Anxiety and Substance Abuse

Anxiety

• adaptability
• support
• coping mechanisms
• genetics
• presence of neurotransmitters

mild anxiety

moderate anxiety

ie taking an exam

sever anxiety

ie witnessed a car accident

Panic anxiety

ie devastating earthquake

when a person has excessive worrying about every day things.  This occurs more days than not for at least 6 months.

• interference with ability to function-
• difficulty concentrating
• irritability
• muscle tension
• cant complete tasks

• cognitive therapy (explore feelings/thoughts and learning new ways to respond to stimuli)
• teach relaxation techniques
• teach thought stopping
• help patient to discuss irrational fears

presence of recurrent, unexpected panic attacks.  After the first attack the person will have a persistent concern about having another panic attack (anticipatory fear)

characterized-disorganized thinking, feelings of terror, helplessness and non purposeful behavior

physical-dizzy, derealization, nausea, chest pains, SOB, hyperventilation

• stay with patient
• talk in a calm quiet voice
• ask if have any distractors that relieve their physical symptoms

an exaggerated behavioral response to an old fear that no longer is an adaptive coping mechanism.

avoidance...it is used to take the threat away, but it makes the anxiety worse cuz the patient eventually becomes for dependent on others.

• help the client learn to function in the presence of the phobic object without experiencing panic anxiety
• assist the client to overcome fear of leaving their home
• teach relaxation techniques

unwanted repetitive and intrusive thoughts, impulses or images that interfere with ADL's and cause distress.

Theme-contamination/dirt, violence/safety, blasphemous thoughts and thoughts about one's own performance

recurrent, irrational and infinitely repetitive behaviors USED TO DECREASE ANXIETY.

Behaviors include: hand washing, cleaning, checking, counting, repeating words, hoarding objects

when a person has a fear that's pushed out of their consciousness...anxiety occurs which causes compulsive thinking.  The person gets a feeling of inadequacy.  Those feelings are displaced on to an object or item and it creates a symbolic event.  This symbolic event (compulsion) is used as an attempt at being able to control something which will in turn bring down their anxiety level.

• Id the underlying emotion behind the compulsion
• help the pt recognize whats going on prior to the compulsion (triggers)
• Later in therapy....relaxation techniques, reinforce positive behaviors and alter diet to not include caffeine/alcohol

follows exposure to extreme trauma.  Emotional response to the event involves intense fear, helplessness or horror.

• type of traumatic experience
• age of traumatic experience (older has more coping skills)
• recovery environment (with family or away)

• R-reliving the event through nightmares or repetitive thoughts
• A-autonomic Arousal (fight or flight)
• N-numbing (person is emotionless)

• obtain accurate history from significant others about the traums
• stay with pt during flashbacks/nightmares
• let pt talk about trauma at their own pace
• assist pt to try and comprehend trauma
• discuss feelings of vulnerability and their "place" in the world

Benzodiazepines-has the most immediate action

• Klonopin
• Ativan
• Xanax

• best for short term use
• high abuse potential
• withdrawals will occur if don't maintain steady state
• don't drink alcohol-additive effect

Buspar

• Positive-no risk for physical dependence
• Negative-takes 2 weeks to start working

• SSRI
• Tricyclic

SSRI's

Imipramine (Tricyclic Anti Depressant)

Clomipramine (Tricyclic Anti Depressant)

Beta Blockers....decreases palpitations and heart rate

Vistaril-antihistamine

• consider their anxiety level prior to trying to teach
• teach anxiety reduction techniques
• safety, safety, safety
• assist pt with problem solving
• encourage proper diet and rest/sleep

• 15 min
• 40-70 min

• peripheral neuropathy
• myopathy
• Wernickes encephalopathy
• korsakoffs psychosis
• cardiomyopathy
• leukopenia
• thrombocytopenia

• serious form of THIAMIN deficiency
• paralysis of ocular muscle
• diplopia
• ataxia
• somnolence stupor

• seen with chronic alcohol use
• syndrome of confusion
• loss of recent memory
• confabulation

Permanent

• N/V
• shallow respirations
• cold, clammy skin
• weak, rapid pulse
• coma
• death

• seizures
• hallucinations
• irritability
• anxiety
• insomnia
• tremors
• sweating
• tachy

• 6-8 hrs
• 6-96 hrs
• 6-96 hrs

• confusion
• disorientation
• hallucinations
• tachy
• extreme tremors
• agitation
• diaphoresis
• fever

usually 2-3 days after last drink, but can be as long as 14 days after

last about 5 days

visual and tactile

• Vitamin and Mineral replacement
• meds to prevent hyper excitability and seizures
• protect from injury
• monitor fluids

• Valium
• Ativan
• Librium

Thiamin

Helps to detox a person from alcohol

• will cause person to have bad N/V if drink while on this medication
• teach pt to stay away from all alcohol, including:
• mouthwash, aftershave and perfume

14 days

• SOB
• throbbing head
• low BP
• seizures
• death

opiate and alcohol dependency

It is an abstinence promoter and relapse reducer (for alcohol) by blocking euphoric response to substance

Campral

• Asking the patient....
• Cut down-Have you ever felt you should cut down?
• Annoyed-Do you feel annoyed when people talk to you about drinking?
• Guilt-Have you ever felt guilty about your drinking?
• Eye Opener-Have you ever needed an eye opener?

• N/V
• Tremor
• Sweating
• Anxiety/Agitation
• Tactile/Auditory/Visual disturbances
• headache
• clouding of sensorium

CNS depressants-include barbituates, non barbiturate hypnotics and anti anxiety agents

Rohypnol/Roofies/Flunitrazepam/GHB

depress CNS (brain, nerves, muscles and heart)

level of depression depends on dose and potency(mild to death)

long acting barbituates or phenobarbital

• heroin
• morphine
• codeine
• dilaudid
• demerol
• vicodin
• oxycodone

• euphoria/mood change/mental cloud
• papillary constriction
• respiratory depression
• antitussive-suppresses cough center
• N/V
• constipation
• hypotension

Narcan

• shallow breathing
• shallow pulse
• clammy skin
• pulmonary edema
• respiratory distress
• convulsions/coma/death

• terrible craving
• chills/sweats
• goose bumps
• abdominal pain/cramps/diarrhea
• runny nose
• irritability
• tearfulness

• phenobarbital
• muscle relaxants
• anti diarrheal agents
• additional benzos
• clonidine

it suppresses the opiate withdrawal symptom and is non addicting when used with Methadone

• Buprenorphine
• methadone

must do in an office and it is less powerful than methadone and safer with fewer side effects.

addiction certificate

prevents withdrawal from opiates by filling opiate receptor sites.

Must decrease the dose

• feelings are shut down
• needs/wants go unmet
• secrets

Denial is prevalent, walking on eggshells

partner stays in a relationship with substance abuser and becomes the care taker.  All effort goes in to taking care of the other, thus they fail to fully take care of themselves

consciously or unconsciously facilitating the behavior of the substance abuser.  It perpetuates the problem and and facilitates denial

• oldest
• shift of parent/child relationship by child taking on parents role

transitioning in to an adult role

the person the family blames for all of their problems

• they get in to trouble at school
• family goes in to counseling and they find out about the alcoholic because the scapegoat got in to trouble

they fly under the radar and do anything not to get hurt

jokster....learn to break the tension in the family

the use of various medications to decrease the intensity of symptoms in an individual who is withdrawing.

a memory disturbance characterized by information that appears to be made up rather than true....fill in the gaps with lies

recurrent use of a substance resulting in failure to fulfill major role obligations at work, school and home

• evidence of tolerance
• evidence of withdrawal symptoms
• substance is taken in larger amts or longer than intended
• pt spends lots of time trying to obtain substance
• important social/occupation are given up cuz of substance
• substance is used even though problems are occurring

use of alcohol to relieve every day stress and tension in life

• begins with blackouts
• alcohol is no longer a source of pleasure or relief

person starts to sneak drinks and feels guilty when drinks and becomes defense when talked to about drinking habits

binge drinking-lasts hours to weeks

loss of job, marriage, family, friends and self respect

loss of control and physiologic dependence

• helplessness and self pity
• person is now intoxicated more than sober
• life threatening physical manifestations in all body systems
• if abstain from alcohol-hallucinate, tremors, convusions, panic, and agitation

minimum of 12 hrs.

compulsive or chronic requirement for a substance....if don't have it will experience physiological or psychological distress

Euro Americans

alcohol

alcohol

Pot and coke

Asian Americans

Native Americans

• alcohol-leading cause of preventable birth defects
• cigarettes-low birth weight and resp. problems
• marijuana-low birth weight and small heads

• facial deformities
• hearing loss
• visual problems
• growth retardation
• cognitive problems/learning disabilities
• heart and kidney defects

• suppression is voluntary
• repression is involuntary

• mentally ill in need of treatment
• emergency commitment (behavior clearly trouble to self or others)
• involuntary outpatient (court ordered)
• gravely disabled client (cant basic necessities for self)

• Dr. must be notified within 1hr of restraing
• then.....order must be reviewed by  Dr. within 4 hrs.
• In person re-evaluation at 8 hrs.

If pt no longer in restraints when verbal order expires, Dr. must reevaluate within 24 hrs.

false imprisonment

judicial review-go before judge and state why shouldn't be kept in a 5250

a person may request 1 per hold, they can choose to do this instead of probable cause hearing

somatic delusion

nihilistic delusion

patients thoughts have control over things or people

literal interpretation and lack of abstract thinking

repetitive or ritualistic movement or utterance

rocking

inventing new words

rhyming all of the time

a group of words put together randomly

Zofran

give 2mg or lorazepam and thiamine

below 8...nothing

decreased time in REM...but when in withdrawal, their dreaming becomes vivid and excessive

• alcohol
• sedative-hypnotics
• anxiolytics

10-14 days after abstinence....must wean off slowly

an anticonvulsant

Buprenorphine is done in an office and Methadone can be taken at home or wherever

Flumazenil

tweeking eye when drunk

anxiety about being in places or situations from which escape would be difficult or embarrassing or in which help might no be available in the event of a panic attack

agoraphobia....avoidance

a vital response to physical and emotional danger...intellectual and cognitive response

conscious attempts to protect oneself from the emotional pain of anxiety....may be ineffective or effective

unconscious attempts to manage anxiety also may be adaptive or maladaptive

• women have it more often
• minority and poor children are at risk

• need to be reduced to protect kidney and liver functioning
• they cause cognitive impairment in them

• stay with pt
• reassure safety
• maintain calm nonthreatening matter of fact approach
• simple words
• consider level of anxiety when doing pt teaching
• anxiety reduction techniques
• help with problem solving
• encourage nutrition, sleep and rest

a sense of unreality or self estrangement

seeing oneself from a distance, like in a dream

perception that the environment has changed....things seem unreal, smaller, fuzzy or out of focus. 

Familiar objects become strange