personality_disorder_x_substance_abuse - Personality...

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Unformatted text preview: Personality Disorders Characteristics of each personality disorder Nursing Interventions Issues related to the nursing care ethical & cultural consideration 1 Introduction Lifelong, inflexible, dysfunctional patterns or relating and behaving -> distress to others, not to themselves unless from others' reactions or behaviors toward them. Listed on DSM axis II with others Most commonly treated borderline personality disorder Interventions focus primarily on N-P R Etiology combination of psychosocial & biological variables 2 Criteria for a personality disorder Disturbances in 2 or more of the following Cognition (thinking about self, people, & events) Affectivity (range, intensity, lability, & appropriateness of emotional response) Interpersonal functioning Impulse control 3 Clusters A. Odd or eccentric behaviors Paranoid, schizoid, schizotypal personality disorder B. Dramatic, emotional or erratic behaviors Antisocial, borderline, histrionic, narcissistic personality disorder C. Anxious or fearful behaviors Avoidant, dependent obsessivecompulsive disorder 4 Odd- eccentric cluster of PD Type Paranoid Schizoid Characteristics Suspicious & mistrust Hermitlike lifestyle, aloneness Schizotypal Similar to but less severe than those of schizophrenia 5 Criteria for paranoid personality disorder Suspicious of others Doubt trustworthiness or loyalty of friends & others Fear of confiding in others Suspicious, without justification, of spouse's or sexual partner's fidelity Interpret remarks as demeaning or threatening Hold grudges toward others Become angry & threatening when they perceive they are attacked by others 6 Criteria for schizoid personality disorder Lacks desire for close relationships or friends Chooses solitary activities; a lifelong loner Little interest in sexual experiences Avoids activities Appears cold & detached Lacks close friends Appears indifference to praise or criticism 7 Criteria for schizotypal personality disorder Ideas of reference Magical thinking or odd beliefs Unusual perceptual experience, including bodily illusion Odd thinking & vague, stereotypical, overlaborate speech Suspicious blunted or inappropriate affect Odd or eccentric appearance or behavior Few close relationships Excessive social anxiety 8 Dramatic-erratic cluster of PD Type Antisocial Characteristics Disregard of others' rights without guilt Borderline Problems with self-identity, IPRs, mood shifts, & self-destructiveness. Narcissistic Over-evaluation of self, arrogance, & indifference to the criticism of others Histrionic Dramatic behaviors, attention seeking, & superficiality 9 Criteria for antisocial personality disorder Deceitfulness as seen in lying or conning others Engages in illegal activities Aggressive behavior; violence Lack of guilt or remorse Irresponsible in work & with finances Impulsiveness Reckless disregard of safety for self or others Insensitivity 10 Criteria for borderline personality disorder Frantic avoidance of abandonment; real or imagined Unstable & intense IPR; Identity disturbances Impulsivity; Affective instability Recurrent suicidal behavior or self-mutilating behavior to express feelings of anger/frustration Rapid mood shifts Chronic feelings of emptiness Transient dissociative & paranoid symptoms 11 Criteria for narcissistic personality disorder Grandiose self-importance Fantasies of unlimited power, success, or brilliance Believes he/she is special or unique; Needs to be admired Sense of entitlement (i.e., deserves to be favored or given special treatment) Takes advantage of others for own benefit Lacks empathy Envious of others or others are envious of him/her Arrogant or naughty 12 Criteria for histrionic personality disorder Needs to be center of attention Displays sexually seductive or provocative behaviors Shallow, rapidly shifting emotions Uses physical appearance to draw attention Uses speech to impress others but is lacking in depth Dramatic expression of emotion Easily influenced by others Exaggerates degree of intimacy with others 13 Anxious-fearful cluster of PD Type Dependent Characteristics Submissiveness, helplessness, fear of responsibility, & reliance on others for decision making Timidity, social withdrawal behavior, & hypersensitivity to criticism Indecisiveness, perfectionism, inflexibility, & difficulty expressing feelings 14 Avoidant Obsessivecompulsive Criteria for dependent personality disorder Unable to make daily decisions without much advice & reassurance Needs others to be responsible for important areas of life Seldom disagrees with others because of fear of loss of support or approval Problem with initiating projects or doing things on own because of little self-confidence Performs unpleasant tasks to obtain support from others Anxious or helpless when alone because of fear of being unable to care for self Urgently seeks another relationship for support & care after a close R ends Preoccupied with fear of being alone to care for self 15 Criteria for avoidance personality disorder Avoids occupations involving interpersonal contact because of fears of disapproval or rejection Uninvolved with others unless certain of being liked Fears intimate Rs due to fear of shame or ridicule Preoccupied with being criticized or rejected in social situations Inhibited & feels inadequate in new interpersonal situations Believes self to be socially inept, unappealing, or inferior to others Very reluctant to take risks or engage in new activities due to possibility of being embarrassed 16 Criteria for obsessive-compulsive personality disorder Preoccupied with details, rules, lists, organization Perfectionism that interferes with task completion Too busy working to have friends or leisure activities Over conscientious & inflexible Unable to discard worthless or worn-out objects Others must do things his/her way in work or task related activity Reluctant to spend and hoards money Rigid and stubborn 17 Related Nursing Diagnoses Anxiety High risk for self-mutilation Hopelessness Impaired communication Ineffective individual coping Self-esteem disturbance Social isolation 18 Nursing Care Nurse-Patient relationship trust, empathy, authenticity Focus on specific behaviors, distress to self or others or both & awareness of dysfunctional & self-defeating patterns Case management stress reduction & crisis intervention Assertive training; Social skill training Psychobiological therapy (with caution) Milieu therapy setting limits 19 Conclusion Personality traits -> individualization Disorder = rigid, dysfunctional, distress Distress come from others' reaction to or behaviors toward that person -> evoke interpersonal conflict Usually have more than one DSM diagnosis Long-term hospitalization is unnecessary Limit setting multidisciplinary work Px - have a fairly good prognosis only with therapy 20 Substance-related disorders Personal and societal toll Terminology & criteria for diagnoses Care plan and interventions 21 Introduction Epidemiology - # 1 health problem in the US -> effects on cost, quality of life, society Types - Alcohol, tobacco, other drugs ie opium, heroin, codeine, synthetic narcotics. Cigarettes and alcohol gateway drugs History medical use, social use, illegal use Central nervous system (CNS) was affected Substance dependency Client experiences tolerance and withdrawal symptoms 22 Substance Prescribed medications i.e. Ritalin, OxyContin Over-the-counter cough, cold, sleep, and diet medication Narcotics ie. Heroin, morphine, demerol, methadone Inhalants Hallucinogen ie. Marijuana, LSD, PCP... Stimulants ie. cocaine, amphetamines 23 Other Substance & Trends Club drugs ie MDMA (ecstasy), GHB, Rohypnol, ketamine, methamphetamine, LSD CNS depressants ie. Valium, phenobarbital Steroids 1960 hallucinogens, amphetamines 1970 heroin, marijuana, sedatives 1980 cocaine injection, smoking 24 Terminology Dependence physical & psychological Codependence Tolerance Cross-tolerance Withdrawal abstinence syndrome Dual diagnosis CAGE cutdown, annoy, guilty, eye opener Blackout 25 A continuum of substance use Nonuse Social use Social Recreational Medical Dependence Physical Tolerance Withdrawal Psychological Compulsive use Craving Addiction Loss of control of ingestion Using despite related problems Tendency to relapse 26 Etiology Biological theories genetic predisposition Psychological theories psychoanalytic theories, interpersonal theories Family theories family system theory Learning theories positive effect of mood alternations, media reinforcement, peer pressures Psychosocial and behavioral factors increase the client's vulnerability to drug or alcohol abuse. 27 Age & Substance Use Grade 8th Grade 12th Grade College Substance 1993 1993 2001 Alcohol Cigarettes Marijuana Cocaine 70 % 44 % 10 % 2 % 80 % ->92%(2001) 63 % 37 % 8 % 28 90% Perinatal concerns 25-30% of women expose their children to nicotine in utero 3 out of every 5 women of childbearing age drink alcohol 10% of women of childrearing age use an illicit drug Substances = teratogens -> malformations in the fetus, intrauterine growth retardation, subtle mental and behavioral deficits. 29 Fetal Alcohol Syndrome (FAS) Low birth weight Certain facial characteristics ie. microcephaly, microthalmia, short palpebral fissures, poorly developed philtrum, thin upper lip, short nose, small chin, flattening of the maxillary area Neurological abnormalities ie developmental and/or intellectual delays; it is a preventable cause of mental retardation Fetal Alcohol Effect (FAE)- Less severe cases 30 Other problems of FAS & FAE Other organs heart, hearing, visual, dental, genital anomalies Hyperactivity, poor coordination, short attention spans, dependency, social withdrawal, impulsivity... Co-morbidity Depression, anger, suicidal ideation, antisocial behaviors Preventable health problem for children 31 Adolescent Substance Abuse Health & social problem School drop-out Victim of abuse child/parental, sexual Experienced trouble with law Suicide attempts Feelings of inferiority, history of mental problems 32 Signs of Adolescent Drug Use Sudden behavioral changes Sweating, especially at night Needle marks Inebriation (intoxicated, drunk) Change in nutritional intake Nasal congestion Rhinorrhea with cocaine use School problems 33 Warning Ss of Teen Sub. Abuse Physical Fatigue, health complaints, red/glazed eyes, lasting cough Emotional Personality, mood change, irritability, irresponsible behavior, depression... Family Arguments, breaking rules, withdrawing School Decreased interest, neg. attitude, drop in grades, absences, truancy Social Problems with law, changes to less problems conventional styles in dress and music 34 Prevention of Adolescent substance Use Positive role modeling Reinforce positive behaviors Support cope with social pressure Establish normative expectations Help to anticipate pressures Involve in life skills training programs Open communication 35 Alcohol Abuse Body damage - brain cell -> neurological S/S Liver, G-I, muscle, heart, sexual function ... Blackouts Wernicke's syndrome - intact intellectual function but poor memory, ataxia, confusion, vit B deficiency Korsakoff's syndrome disorientation Alcohol withdrawal syndrome (AWS) Alcohol withdrawal delirium - Delirium tremens (DT) confusion, disorientation, hallucination, tachycardia, tremor, ... 36 Wernicke's encephalopathy Clouding of consciousness with an abrupt onset of confusion and mental status changes along with drowsiness. Ocular motor abnormalities. Ataxia of gait from weakness in limbs or coordination of muscles or poor balance 37 Korsakoff syndrome Difficulty in acquiring new information or learning new skills Lack of insight into their deficit Amnesia Impaired short term memory Tendency for confabulation Apathy Inattention Impaired fine motor skills Impaired sense of smell Talkative an repetitive behaviors 38 Treatment of WKS IV or IM thiamine Medications Cholinersterase inhibitors Atypical antipsychotics SSRI Alcohol cessation Dietary consumption 39 Clinical Description Denial Dependence compulsive use Abuse dysfunction in work, ... Intoxication Withdrawal Delirium Psychotic disorders 40 Alcohol-related Disorders Alcohol intoxication Slurred speech Incoordination Unsteady gait Nystagmus Attention/ memory impairment Stupor or coma Alcohol withdrawal Substance induced delirium Nausea/vomiting Impaired Anxiety consciousness Hallucination Cognitive change Sweating (memory, Psychomotor disorientation, agitation hallucination) Grand mal seizure Short period of Hand tremor time/fluctuates Evidence of sub. abuse 41 Alcohol Detoxification 3Ss- Secure environment Sedation Supplements 42 CNS depressant - Narcotics Opioids endorphin agonist, euphoria Increasing pain threshold, reducing anxiety and fear Decreased pulmonary ventilation/esp. elders Respiratory depression in neonates/preg Withdrawal is rarely fatal, but painful ie yawning, tearing, rhinorrhea, sweating, flushing, tachycardia, tremor, restlessness, irritability, muscle spasm, fever, nausea, diarrhea, vomiting, repetitive sneezing, abdominal cramps, backache 43 CNS depressant - Barbiturates Medical relieve anxiety, produce sleep, anesthesia, epilepsy, soften withdrawal from heroin Narrow therapeutic index Classification- ultrashort (30'-3h), short (34h), intermediate (6-8h), long (10-12h) Intoxication: unsteady gait, slurred speech, sustained nystagmus, confusion, irritability, insomnia Tolerance 44 Stimulant - Cocaine Medical relief for altitude sickness, anesthetics, Block norepinephrine & dopamine reuptake CNS & PNS effects euphoria, alertness, anorexia, sexual stimulation Derivatives: crack, rock Physical dependence is less severe Psychological dependence is intense Highs (+ reinforcement) & lows ( - reinforcement) Cocaine-induced depression, suicide Death caused by meta. & resp. acidosis, and hyperthermia, prolonged seizure, tachyarrhythmias 45 Stimulant - Amphetamine Speed, ice, crank, poor person's cocaine Medical ADD, narcolepsy, obesity CNS effects wakefulness, alertness, heightened concentration, energy, euphoria, insomnia, amnesia, restlessness, agitation, PNS effects- palpitations, tachycardia, hypertension Amphetamine-induced psychosis Facilitate excretion by acidification of urine 46 Hallucinogen Natural & synthetic Heighten awareness of reality or cause a terrifying psychosis-like reaction, distortions in body image, sense of depersonalization, loss of the sense of reality, panic, anxiety, confusion, paranoid reaction Altered perception -> unable to perform simple tasks or lead to violent behaviors 47 Dual Diagnosis Comorbidity 2 or more disorders in the same person Dual diagnosis- 2 initial unrelated disorders that interact and cause increased manifestations of the other disorder Personality disorders higher incidence 47% of antisocial; 2/3 of borderline; 4.5-15% above the norm in Schizophrenia 48 Etiology of Dual Diagnosis Substance use -> calmer, feel better, less anxious, decrease the intensity of hallucinations. Compare with using antipsychotics less uncomfortable side effects Increase social acceptance, feeling of autonomy or power -> self-esteem 49 Tx for Dual Dx Multifaceted & multidisciplinary case management, ind/gr therapy, skill training, vocational counseling, ... N-Pt Relationship knowledgeable, skilled, nonjudgmental, empathic Monitoring S/s of withdrawal Milieu therapy set limits Psychopharmacology - compliance 50 Impaired Professionals Incidence: 5% - chemical abuser 8-10% (or higher) -chemically dependent Common profile Family hx of sub abuse, depression, sexual abuse Academically and professionally successful Divorced Received professional treatment for sub abuse Regularly attends recovery self-help groups Report to supervisor immediately 51 Common Nursing Diagnoses Anxiety Ineffective individual coping/ self-care Altered health maintenance/ nutrition/ sensory- perception/ family process, Risk for injury/infection Impaired communication/ social interaction Violence, potential for 52 Substance Abuse Problems Needing Collaboration 53% of drug abusers have at least 1 serious psychiatric problem 37% of alcohol abusers have at least 1 serious psychiatric problem 53 Pharmacological Treatment Alcoholism Naltrexone (Trexan, ReVia) Disulfiram (Antabuse) Opiod addict Methadone (Dolophine) L-alpha Acetylmethadol (LAAM) Naltrexone (Trexan, ReVia) Clonidine 54 Pharmacological Treatment (II) Stimulant dependence Dopaminergic drugs ie. Amantadine (Symmetrel), bromocriptine (Parlodel) Anticonvulsants ie carbamazepine (Tegretol) TCA ie desipramine (Norpramine) Hallucinogen dependence Diazepam (Valium) 55 Supplementary treatment Sedatives Benzodiazepine ie Librium, Valium Phenobarbital Thiamine (Vit B1) Folic Acid Magnesium sulfate Anticonvulsant Multivitamins 56 N-Pt Relationship Trust - communication Support minimizes anxiety Consistency objective & nonjudgmental Continually assess Presence of predictable defense style Psychophysiological responses Referral local resources/ community agencies 57 Milieu Therapy Drug-free safety, structure, norms, limit setting Motivation Dependency vs. face the consequences 3Cs family members did not cause the disease, cannot control it, cannot cure it Belongingness significant relationship, social skills, 58 Interdisciplinary Interventions Breaking through defenses - denial Understanding and accepting the disorder Identification with peers Development of hope Re-socialization Developing self-esteem and self-worth 59 Persons with HIV Disease Sexual risk-taking behavior 60alcohol, substance use Injectable drug abuse Alcohol immunosuppressive effects & damage to live -> susceptibility to the HIV60 60 60 ...
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This note was uploaded on 09/08/2010 for the course NURS 127A at San Jose State.

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