Nursing psychiatry

1. 1
Co-occurring Alcohol and Other Drug and
Mental Health Conditions in Alcohol and
other Drug Treatment Settings
Session 2:
Classification
of Mental Disorders

2. 2
Comorbidity Guidelines
 Refer to:
 Chapter 5

3. 3
Classification - Key Points
 Disorders represent particular combinations
of signs and symptoms grouped together to
form criteria as per DSM-IV-TR
 Certain number of criteria need to be met
within a certain time frame for a person to be
diagnosed as having a disorder
 Not all AOD workers are able to formally
diagnose the presence or absence of mental
health disorders

4. 4
Classification – Key Points (2)
 Diagnoses of mental health disorders should
only be made by suitably qualified and
trained health professionals
 Useful for all AOD workers to be aware of
characteristics of disorders so are able to
describe and elicit mental health symptoms
when undertaking screening and assessment,
and to inform treatment planning

5. 5
Symptoms without Diagnosis
 Classified as mental health disorder must
meet diagnostic criteria
 However, large number in AOD services who
display symptoms but do not meet criteria
(Eg: anxiety but without an anxiety disorder)
 Can still impact significantly on functioning
and treatment outcomes

6. 6
Categories of MH Disorders in
Comorbidity Guidelines
 Mood disorders
 Anxiety disorders
 Personality disorders
 Psychotic disorders
 Substance-induced disorders

7. 7
Mood Disorders
 Major depressive episodes
 Manic episodes
 Mixed episodes
 Hypomanic episodes.
Manic
episode
Hypomanic
episode
Normal mood
Depressed mood Elevated mood
Major
depressive
episode

8. 8
Major Depressive Episode
Some of following symptoms experienced
nearly every day for at least 2 weeks:
 Depressed mood or loss of interest or
enjoyment in activities
 Reduced interest or pleasure in almost all
activities
 Change in weight or appetite
 Difficulty concentrating or sleeping (i.e.,
sleeping too much or too little)

9. 9
Major Depressive Episode (2)
 Restlessness and agitation
 Slowing down of activity
 Fatigue or reduced energy levels
 Feelings of worthlessness or
excessive/inappropriate guilt
 Recurrent thoughts of death, suicidal
thoughts, attempts or plans

10. 10
Manic Episode
Person experiences abnormally elevated,
expansive, or irritable mood for at least 1
week characterised by:
 Inflated self-esteem
 Decreased need for sleep
 Increased talkativeness or racing thoughts
 Distractibility
 Agitation or increase in goal directed activity (e.g.,
at work or socially)
 Excessive involvement in pleasurable activities that
have a high potential for negative consequences.

11. 11
Hypomanic and Mixed
Episodes
 Hypomanic same as manic episode but is less
severe
 May only last 4 days and does not require the
episode to be severe enough to cause
impairment in social or occupational
functioning
 In mixed episode, person experiences both a
manic episode and major depressive episode
for at least 1 week

12. 12
Anxiety Disorders
 Many people feel anxious because they have
reason to eg: trouble with law, homelessness
 Many in AOD treatment will experience
anxiety as consequence of intoxication,
withdrawal, or living without using AOD
 Usually reduces over time with period of
abstinence
 Problematic when persistent, or so frequent
and intense that prevents person from living
his/her life in the way that he/she would like

13. 13
Panic Attack
 Sweating
 Shaking
 Shortness of breath
 Feeling of choking
 Light headedness
 Heart palpitations, chest
pain or tightness
 Numbness or tingling
sensations
 Chills or hot flushes
 Nausea and/or vomiting
 Fear of losing control,
going crazy or dying
 Feelings of unreality or
being detached from
oneself

14. 14
Types of Anxiety Disorders
 Generalised anxiety disorder (GAD)
 Obsessive compulsive disorder (OCD)
 Panic disorder
 Agoraphobia
 Social phobia
 Specific phobia
 Post traumatic stress disorder (PTSD)
 Acute stress disorder.

15. 15
PTSD
 Can develop after traumatic event
 May experience some of following:
 Intrusions: re-experiencing event as
nightmares, or “flashbacks”
 Avoidance: avoiding thoughts, feelings, people,
places or activities that remind him/her of the
event,
 Hyperarousal: increased startle response,
irritability or anger, difficulty sleeping and
concentrating

16. 16
Personality Disorders
 Enduring destructive patterns of thinking,
feeling, behaving, and relating to other
people across wide range of social and
personal situations
 Maladaptive traits are stable and long lasting
 Tend to develop in adolescence or early
adulthood and are generally lifelong
 Most common in AOD context ASPD and BPD

17. 17
AOD and Personality Disorders
 AOD use disorders may cause fluctuating
symptoms that mimic symptoms of
personality disorders
 Eg: impulsivity, aggressiveness, self-
destructiveness, relationship problems, work
dysfunction, engaging in illegal activity,
dysregulated emotions and behaviour
 Can be difficult to determine whether a
person has a personality disorder

18. 18
Antisocial Personality Disorder
 Failure to conform to social norms with
respect to lawful behaviour
 Disregard for the wishes, rights and feelings
of others
 Deceptive and manipulative in order to gain
personal profit or pleasure; may repeatedly
lie or con others
 Reckless disregard for own or other’s safety

19. 19
Antisocial Personality Disorder (2)
 Impulsive behaviour; decisions made on spur
of the moment, without forethought, and
without consideration of the consequences
for self or others
 May lead to sudden change of jobs,
residences or relationships
 Irritability and aggression; repeated
involvement in physical fights or assaults
 Consistent and extreme irresponsibility

20. 20
Borderline Personality Disorder
 Persistent patterns of instability in
relationships, mood, and self-image
 Marked impulsivity, particularly in relation to
behaviours that are self-damaging
 Extreme efforts to avoid rejection or
abandonment
 Pattern of unstable and intense relationships
 Unstable self-image or sense of self

21. 21
Borderline Personality Disorder (2)
 Impulsivity
 Recurrent suicidal behaviour, threats or self-
mutilating behaviour
 Unstable mood
 Chronic feelings of emptiness
 Inappropriate, intense anger
 Stress-related paranoid thoughts or severe
dissociative symptoms

22. 22
Psychotic Disorders
 Loss of touch with reality
 Feelings, thoughts and perceptions severely
altered
 Delusions and Hallucinations
 May be due to intoxication or withdrawal
from substances
 If the person experiences psychotic episodes
when not intoxicated or withdrawing, possible
they may have one of the disorders described

23. 23
Delusions
 Fixed, false beliefs not consistent with cultural
context
 Involve a misinterpretation of perceptions or
experiences
 Eg: feel that someone is out to get them,
they have special powers, or passages from
newspaper have special meaning for them

24. 24
Hallucinations
Disturbance of sensory perceptions
 Auditory (hearing voices or sounds)
 Visual (seeing things not present)
 Olfactory (smelling things not present)
 Tactile (feeling or sensing something)
 Gustatory (taste)

25. 25
Other Symptoms of Psychosis
 Disorganised speech
 Grossly disorganised behaviour
 Catatonic behaviour (eg decreased reactivity)
 Affect flattening (reduced range of emotional
expressiveness)
 Alogia (restricted thought and speech)
 Avolition (reduced involvement with activities)

26. 26
Schizophrenia
 Most common and disabling of psychotic
disorders
 Affects ability to think, feel and act
 To be diagnosed symptoms must have been
continuing for a period of at least 6 months
 Symptoms are grouped within 2 types:
 Positive symptoms
 Negative symptoms

27. 27
Positive Symptoms of
Schizophrenia
 (Not as in pleasurable!)
 Presence of excess or distortion of normal
functioning and include hallucinations,
delusions, disorganised speech, grossly
disorganised behaviour and catatonia

28. 28
Negative Symptoms of
Schizophrenia
 Absence of normal functioning including
affective flattening, avolition, alogia
 Can cause significant impairment in a
person’s functioning
 Classification of “types” of schizophrenia
depending upon the predominance of
symptoms displayed (paranoid, disorganised,
catatonic, undifferentiated, residual type)

29. 29
Other Psychotic Disorders
 Schizophreniform disorder: equivalent to
schizophrenia except its duration limited to
less than 6 months
 Schizoaffective disorder: symptoms of
schizophrenia alongside major depressive,
manic or mixed episode
 2 types: i) bipolar type (if manic or mixed);
ii) depressive type (if major depressive)

30. 30
Substance-Induced Disorders
 Occur as direct consequence of AOD
intoxication or withdrawal
 Diagnosis requires symptoms only present
following intoxication or withdrawal
 If symptoms in absence of intoxication or
withdrawal, possible they have independent
mental health disorder
 Symptoms tend to reduce over time with
period of abstinence

31. 31
Examples of Substance Induced
Disorders
 Alcohol use/withdrawal - symptoms of
depression or anxiety
 Manic symptoms induced by intoxication with
stimulants, steroids, hallucinogens
 Psychotic symptoms induced by withdrawal
from alcohol, intoxication with amphetamines,
cocaine, cannabis, LSD or PCP
 Other disorders - substance-induced delirium,
amnestic disorder, dementia, sexual
dysfunction, sleep disorder

32. 32
Substance-Induced Psychosis
 Difficult to distinguish substance-induced
psychosis from other psychotic disorders
 Substance-induced psychosis - symptoms
appear quickly and last relatively short time,
from hours to days until the effects of drug
wear off
 Psychosis can persist for days, weeks, months
or longer
 Possible individuals already at risk for
developing psychotic disorder triggered by
substance use

33. 33
Substance-Induced Psychosis (2)
 Visual hallucinations more common in
substance withdrawal and intoxication
 Stimulant intoxication more commonly
associated with tactile hallucinations, person
experiences physical sensation interpret as
having bugs under skin ("ice bugs" or
"cocaine bugs“)
 Tactile hallucinations can occur in alcohol
withdrawal; auditory and visual hallucinations
are more common

34. 34
Substance-Induced Psychosis (3)
 Stimulant psychosis sometimes more
agitated, energetic, more difficult to calm
with sedating or psychiatric medication
compared to non-drug induced psychosis
 Difference with schizophrenia - lack of
negative and cognitive symptoms with return
to normal inter-episode functioning during
periods of abstinence

35. 35
Delirium
 Disturbance of consciousness and cognition
that represents significant change from
previous level of functioning
 Reduced awareness of surroundings, difficulty
concentrating, may be difficult to engage
him/her in conversation
 Changes in cognition include short-term
memory impairment, disorientation (in regards
to time or place), language disturbance (eg
difficulty finding words, naming objects,
writing)

36. 36
In sum…
 Not all clients with symptoms of mental
illness will meet diagnostic criteria
 Diagnostic labels can be very useful but
should not be limiting!
 Diagnosis needs to be undertaken by
trained professionals however important to
be aware of symptoms and to be able to
communicate with other professionals,
clients and families/carers