study notes

1. University of Embu, School of Nursing
Unit: HNS 332: Mental H & Psychiatric Nursing 2
Topic 1 : Substance abuse and related addictive
disorders (continued)

2. Classification of substance-related & addictive disorders
• Alcohol-related disorders
Alcohol abuse disorder
 Alcohol withdrawal disorder
 Alcohol intoxication
 Other alcohol induced disorders such as delirium tremens(DTs), Korsakoff’s psychosis etc.
• Same pattern of classification as alcohol disorders followed with other
substances
• Non-substance related disorders : Gambling disorder

3. Alcoholism
• Prevalence: More men than women but effects on women more than men
• Multifactorial aetiology with familial alcoholism genetically linked
• Terms
 Harmful use: pattern caused actual physical harm
 Dangerous use: pattern increases risk of future harm
 Problem drinking: Pattern caused actual harm but not dependence
• Reading: Read on safe levels of alcohol consumption and calculations in either
pints, mls or units

4. Associated disorders
• Alcohol abuse disorder
• Alcohol withdrawal disorder
• Alcohol intoxication
• Other alcohol induced disorders such as delirium tremens(DTs), Korsakoff’s
psychosis, alcohol withdrawal syndrome, alcohol dementia etc

5. Effects of alcohol
• Remember the metabolism of ethanol involving alcohol dehydrogenase
and acetaldehyde dehydrogenase
• Affects all body systems and dose-dependent, type and duration of
drinking
• Driving: 80-100mg/dl: allowed by most countries but still unsafe

6. Warning signs of developing drinking problem
• Early morning drinking
• Taking extra drinks before parties
• Drinking during the day
• Avoids topic of alcoholism
• Carrying drinks to work
• Experiencing amnestic gaps
• Puffy and red- faced

7. Screening for alcoholism
• Note: Persons with alcohol problem often deny it, and important to increase
objectivity to differentiate it with healthful drinking
• CAGE Questionnaire (4 Questions): Cut, Annoyed, Guilty, and Eye-opener
• AUDIT questionnaire (10 questions): Alcohol Use Disorders Identification Test
Further reading: Components, scoring & interpretation each of the above
questionnaires

8. DSM-5 diagnostic criteria
Check for:
Alcohol abuse disorder
 Alcohol withdrawal disorder/ DTs
 Alcohol intoxication

9. Clinical features
• Depends on the presenting state: Intoxication, withdrawal or voluntarily seeking
help
• Intoxication: Slurred speech, Incoordination, Unsteady gait, Nystagmus, Impairment
in attention or memory, Stupor or coma
• Withdrawal: Autonomic hyperactivity, Increased hand tremor, Insomnia, Nausea or
vomiting, Transient visual, tactile, or auditory hallucinations or illusions,
Psychomotor agitation, Generalized tonic-clonic seizures
• Intoxication or withdraw require active treatment , including life support and dialysis
if need be

10. Biopsychosocial management
• Depends on the presenting state: Intoxication, withdrawal or voluntarily seeking
help. May constitute a psychiatric emergency e.g. DTs
• Intoxication and withdrawal: Focus on physical management such as
Rehydration
 Wait for body to clear alcohol with supportive care
 Provide alcohol for withdrawal
 Benzodiazepines for withdrawal
 Antipsychotics for hallucinations
 50% dextrose
 Vitamins B complex esp. thiamine(B1)

11. Non- emergency treatment
• Collaborative negotiation of treatment plan
• Patient cooperation with treatment team is critical
• Overall plan
Review problem with patient/client
 Arrange withdrawal of alcohol/detoxification
 set attainable goals for treatment and associated difficulties
 Involve partner (if any)
 Plan for long term help and follow up care (rehabilitation program)

12. Detoxification process
• Chlordiapoxide/diazepam with doses reduced gradually over days
• fruit juices and soft drinks
• Antipsychotics e.g. chlorpromazine for hallucinations etc.
• vitamins B complex esp. thiamine and C
• Opioid blocker, Naltrexone reduces craving
• If seizures use phenytoin
• 50% dextrose
• Minor vital signs

13. Other therapies for alcoholism treatment
• Depends on the patient and the etiological factors
• Aversion therapy
• Group therapy e.g. alcohol anonymous-read further
• Family therapy
• Sociotherapy

14. Non-substance related addictive disorders
Gambling disorder (the only DSM-5 classified-for 1st time)
 Online gaming disorder
 Internet addiction (compulsive internet use, excessive use of internet, pathological
internet use, net addiction)

15. Internet addiction Diagnostic Questionnaire
(IADQ)[Young, 1998]
• The person is preoccupied with the internet
• There is a need to spend more and more time on the internet to achieve
satisfaction
• Unsuccessfully attempts to control, reduce, or interrupt the use of the
internet
• Feels anxiety and depression in reducing or stopping the use of the internet
• Remains on the internet much longer than it is intended
• Endangers personal contacts, job, study, career
• Conceals the truth about addiction from family members and helping
professional
• Uses the internet to escape the problem

16. Internet addiction Test(IAT)[Young, 1998]
• Emerged from the questionnaire to measure presence and severity pf internet
addiction
• 20-statements tool using a 0- 5 level Likert scale
• Symptom-based
• Severity criteria: lack of addiction, mild signs of addiction, moderate
addiction and severe addictive behaviour
• Useful for both research and clinical diagnosis since it was developed based
on DSM IV criteria for pathological gambling
• Personal assignment: Apply and interpret the 20 IAT statements to detect if
your internet use is diagnostic of a disorder -results in the next class

17. Other tools for measuring internet addiction
• Chen’s internet addiction scale
• Internet addiction scale

18. Gambling disorder
• Gambling is risking something of value for something of greater value
• Different from professional of social gambling
• Gambling disorder: becomes persistent and recurrent maladaptive gambling
behaviour that disrupts family, personal and occupational pursuits
• onset: usually adolescence or early adulthood
• Gradual development
• Personality predisposition: lonely/depressed, impulsive, energetic, attention
seeking,
• Comorbidities: antisocial personality disorder, manic episode, depression
and anxiety disorders

19. DSM-5 diagnostic criteria
• Persistent and recurrent problematic gambling behavior leading to clinically
significant impairment or distress, as indicated by the individual exhibiting
four (or more) of the following in a 12month period:
• a. Needs to gamble with increasing amounts of money in order to achieve the
desired excitement.
• b. Is restless or irritable when attempting to cut down or stop gambling.
• c. Has made repeated unsuccessful efforts to control, cut back, or stop
gambling.
• d. Is often preoccupied with gambling
• e. Often gambles when feeling distressed

20. • f. After losing money gambling, often returns another day to get even
(“chasing” one’s losses).
• g. Lies to conceal the extent of involvement with gambling.
• h. Has jeopardized or lost a significant relationship, job, or educational or
career opportunity because of gambling. i. Relies on others to provide
money to relieve desperate financial situations caused by gambling.
B. The gambling behavior is not better explained by a manic episode.

21. Further reading
• Tobacco abuse and related disorders esp. smoking
• Psychostimulants
• Internet addiction disorder(IAD), esp. internet gaming disorder