrhea,

sweating, diarrhea, yawning, fever, and insomnia
• Symptoms cause significant distress, but do not require
pharmacologic intervention to support life or bodily functions
• Short-acting drugs (e.g., heroin): onset in 6 to 24 hours;
peaking in 2 to 3 days and gradually subsiding in 5 to 7 days
• Longer acting drugs (e.g., methadone): onset in 2 to 4 days,
subsiding in 2 weeks
Opioid Treatment

Withdrawal
• Clonidine
• Bentyl
• Buprenorphine (Buprex) synthetic partial opioid agonist, short acting
• Does NOT produce euphoria/sedation caused by illicit opioids, but does
reduce or eliminate withdrawal symptoms
• low risk of overdose.
Maintenance treatment
• Suboxone Buprenorphine & Naloxone
• Naltrexone Blocks the action of opioids
Not addictive, no high, not sedating Poor compliance
• Methadone long acting synthetic opioid agonist
• can prevent withdrawal symptoms and reduce craving
• can also block the effects of illicit opioids.
 CNS Depressants
Includes:
Benzodiazepines: such as Valium, Librium, Rohypnol (“Date rape” drug)
• Barbiturates such as Phenobarbital, Nembutal, Seconal
• Nonbarbiturate hypnotics
• Intensity of symptoms depends on drug ingested
• Intoxication symptoms: slurred speech, lack of coordination, unsteady gait, labile
mood, stupor
• Onset of withdrawal dependent on half-life of drug
• Symptoms opposite of drug’s acute effect
• Barbiturate overdose possibly lethal; coma, respiratory arrest, cardiac failure,
death
• Detoxification via drug tapering

Overdose: Most overdoses are a result of using multiple CNS depressant drugs
 CNS Stimulants
“Speed”, cocaine, methamphetamine
• In low doses, energetic and euphoric, talkative, appetite loss
Intoxication and overdose
• High or euphoric feeling, hyperactivity, hypervigilance, anger;
elevated blood pressure, chest pain, confusion
• Seizures, coma with overdose
Withdrawal
• Onset within hours to several days
• Primary symptom is marked dysphoria.
• “Crashing”
• Not treated pharmacologically
Chronic use: argumentative, delusions, panic, can look manic
 Hallucinogens
LSD, GHB,
• Reality distortion; symptoms similar to psychosis including hallucinations
(usually visual), depersonalization (can have bad trips)
• Cause increased pulse, blood pressure, and temperature; dilated pupils;
and hyperreflexia
• Intoxication: maladaptive behavioral/psychological changes, anxiety,
depression, paranoid ideation
• No overdose; toxic reactions are primarily psychological
• No withdrawal syndrome
• Can cause psychosis
• flashbacks ( may continue up to 5 years)
 PCP Phencyclidine
• Originally animal tranquilizer
• Dissociative anesthetic
• High 5 minutes after take drug; lasts 4-6 hours
Immediate effect: Psychotic, violent, agitated, very strong, hallucinations,
elevated vital signs ataxia, tremors, palpitations, insensitivity to pain
PCP toxicity: seizures, hypertension, hyperthermia, kidney failure, respiratory
depression
• Medications to control seizures and blood pressure
• Cooling devices
• Mechanical ventilation

• Ketamine: very similar, short acting

 Inhalants
• Glue, fuel, paints, aerosols, air fresheners, hand sanitizers, hairspray,
whipped cream propellant, amyl nitrate
• Many children and teens use
• Euphoria, light-headed, hilarity, headache
• Acute toxicity
• Anoxia, respiratory depression, vagal stimulation, dysrhythmias
• Death possible from bronchospasm, cardiac arrest, suffocation, or
aspiration
• No withdrawal or detoxification
• Frequent users report cravings
• Symptomatic treatment of related disorders
 Designer Drugs
• MDMA or Ecstasy, Molly, Special K, bath salts
• Chemically similar to stimulants and hallucinogens
• Take orally or snort
• Onset one hour, lasts up to 6 hours
• Immediate effects: Euphoria, Extreme emotional warmth, Distortions in
time perception and tactile experiences, feelings of closeness
• Chronic use: Depression due to long-term damage to serotonin-
containing neurons in the brain
• can cause a variety of behavioral and cognitive consequences as well as
impair memory
• Withdrawal: Confusion, Depression, Sleep problems, fatigue, severe
anxiety
• High doses impair body’s ability to regulate temperature
 Plan
• Nursing Diagnosis
• Physiological Safety
• Ineffective Health Maintenance
• Short Term Goals
• Maintain vital signs and neurological checks within normal limits within 24 hours of
admission.
• Be safe and free from injury with nursing supervision on admission to the unit.
• Identify 3 problems that are associated with substance use within 24 hours.
• Long Term Goals
• Maintain physiological status at baseline.
• Verbalize knowledge that drug addiction is a disease.
• Verbalize risks related to drug intake and relapse potential within 1 week.
• Describe three ways to manage the problems (finances, unemployment, homeless,)
that are associated with substance use within 2 weeks.
See care plan p. 369 Dual diagnosis
Substance Abuse Treatment
• Detox (may be the beginning of sobriety, or may be for other reasons)
• Inpatient and Outpatient treatment
• May use CBT
• Substance abuse counseling (often hard to get appointments)
• AA, NA or other self-help
• Changing lifestyle, changing friends, challenging denial
• Repeated relapse frequent
• Residential treatment (3 to 6 months or longer)
• Can be expensive
• Limited beds
• Many have dual diagnosis
• estimated 50% of people with a substance abuse disorder also have mental
health diagnoses
Elder Considerations

• Approximately 30% to 60% of elders in treatment began drinking

abusively after age 60.
• Risk factors for late-onset substance include
• chronic illness that causes pain,
• long-term use of prescription medication (sedative –hypnotics, anxiolytics)
• life stress, loss, social isolation, grief,
• depression
• an abundance of discretionary time and money
• Physical problems associated with substance abuse develop rather
quickly.
Nurses and Addiction

• Most common disciplinary action by Board of Nursing

• Opiates most common substance of addiction for healthcare
providers
• Diversion of medications
• 39 states (including Maryland) have Recovery Programs
• MBON assesses and assists the nurse with recovery for 5 yrs.
• All nurses have the duty to report
 Evaluation
• Abstinence is the ultimate end point
• it is extremely difficult to accomplish and maintain and it requires a
major lifestyle change
• abstinence is so difficult the next is to decrease alcohol and other
drug use
• Report instances of alcohol or drug use accurately and continue to
work toward abstinence.
• The patient participates in the outpatient treatment program
and follow-up such as support programs (self help) and
follows the 12 step program.
• The patient uses adaptive coping measures rather than
substances when stressed.
• The patient will be able to work and will have job stability.
• The patient will have improved interpersonal relationships.
Personal Interactions Concept Exemplar:
Personality Disorders
Overview: Personality Disorders
 Are characterized by rigid, enduring patterns of
feeling, thinking,
 Behavior that deviate markedly from the
expectations of the person’s culture.
Patterns of behaviors evident in adolescence, young
adulthood, sometimes childhood
Inflexibility and pervasiveness of behavioral patterns
often cause serious personal, social difficulties, as
well as a general functional impairment
Frequently problems with impulse control
( immature responses)
Altered affect- range, intensity, lability and
appropriateness of emotional responses
 Cluster A
Paranoid Personality Distrustful/ Suspicious
Guarded/ Aloof
Disorder Fear Exploitation
Misread Compliments Think Odd
and
eccentric
Schizoid Personality Detachment
Social isolation
Disorder Restricted Affect
Unresponsive to Praise or
Criticism Shy/Introverted

Schizotypal Discomfort/Distance in
Relationships
Personality Disorder Cognitive/Perceptual
Disturbance.
Eccentric
Odd Beliefs
Magical Thinking
Ideas of reference
 Cluster B
Antisocial Disregard /Violate Rights of Others
Superficial Charm
Personality Impulsive/Irresponsible/
Disorder Manipulative
Think
Exploit/Take advantage of other
Lie/Cheat Dramatic
No Guilt/No Remorse and erratic
Lack Empathy for Others

Histrionic Excessive/Exaggerated Emotion

Dramatic/Flamboyant
Personality Attention Seeking
Disorder Vain/Demanding/Manipulative

Narcissistic Inflated Self Importance

Sense of Entitlement
Personality Lack of empathy
Disorder Fantasies of Power and Brilliance
Need Recognition
Arrogant/Rude/Patronizing
Greek myth of Narcissus- fell in love
with own reflection
• Many successful people are narcissistic.
• Persons with this personality trait are attracted to acting,
modeling, professional sports, politics, & broadcasting.
Historical example is Hitler.
• Have fragile self esteems, driving them to constantly seek
appreciation and admiration, egocentric attitude, envy, rage
with others do not support them.
 Exemplar Cluster B:
Borderline Personality Disorder
• Often raised in chaotic environment, sometimes abused
• Extremely labile mood and affect
• Relationships are intense and unstable
• Chronic feeling of emptiness and boredom
• Self Image and identity disturbance
• Manipulate and Split, seeing things as “black or white”
• Impulsive/Unpredictable
• NEEDY! With an intense fear of abandonment
• Suicidal Behaviors/ Self Mutilation

• http://www.youtube.com/watch?v=eOphgCJX1FY
Borderline Personality: Interventions
• Milieu management
• All treatment team members must meet often to prevent
splitting and manipulation
• Same approach by all staff (unified approach)
• Behavioral contracts for self-destructive behaviors
• Consistency, keeping promises
• Teaching about interactions with others
• DBT/CBT
• make referrals for substance abuse treatment (very
common co-occurring disorder)
• Medications for anxiety, PTSD, emotional instability
 Cluster C
Avoidant Personality Social inhibition
Feelings of Inadequacy
Disorder Hypersensitivity to Negative
remarks Think
Shy anxious
Fear rejection
Reluctant to Take Risks and
fearful
Dependent Personality Submissive clingy
Need to be Taken Care of
Disorder Generally have a Caretaker
Anxious/Helpless
Needy

Obsessive-Compulsive Preoccupation with

Orderliness Perfectionism,
Personality Disorder control
Preoccupation with rules
Psychopharmacology: All personality D/O

Usually just for symptoms

Do not change personality, change behavior
Medications with caution
Avoid benzodiazepines long term
Trauma Related Disorders
PTSD
Dissociative Identity
Disorder (DID)
Post Traumatic Stress Disorder (PTSD)

• PTSD can occur at any age, including childhood.

• Women are more likely to develop PTSD than men
• There is some evidence that susceptibility to the disorder may run in
families
• PTSD is often accompanied by depression, substance abuse, or one
or more of the other anxiety disorders.
• The criteria for Post Traumatic Stress Disorder (PTSD) are:
• The person has been exposed to a traumatic event in which both of the
following were present: 
• the person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, to self or others 
• the person's response included intense fear, helplessness, or horror
PTSD

Event Re-Experienced in the following ways:

• Flashbacks: recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions.
can occur when awake, intoxicated, or when just waking up.
• Nightmares
• Intense distress and physical symptoms of panic-level anxiety at exposure to
internal or external cues that resemble part of the traumatic event
Leads to
• Avoidance
• Negative cognition/thoughts
• Being on guard/hyperarousal
See Box 13.2 for PTSD checklist
Dissociative Disorders (DID)
• Dissociation is a way for the mind to separate certain memories or
thoughts from conscious awareness.
• Dissociation in Dissociative Disorders is a way of coping by removing
oneself from traumatic and anxiety-producing situations
• Inability to recall information about past, particularly around traumatic events
• Split-off mental contents are not erased and may surface later.
• Dissociation involves an interruption of a person's fundamental aspects
of waking consciousness (such as one's personal identity or memory).
• Usually associated with a traumatic event
•  More prevalent among those with histories of childhood physical
and sexual abuse
• Rare disorder also known as multiple personality
Plan

• Post-Trauma Syndrome Powerlessness

• Related to a traumatic event such as combat, natural disaster
as evidenced by verbalizations of the attack, detachment,
avoidance, outbursts of anger,…
• Short term Goal
• Express feelings such as helplessness, fear, anger, guilt, shame, and
talk with staff about these feelings for at least 30 minutes at least
twice per day within 24 hours.
• Demonstrate a decrease in stress-related symptoms within 24 hours
via a 1-10 point scale.
• Long Term Goals
• Verbalize plans for continued individual/group therapy.
 Interventions for PTSD and Dissociation

• Spend time with patient and allow patient to go at own

speed
• Do Not Push Patient to remember a traumatic event they are
not ready to deal with psychologically
• Monitor your own response and remain non-judgmental
• Listen attentively/refrain from interrupting or minimizing
• Encourage expression of feelings via talking, writing, role
playing…
• Teach cognitive, behavioral, stress reduction, coping and
problem solving principles and techniques
 Intervention: Grounding Technique

• Helpful with dissociation or flashback.

• Remind the person that he or she is present, is an adult, and is safe.
• Increase contact with reality.
• Diminish the dissociative experience by focusing on current experiences.
• Focus the client in the present.
Evaluation

• The patient will maintain safety.

• The patient uses support systems outside the hospital, such as, support
groups or significant others.
• The patient participates in the necessary outpatient treatments.