Psychiatric Disorders

INTRODUCTION

In recent years, social, economic, and professional developments have dramatically changed the mental health field. For instance, community and professional organizations have established family advocacy programs, substance abuse rehabilitation programs, stress management workshops, bereavement groups, victim assistance programs, and violence shelters. The public education system has established widespread information programs about mental health issues. Mental illness isn’t as much of a stigma as it once was. Self-help and coping books have proliferated, and media attention to mental and emotional disorders has increased. Finally, more effective drugs are available to treat many of these illnesses.

Social changes

Today, more people than ever experience mental health problems. Some researchers blame social changes, which have altered the traditional family structure and contributed to the loss of the extended family. The result: more single parents, dysfunctional families, troubled children, and homeless people.

The loss of effective support systems strains a person’s ability to cope with even minor problems. For example, a working mother may lack the needed support to meet the demands of her job, her home, her spouse, and her children. When she views herself as ineffective in these roles, her self-esteem falters and her level of stress intensifies.

Alcohol and substance abuse are also increasing, particularly among younger people. Up to 7% of adolescents are dependent on alcohol, and 15% to 20% of American teens have experienced a serious episode of depression. Isolation, fear of violent crime, and loneliness have contributed to a similar rise in depression among elderly people. Victims of violence, abuse, and social discord struggle to cope with the trauma they have experienced.

Economic forces

Cuts in Federal funding of mental health programs place future control of mental health services in the hands of state and local authorities, drastically reducing the funds available for training and care. One result of decreased funding is increased collaboration between community psychiatric facilities (short-term inpatient, outpatient, and auxiliary services) and long-term inpatient state facilities. Another result is decreased availability of long-term care and reduced length of stay for acute patient care.

Professional changes

Mental health professionals have experienced enormous changes in perspective, focus, and direction, which are reflected in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). With this system of classifying mental disorders, clinicians must consider many aspects of a patient’s behavior, mental performance, and history, emphasizing observable data rather than subjective and theoretical impressions.

DSM-IV-TR defines a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that’s associated with current distress (a painful symptom), disability (impairment in one or more important areas of functioning), or a significantly greater risk of suffering, death, pain, disability, or an important loss of freedom. This syndrome or pattern must not be merely an expected response such as grief over the death of a loved one. Whatever its original cause, it must currently be considered a sign of a behavioral, psychological, or biological dysfunction.

To add diagnostic detail, DSM-IV-TR uses a multiaxial approach. It specifies that every patient be evaluated on each of these five axes:

Axis I—clinical disorder, the diagnosis (or diagnoses) that best describes the presenting complaint
Axis II—personality disorders and mental retardation
Axis III—general medical conditions, a description of any concurrent medical conditions or disorders
Axis IV—psychosocial and environmental problems
Axis V—global assessment of functioning (GAF), based on a scale of 1 to 100. The GAF scale allows evaluation of the patient’s overall psychological, social, and occupational functioning.

The first three axes, which constitute the official diagnostic assessment, encompass the entire spectrum of mental and physical disorders. This system may require multiple diagnoses. For example, on axis I, a patient may have a psychoactive substance abuse disorder and a mood disorder. He may even have multiple diagnoses within the same class, as in major depression
superimposed on cyclothymic disorder. A patient also may have a disorder on axes I, II, and III simultaneously.

Axis IV documents the effect of psychosocial and environmental stressors on the patient. Examples of such stressors include marital, familial, interpersonal, occupational, domestic, financial, legal, developmental, and medical concerns as well as environmental factors and natural disasters.

Axis V measures how well the patient has functioned over the past year and includes his current level of functioning.

A patient’s diagnosis after being evaluated on these five axes may look like this:

Axis I—adjustment disorder with anxious mood
Axis II—obsessive-compulsive personality Axis III—Crohn’s disease, acute bleeding episode
Axis IV—recent remarriage, death of father
Axis V— GAF = 65 (current)

Related professional forces

An increased emphasis on holistic care has brought a closer relationship between psychiatry and the rest of medicine. More hospitalized patients benefit from psychiatric consultations, reflecting a growing recognition of the emotional basis of physical disorders. Advances in neurobiology have increased our understanding of the physiologic basis of mental function. This has resulted in better diagnosis and treatment of mental disorders. Complementary and alternative therapies such as acupuncture, massage, and aromatherapy are also being integrated into treatment.

BIOPSYCHOSOCIAL ASSESSMENT

The biopsychosocial model of health and illness assessment stresses an integrated approach to human behavior or disease. The biological system refers to evaluating an illness’ anatomy, structure, and function at a chemical or molecular level. Psychosocial refers to looking at the psychodynamic factors such as motivation, personality, social issues, and reaction to illness. This model of assessment examines how cultural influences and the environment interact to affect the development of disease. Some clinicians believe this model promotes a more comprehensive understanding of illness and treatment.

Psychosocial assessment

You’ll encounter patients with mental and emotional problems in all clinical areas and settings. Begin your care of these patients with a psychosocial assessment.

For this assessment to be effective, you need to establish a therapeutic relationship with the patient that’s based on trust. You must communicate to him that his thoughts and behaviors are important. Effective communication involves sending and receiving clear messages. (See Communication barriers, page 1108.) Words count, as does nonverbal communication—such as eye contact, posture, facial expressions, gestures, clothing, affect, and even silence. All can convey a powerful message.

Choose a quiet, private setting for the assessment interview. Interruptions and distractions threaten confidentiality and interfere with effective listening. If you’re meeting the patient for the first time, introduce yourself and explain the interview’s purpose. Sit at a comfortable distance from the patient, and give him your undivided attention.

During the interview, adopt a professional but friendly attitude, and maintain eye contact to the level that the patient can tolerate. A calm, nonthreatening tone of voice will encourage the patient to talk more openly. Avoid value judgments. Don’t rush through the interview; building a trusting therapeutic relationship takes time.

Patient history

A patient history establishes a baseline and gives clues to the underlying or precipitating causes of the current problem. The patient may not be a reliable source of information, particularly if he has a significant mental illness that affects his functioning. If possible, verify his responses with family members, friends, or health care personnel. Also check facility records from previous admissions, if possible, and compare his past behavior, symptoms, and circumstances with the current situation.

Explore the reason for the evaluation, current symptoms, psychiatric history, demographic data, socioeconomic data, cultural and religious beliefs, medication history, and physical illnesses. Identify the patient’s strengths as well as problems.

Reason for evaluation. The patient may not voice his chief complaint directly. Instead, you or others may note that he’s having difficulty coping or is exhibiting unusual behavior. If this occurs, determine whether the patient is aware of the problem. When documenting the patient’s response, write it verbatim and enclose it in quotation marks.

Communication barriers

Ineffective communication can prevent a successful interview.

Language difficulties or differences

If the patient speaks English, try to use language that’s appropriate to his educational level and culture. Avoid medical terms that he may not understand.

If the patient speaks a foreign language or an unfamiliar dialect, try to have an interpreter on hand. The presence of a third person, though, may make the patient less willing to share his feelings.

Be aware of words that can have more than one meaning. For instance, the word bad also can be used as slang to mean “good.”

Inappropriate responses

Your responses to the patient can inadvertently suggest disinterest, anxiety, or annoyance, or they can imply value judgments. Examples include abruptly changing the subject or discounting the patient’s feelings.

Hearing loss

If the patient can’t hear you clearly, he may misinterpret your responses. If you’re interviewing a patient with impaired hearing, check whether he’s wearing a hearing aid. If so, is it turned on? If not, can he read lips? If possible, face him and speak clearly and slowly, using common words and keeping your questions short, simple, and direct.

If the patient is elderly, use a low tone of voice. With aging, the ability to hear highpitched tones deteriorates first. If his hearing impairment is severe, he may have to communicate by writing, or you may need to collect information from his family or friends.

Thought disorders

If the patient’s thought patterns are incoherent or irrelevant, he may be unable to interpret messages correctly, focus on the interview, or provide appropriate responses.

When assessing such a patient, ask simple questions about concrete topics and clarify his responses. Encourage him to express himself clearly.

Paranoid thinking

Deal with a paranoid patient in a nonthreatening way. Avoid touching him because he may misinterpret your touch as an attempt to harm him. Restrict hand motions and maintain physical distance. Accept the patient’s statements of paranoid thoughts in a nonjudgmental manner.

Hallucinations

A hallucinating patient experiences imaginary sensory perceptions with no basis in reality. These distortions prevent him from hearing and responding appropriately.

Show concern if the patient is hallucinating, but don’t reinforce his perceptions. Be as specific as possible when you give him commands. For instance, if he says he’s hearing voices, tell him to stop listening to the voices and to listen to you instead.

Delusions

A deluded patient defends irrational beliefs or ideas despite factual evidence to the contrary. Some delusions may be so bizarre that you’ll immediately recognize them; others may be difficult to identify.

Don’t condemn or agree with a patient’s delusional beliefs and don’t dismiss a statement because you think it’s delusional. Instead, gently emphasize reality without being argumentative.

Delirium

A delirious patient experiences a disturbance in awareness and cognition that develops rapidly. Misinterpretation and inappropriate responses commonly result. Talk directly to such a patient and ask simple questions. Offer frequent reassurance. Provide protection and appropriate physical care for the underlying cause of the delirium.

Dementia

The patient who suffers dementia—an irreversible deterioration of mental capacity— may experience changes in memory and thought patterns, and his language may become distorted or slurred.

When interviewing such a patient, use simple, concise language and minimize distractions. Don’t make statements that he may easily misinterpret. Maintain calm and establish a routine.

Current symptoms. Find out about the onset of symptoms, their severity and persistence, and whether they occurred abruptly or insidiously. Compare the patient’s condition with his normal level of functioning.
Psychiatric history. Discuss past psychiatric disturbances, such as episodes of delusions, violence, depression, attempted suicides, drug or alcohol abuse, previous psychiatric treatment, and the patient’s adherence to past recommended treatments.
Demographic data. Determine the patient’s age, sex, ethnic origin, primary language, birthplace, religion, and marital status. Use this information to establish a baseline and validate the patient’s record.
Socioeconomic data. Obtain information about the patient’s educational level, housing conditions, income, current employment status, and family, because these data may provide clues to his current problem and may aid in the development of a treatment plan. Determine current stressors from a holistic perspective.
Cultural and religious beliefs. A patient’s background and values affect his response to illness and his adaptation to care. Certain questions and behaviors considered acceptable in one culture may be inappropriate in another. Determine the extent to which the patient may utilize cultural rituals, treatments, and healing practices.
Medication history. Certain drugs can cause symptoms of mental illness. Review any medications the patient may be taking, including over-the-counter drugs and herbal supplements or remedies, and check for interactions. If he’s taking an antipsychotic, antidepressant, anxiolytic, or antimanic drug, ask if his symptoms have improved, if he’s taking the medication as prescribed, and if he has had any adverse reactions.
Physical illnesses. Find out if the patient has a history of medical disorders that may cause distorted thought processes, disorientation, depression, or other symptoms of mental illness. For instance, does he have a history of renal or hepatic failure, infection, thyroid disease, increased intracranial pressure, or a metabolic disorder? Additionally, has the patient suffered recent head trauma, infection, or physical illness?

Patient appearance, behavior, and mental status

Assess the patient’s appearance, behavior, mood, thought processes, cognitive function, coping mechanisms, and potential for self-destructive behavior, and record your assessment.

General appearance. The patient’s appearance helps to indicate his emotional and mental status. Specifically, note his dress and grooming. Is his appearance clean and appropriate for his age, sex, and situation?

Is the patient’s posture erect or slouched? Is his head lowered? What about his gait? Is it brisk, slow, shuffling, or unsteady? Does he walk normally? Note his facial expression. Does he look alert or does he stare blankly? Does he appear sad or angry? Does the patient maintain direct eye contact? Does he stare at you for long periods?
Behavior. Note the patient’s demeanor and overall attitude as well as any extraordinary behavior such as speaking to a person who isn’t present. Also record mannerisms. Does he bite his nails, fidget, or pace? Does he have any tics or tremors? How does he respond to the interviewer? Is he cooperative, friendly, hostile, or indifferent?

Behavior should be evaluated also in light of the patient’s culture. For instance, making eye contact is considered respectful and attentive behavior in most Western cultures. However, eye contact may be considered rude and aggressive in several Asian and Native American cultures, and avoiding eye contact is considerate and respectful. Blacks may be more actively verbal within their culture group, where oral tradition and multiparty conversations are common. In a traditional medical setting, this patient may be restrained or silent.
Mood. Does the patient appear excited or depressed? Is he sweating, breathing heavily, crying, or trembling? Does his mood change with little provocation? Ask him to describe his current feelings in concrete terms and to suggest possible reasons for these feelings. Note inconsistencies between body language and mood (such as smiling when discussing an anger-provoking situation).
Thought processes and cognitive function. Evaluate the patient’s orientation to time, place, and person, noting any confusion or disorientation. Look for delusions, hallucinations, obsessions, compulsions, fantasies, and daydreams.

Assess the patient’s attention span and ability to recall events in the distant and recent past. For example, to assess immediate recall, ask him to repeat a series of five or six names of objects. Test his intellectual functioning by asking him to add a series of numbers and his sensory
perception and coordination by having him copy a simple drawing. Inappropriate responses to a hypothetical situation (“What would you do if you won the lottery?”) can indicate impaired judgment. Keep in mind that the patient’s cultural background and personal values will influence his answer.

Coping mechanisms defined

Coping, or defense, mechanisms help to relieve anxiety. Common ones include:

denial—avoiding the awareness of truth or reality
displacement—shifting of an emotion from its original object to a substitute
fantasy—creation of unrealistic or improbable images to escape from daily pressures and responsibilities
identification—unconscious adoption of the personality characteristics, attitudes, values, and behavior of another person
projection—displacement of negative feelings onto another person
rationalization—substitution of acceptable reasons for the real or actual reasons motivating behavior
reaction formation—conduct in a manner opposite from the way the person feels
regression—return to behavior of an earlier, less worrisome time in life
repression—exclusion of unacceptable thoughts and feelings from the conscious mind, leaving them to operate in the subconscious

Note speech characteristics that may indicate altered thought processes, including monosyllabic responses; irrelevant or illogical replies to questions; convoluted or excessively detailed speech; repetitious, accelerated, or slowed speech patterns; flight of ideas; and sudden silence with an obvious reason.

Finally, assess the patient’s insight by asking if he understands the significance of his illness, the plan of treatment, and the effect it will have on his life.

Coping mechanisms. The patient who’s faced with a stressful situation will utilize coping, or defense, mechanisms—behaviors that operate on an unconscious level to protect the ego. Examples include denial, regression, displacement, projection, reaction formation, and fantasy. Look for an excessive reliance on these coping mechanisms. (See Coping mechanisms defined.)
Potential for self-destructive behavior. Mentally healthy people may intentionally take deathdefying risks such as participating in dangerous sports. The risks taken by self-destructive patients, however, aren’t death-defying but rather death-seeking.

Not all self-destructive behavior is suicidal in intent. The patient may engage in selfdestructive behavior because it helps him feel alive. A patient who has lost touch with reality may cut or mutilate body parts to focus on physical pain, which may be less overwhelming than emotional distress.

Assess patients for suicidal tendencies, particularly if they report signs and symptoms of depression. (See Suicide’s warning signs.) Not all such patients want to die; however, the incidence of suicide is higher in depressed patients than in patients with other diagnoses.

Diagnostic tests

The laboratory tests, psychological tests, and EEG and brain imaging studies summarized here provide information about the patient’s mental status and possible physical causes of his signs and symptoms.

Laboratory tests

Urinalysis, hemoglobin level, hematocrit, serum electrolyte and serum glucose levels, and liver, kidney, and thyroid function tests screen for physical disorders that can cause psychiatric signs and symptoms. Toxicology studies of blood and urine can detect the presence of many drugs, and current laboratory methods can quantify the blood levels of these drugs. Patients on psychoactive drugs may need routine toxicology screening to ensure that they aren’t receiving a toxic dose. (See Toxicology screening, page 1112.)

Psychological and mental status tests

These tests evaluate the patient’s mood, personality, and mental status. Commonly used tests include the following:

The Mini-Mental Status Examination measures orientation, registration, recall, calculation, language, and graphomotor function.
The Cognitive Capacity Screening Examination measures orientation, memory, calculation, and language.
The Cognitive Assessment Scale measures orientation, general knowledge, mental ability, and psychomotor function.
The Global Deterioration Scale assesses and stages primary degenerative dementia, based
on orientation, memory, and neurologic function.
The Functional Dementia Scale measures orientation, affect, and the ability to perform activities of daily living.
The Beck Depression Inventory helps diagnose depression, determine its severity, and monitor the patient’s response during treatment.
The Eating Attitudes Test detects patterns that suggest an eating disorder.
The Minnesota Multiphasic Personality Inventory helps assess personality traits and ego function in adolescents and adults. Test results include information on coping strategies, defenses, strengths, gender identification, and selfesteem. The test pattern may strongly suggest a diagnostic category, point to a suicide risk, or indicate the potential for violence.

EEG AND BRAIN IMAGING STUDIES

To screen for brain abnormalities, the physician may order tests that visualize electrical brain-wave pattern disturbances or anatomic alterations.

An EEG graphically records the brain’s electrical activity. Abnormal results may indicate organic disease, psychotropic drug use, or certain psychological disorders.
A computed tomography (CT) scan combines radiologic and computer analysis of tissue density to produce images of intracranial structures not readily seen on standard X-rays. This test can help detect brain contusions or calcifications, cerebral atrophy, hydrocephalus, inflammation, space-occupying lesions, and vascular abnormalities.
A magnetic resonance imaging (MRI) scan is a noninvasive imaging technique. MRI localizes atomic nuclei that magnetically align and then fall out of alignment in response to a radio-frequency pulse. The MRI scanner records signals from nuclei as they realign; it then translates the signals into detailed pictures of anatomic structures. Compared with conventional X-rays and CT scans, the MRI scan provides superior contrast of soft tissues and sharper differentiation of normal and abnormal tissues. It also provides images of multiple planes, including sagittal and coronal views, in regions where bones usually interface.
A functional MRI (fMRI) detects blood flow in the brain. It is useful to localize neuronal activity to a particular lobe or subcortical nucleus and even to a single gyrus. No radioactive isotopes are used. fMRI has recently been used to evaluate details about the organization of language in the brain. This imaging technique is used to study brain abnormality related to cognitive dysfunction.

Suicide’s warning signs

Withdrawal and social isolation
Signs and symptoms of depression, which may include crying, fatigue, sadness, helplessness, poor concentration, reduced interest in sex and other activities, constipation, and weight loss. Note that a patient is more likely to attempt suicide if he gains more energy. This may occur in the early stages of treatment with antidepressants.
Farewells to friends and family
Putting affairs in order
Giving away prized possessions
Covert suicide messages and death wishes
Obvious suicide messages (“I’d be better off dead.”)

A positron emission tomography (PET) scan provides colorimetric information about the brain’s metabolic activity by detecting how quickly tissues consume radioactive isotopes. PET scanning is used mainly for diagnosing neuropsychiatric problems, such as Alzheimer’s disease, and some mental illnesses.

DISORDERS OF INFANCY, CHILDHOOD, AND ADOLESCENCE

Intellectual disability

The American Association on Intellectual and Developmental Disabilities (AAIDD) defines intellectual disability as “a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before the age of 18.” Intellectual disability commonly is accompanied by other physical and emotional disorders that may constitute disabilities in themselves. Intellectual disability can place a significant burden on patients and their families, resulting in stress, frustration, and family problems.

Toxicology screening

Toxic levels of certain drugs can be detected in blood, urine, or both.

Blood

Alcohol (ethyl, isopropyl, and methyl)
Ethchlorvynol

Urine

Chlorpromazine
Cocaine
Desmethyldoxepin (metabolite of doxepin)
Heroin (metabolized to and detected as morphine)
Imipramine
Methadone
Morphine
Phencyclidine (PCP)

Blood and urine

Acetaminophen
Amitriptyline
Amobarbital
Butabarbital
Butalbital (component in Fiorinal)
Caffeine
Carisoprodol
Chlordiazepoxide
Codeine
Desipramine
Desmethyldiazepam (metabolite of diazepam)
Diazepam
Diphenhydramine
Doxepin
Flurazepam
Glutethimide
Ibuprofen
Meperidine
Mephobarbital
Meprobamate
Methapyrilene
Methaqualone
Methyprylon
Norpropoxyphene (metabolite of propoxyphene)
Nortriptyline
Oxazepam
Pentazocine
Pentobarbital
Phénobarbital
Propoxyphene
Salicylates and their conjugates
Secobarbital

Causes and incidence

A specific cause is identifiable in only about 25% of people who are intellectual disability, and, of these, only 10% have the potential for cure. (See Causes ofintellectual disability.) In the remaining 75%, predisposing factors, such as deficient prenatal or perinatal care, inadequate nutrition, poor social environment, and poor child-rearing practices, contribute significantly to intellectual disability.

Prenatal screening for genetic defects (such as Tay-Sachs disease) and counseling for families at risk for specific defects have reduced the incidence of genetically transmitted intellectual disabilities.

An estimated 1% to 3% of the population has intellectual disabilities, demonstrating an IQ below 70 and associated difficulty in carrying out tasks required for personal independence.

The AAIDD criteria promote a threshold IQ of 75 rather than 70 to be considered in the mild intellectual disability range to enable many more persons to receive social services.

Signs and symptoms

The observable effects of intellectual disabilities are deviations from normal adaptive behaviors, ranging from learning disabilities and uncontrollable behavior to severe cognitive and motor skill impairment. The earlier a child’s adaptive deficit is recognized and he’s placed in a special learning program, the more likely he is to achieve age-appropriate adaptive behaviors. If the patient is older, review his adaptation to his environment.

The family of a patient who’s intellectually disabled may report many problems stemming from frustration, fear, and exhaustion. These problems, such as financial difficulties, abuse, and divorce, can compromise the child’s care. Physical examination may reveal signs of abuse or neglect.

People who are intellectually disabled may exhibit signs and symptoms of other disorders, such as cleft lip, congenital heart defects, and cerebral palsy as well as a lowered resistance to infection.

Diagnosis

The IQ test primarily predicts school performance and must be supplemented by other diagnostic evaluations.

For example, the Adaptive Behavior Scale deals with behaviors important to activities of daily living. This test evaluates self-help skills (toileting and eating), physical and social development, language, socialization, and time and number concepts. It also examines inappropriate behaviors, such as violent or destructive acts, withdrawal, and self-abusive or sexually aberrant behavior.

Age-appropriate adaptive behaviors are assessed by using developmental screening tests such as the Denver Developmental Screening test. These tests compare the subject’s functional level with the normal level for the same chronologic age. The greater the discrepancy between chronologic and developmental age, the more severe the intellectual disability. In most European and North American cultures, the Vineland Social Maturity Scale, a tool used to determine social competence, is recommended for use when appropriate.

In children, the functional level is based on sensorimotor skills, self-help skills, and socialization. In adolescents and adults, it’s based on academic skills, reasoning and judgment skills, and social skills.

Treatment

Effective management requires an interdisciplinary team approach, which continues to assist the patient and his family on primary, secondary, and tertiary levels. A major goal is to develop the patient’s strengths. Another important goal is the development of social adaptive skills.

Children who are intellectually disabled require special education and training, ideally beginning in infancy. An individualized, effective education program can optimize the quality of life for even the profoundly disabled.

The prognosis for people who are intellectually disabled is related more to timing and aggressive treatment, personal motivation, training opportunities, and associated conditions than to the degree of intellectual disability itself. With good support systems, many people who are intellectually disabled become productive members of society. Successful management leads to independent functioning and occupational skills for some and a sheltered environment for others.

Causes of intellectual disability

Chromosomal abnormalities (Down syndrome, Klinefelter’s syndrome)
Disorders resulting from unknown prenatal influences (hydrocephalus, hydrencephaly, microcephaly)
Disorders of metabolism or nutrition (phenylketonuria, hypothyroidism, Hurler’s syndrome, galactosemia, Tay-Sachs disease)
Environmental influences (cultural-familial retardation, poor nutrition, lack of medical care)
Gestational disorders (prematurity)
Gross brain disorders that develop after birth (neurofibromatosis, intracranial neoplasm)
Infection and intoxication (congenital rubella, syphilis, lead poisoning, meningitis, encephalitis, insecticides, drugs, maternal viral infection, toxins)
Psychiatric disorders (autism)
Trauma or physical conditions (mechanical injury, asphyxia, hyperpyrexia)

Special considerations

Support the parents of a child diagnosed with an intellectual disability. They may be overwhelmed by caretaking and financial concerns and may have difficulty accepting and bonding with their child.
Remember that a child who’s intellectually disabled has all the ordinary needs of a healthy child plus those created by his disability. The child especially needs affection, acceptance, stimulation, and prudent, consistent discipline; he’s less able to cope if rejected, overprotected, or forced beyond his abilities.
When caring for a hospitalized patient who’s intellectually disabled, promote continuity of care by acting as a liaison for parents and other health care professionals.
During hospitalization, continue behavioral training programs already in place, but remember that illness may bring on some regression.
For the parents of a child who’s severely disabled, suggest ways to cope with the guilt, frustration, and exhaustion that commonly accompany caring for such a child. The parents may need an extensive teaching and discharge planning program, including physical care procedures, stress reduction techniques, support services, and referral to developmental
programs. Ask the social services department to look into community resources.

Classifying tics

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, motor and vocal tics are classified as simple or complex; however, category boundaries remain unclear. Also, combinations of tics may occur simultaneously.

Motor tics

Simple motor tics include eye blinking, neck jerking, shoulder shrugging, head banging, head turning, tongue protrusion, lip or tongue biting, nail biting, hair pulling, and facial grimacing.

Some examples of complex motor tics are facial gestures, grooming behaviors, hitting or biting oneself, jumping, hopping, touching, squatting, deep knee bends, retracing steps, twirling when walking, stamping, smelling an object, and imitating the movements of someone who is being observed (echopraxia).

Vocal tics

Examples of simple vocal tics include coughing, throat clearing, grunting, sniffing, snorting, hissing, clicking, yelping, and barking.

Complex vocal tics may involve repeating words out of context; using socially unacceptable words, many of which are obscene (coprolalia); or repeating the last-heard sound, word, or phrase of another person (echolalia).

Teach parents how to care for the special needs of a child who’s intellectually disabled. Suggest that they contact the AAIDD.
Teach adolescents who are disabled how to deal with physical changes and sexual maturation. Encourage them to participate in appropriate sex education classes. People who are intellectually disabled may have difficulty expressing sexual concerns because of limited verbal skills.

Tic disorders

Including Tourette syndrome, chronic motor or vocal tic disorder, and transient tic disorder, tic disorders are similar pathophysiologically but differ in severity and prognosis. All tic disorders, commonly known simply as tics, are involuntary, spasmodic, recurrent, and purposeless motor movements or vocalizations. These disorders are classified as motor or vocal and as simple or complex. (See Classifying tics.) Tics usually begin before age 18. Transient tics are usually self-limiting, but Tourette syndrome follows a chronic course with remissions and exacerbations. Some people who have very mild tics don’t seek treatment.

Causes and incidence

Although their exact cause is unknown, tic disorders occur more in certain families, suggesting a genetic cause. Tics commonly develop when a child experiences overwhelming anxiety, usually associated with normal maturation. There is evidence that the dopamine system is involved in the causation of tic disorders. Medications that suppress dopamine (haloperidol, fluphenazine) suppress tics, and medications that increase central dopamine levels (amphetamines, cocaine) increase tics. Immunologic and postinfectious processes may also be involved.

All tic disorders are three times more common in boys than in girls. About 2% of the population has Tourette syndrome.

Signs and symptoms

Assessment findings vary according to the type of tic disorder. Inspection, coupled with the patient’s history, may reveal the specific motor or vocal patterns that characterize the tic as well as the frequency, complexity, and precipitating factors. The patient or his family may report that the tics occur sporadically many times per day. (See Stress disorders with physical signs.)

Note whether certain situations worsen the tics. All tic disorders may be worsened by stress, and they usually diminish markedly during sleep. The patient also may report that they occur during activities that require concentration, such as reading or sewing.

Determine whether the patient can control the tics. Most patients can do so, with conscious effort, for short periods.

Psychosocial assessment may reveal underlying stressful factors, such as problems with social adjustment, lack of self-esteem, and depression, resulting from tics.

Stress disorders with physical signs

Besides tic disorders, stress-related disorders that produce physical signs in children include stuttering, functional enuresis, functional encopresis, sleepwalking, and sleep terrors.

Stuttering

Characterized by abnormal speech rhythms with repetitions and hesitations at the beginning of words, stuttering may involve movements of the respiratory muscles, shoulders, and face. There is no evidence to indicate that psychiatric problems cause stuttering or that people who stutter have more psychiatric disturbances than those with other forms of speech disorders. However, this disorder most commonly occurs in children of average or superior intelligence who fear they can’t meet expectations. Related problems may include low self-esteem, tension, anxiety, humiliation, and withdrawal from social situations.

About 80% of stutterers recover after age 16. Evaluation and treatment by a speech pathologist teaches stutterers to place equal weight on each syllable in a sentence, how to breathe properly, and how to control anxiety.

Enuresis

This disorder is characterized by intentional or involuntary voiding of urine, usually during the night (nocturnal enuresis). Considered normal in children until age 3 or 4, enuresis occurs in about 40% of children at this age. It persists in 10% to age 5, in 5% to age 10, and in 1% of boys to age 18. Enuresis is more common in boys than in girls. Enuretic children were shown in a longitudinal study to be twice as likely to have concomitant developmental delays as nonenuretic children. There is a strong genetic component.

Causes may be related to stress, such as the birth of a sibling, the move to a new home, divorce, separation, hospitalization, faulty toilet training (inconsistent, demanding, or punitive), and unrealistic responsibilities. Associated problems include low self-esteem, social withdrawal from peers because of ostracism and ridicule, and anger, rejection, and punishment by caregivers.

Advise parents that a matter-of-fact attitude helps the child learn bladder control without undue stress. If enuresis persists into late childhood, treatment with imipramine may help. Dry-bed therapy may include the use of an alarm (wet bell pad), social motivation, self-correction of accidents, and positive reinforcement.

Encopresis

Encopresis is denoted by evacuation of feces into the child’s clothes or inappropriate receptacles. Some children show inefficient and ineffective gastric motility. Related problems may include repressed anger, withdrawal from peer relationships, and loss of self-esteem.

Treatment involves encouraging the child to come to his parents when he has an “accident.” Advise parents to give the child clean clothes without criticism or punishment. Medical examination should rule out any physical disorder. Child, adult, and family therapy may help reduce anger and disappointment over the child’s development and improve parenting techniques. Supportive psychotherapy and relaxation therapy techniques maybe useful in reducing anxiety and improving self-esteem.

Sleepwalking and sleep terrors

In sleepwalking, the child calmly rises from bed in a state of altered consciousness and walks around with no subsequent recollection of any dreams. In sleep terrors, he awakens terrified, in a state of clouded consciousness, usually unable to recognize parents and familiar surroundings. Visual hallucinations are common.

Sleepwalking is usually a response to an emotional concern. Tell parents to gently “talk” the child back to his bed. If he wakes, they should comfort and support him, not tease him.

Sleep terrors are a normal developmental event in 2- and 3-year-old children, usually occurring within 30 minutes to 3½ hours of sleep onset. Tachycardia, tachypnea, diaphoresis, dilated pupils, and piloerection are associated with sleep terrors. The child may also fear being alone.

Tell parents to make sure that the child has access to them at night. Sleep terrors usually are self-limiting and subside within a few weeks.

Diagnosing tic disorders

The diagnosis of a tic disorder is based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

Tourette syndrome

The patient has had multiple motor tics and one or more vocal tics at some time during the illness, although not necessarily concurrently.
The tics occur many times per day (usually in bouts) nearly every day or intermittently for more than 1 year.
The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
Onset occurs before age 18.
The disturbance isn’t the direct physiologic effect of a substance or a general medical condition.

Chronic motor or vocal tic disorder

The patient has had single or multiple motor or vocal tics, but not both, at some time during the illness.
The tics occur many times per day nearly every day or intermittently for more than 1 year. During this time, the person never had a ticfree period exceeding 3 consecutive months.
The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
Onset occurs before age 18.
The disturbance isn’t the direct physiologic effect of a substance or a general medical condition.
Criteria have never been met for Tourette syndrome.

Transient tic disorder

The patient has single or multiple motor or vocal tics, or both.
The tics occur many times per day nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
Onset occurs before age 18.
The disturbance isn’t the direct physiologic effect of a substance or a general medical condition.
Criteria have never been met for Tourette syndrome or chronic motor or vocal tic disorder.

Treatment

Medications are not recommended unless the tics are severely disabling. Studies have shown that behavioral therapy such as habit reversal treatments is effective in treating transient tics. Psychotherapy may help with secondary emotional problems caused by tics.

Haloperidol is the drug of choice for treating Tourette syndrome. Pimozide (an oral dopamine-blocking drug) and clonidine are alternative choices. Tetrabenazine has been used but is associated with depression of movement. Anxiolytics may be useful in dealing with secondary anxiety, but they don’t reduce the severity or frequency of the tics.

Special considerations

Offer emotional support and help the patient prevent fatigue.
Suggest that the patient with Tourette syndrome contact the Tourette Syndrome Association to obtain information and support.
Help the patient identify and eliminate any avoidable stress and learn positive new ways to deal with anxiety.
Encourage the patient to verbalize his feelings about his disorder. Help him to understand that the movements are involuntary; he shouldn’t feel guilty or blame himself for them.

Autististic disorder

A severe, pervasive developmental disorder, autistic disorder is marked by unresponsiveness to social contact, gross deficits in language development, ritualistic and compulsive behaviors, restricted capacity for developmentally appropriate activities and interests, and bizarre responses to the environment. Autistic disorder may be complicated by epileptic seizures, depression and, during periods of stress, catatonic phenomena. Autism usually becomes
apparent before the child reaches age 36 months but, in some children, the actual onset is difficult to determine. Occasionally, autistic disorder isn’t recognized until the child enters school. (See Other pervasive developmental disorders.)

The prognosis for autistic disorder is guarded; most patients require a structured environment throughout life. Prognosis improves in a supportive environment.

Causes and incidence

The causes of autistic disorder remain unclear; however, studies show a biological basis for this disorder. Genetic, biological, immunologic, perinatal, and biochemical causes have been proposed. The parents of a child who’s autistic may appear distant and unaffectionate. However, because children who are autistic are unresponsive or respond with rigid, screaming resistance to touch and attention, parental remoteness may be merely a frustrated, helpless reaction to this disorder, not its cause.

Some children who are autistic show abnormal but nonspecific EEG findings that suggest brain dysfunction, possibly resulting from trauma, disease, or a structural abnormality. Autistic disorder has also been associated with maternal rubella, untreated phenylketonuria, tuberous sclerosis, anoxia during birth, encephalitis, infantile spasms, and fragile X syndrome. Studies have established a link with abnormalities in neurotransmitters, including (in some cases) increased dopamine and increased serotonin. There appears to be a genetic component as well; between 2% and 4% of siblings of those with autism also had autistic disorders at a rate higher than the general population.

Autistic disorder is rare, affecting 4 to 5 children per 10,000 births. It affects three to four times more boys than girls.

Signs and symptoms

A primary characteristic of infantile autistic disorder is unresponsiveness to people. Infants with this disorder won’t cuddle, avoid eye contact and facial expressions, and are indifferent to affection and physical contact. Parents may report that the child becomes rigid or flaccid when held, cries when touched, and shows little or no interest in human contact.

As the infant grows older, his smiling response is delayed or absent. He doesn’t lift his arms in anticipation of being picked up or form an attachment to a specific caregiver. Furthermore, he doesn’t show the anxiety about strangers that’s typical in the 8-month-old infant.

Other pervasive developmental disorders

Although autistic disorder is the most severe and most typical of the pervasive developmental disorders, recent evidence points to other similar disorders in this class.

For example, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision category pervasive developmental disorder not otherwise specified refers to those patients who don’t meet the criteria for autistic disorder but who do exhibit impaired development of reciprocal social interaction and of verbal and nonverbal communication skills.

Some patients with this diagnosis exhibit a markedly restricted repertoire of activities and interests, but others don’t. Research suggests that these disorders are more common than autistic disorder, occurring in 6 to 10 of every 10,000 children.

A child who’s autistic fails to learn the usual socialization games (peek-a-boo, pat-a-cake, or bye-bye). He’s likely to relate to others only to All a physical need and then without eye contact or speech. The end result may be mutual withdrawal between parents and child.

Severe language impairment and lack of imaginative play are characteristic. The child may be mute or may use immature speech patterns. For example, he may use a single word to express a series of activities; he may say “ground” when referring to any step in using a playground slide.

His speech commonly shows echolalia (meaningless repetition of words or phrases addressed to him) and pronoun reversal (“you go walk” when he means, “I want to go for a walk”). When answering a question, he may simply repeat the question to mean yes and remain silent to mean no.

He shows little imagination, seldom acting out adult roles or engaging in fantasy play. In fact, he may insist on lining up an exact number of toys in the same manner over and over or may repetitively mimic someone else’s actions.

A child who’s autistic shows characteristically bizarre behavior patterns, such as screaming fits, rituals, rhythmic rocking, arm flapping, crying without tears, and disturbed sleeping
and eating patterns. His behavior may be selfdestructive (hand biting, eye gouging, hair pulling, or head banging) or self-stimulating (playing with his own saliva, feces, and urine). His bizarre responses to his environment include an extreme compulsion for sameness.

Diagnosing autistic disorder

Autism is diagnosed when the patient meets the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. At least six characteristics from the following three categories must be present, including at least two from the social interaction category and one each from the communication and patterns categories.

Social interaction

Impairment in social interaction, as shown by at least two of the following:

marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
failure to develop peer relationships appropriate to developmental level
no spontaneous sharing of enjoyment, interests, or achievements with others
lack of social or emotional reciprocity
gross impairment in ability to make peer friendships

Communication

Impairment in communication, as shown by at least one of the following:

delay in, or total lack of, spoken language development
in individuals with adequate speech, marked impairment in initiating or sustaining a conversation with others
stereotyped and repetitive use of language or idiosyncratic language
lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

Patterns

Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

encompassing preoccupation with one or more stereotyped and restricted patterns of interest that’s abnormal either in intensity or focus
apparently inflexible adherence to specific nonfunctional routines or rituals
stereotyped and repetitive motor mannerisms
persistent preoccupation with parts of objects

Additional criteria

Delays or abnormal functioning in at least one of the following before age 3:

social interaction
language as used in social communication
symbolic or imaginative play

The disturbance isn’t better accounted for by Rett’s disorder or childhood disintegrative disorder.

In response to sensory stimuli, he may underreact or overreact and he may ignore objects—dropping those he’s given or not looking at them—or he may become excessively absorbed in them—continually watching the objects or the movement of his own fingers over the objects. He commonly responds to stimuli by head banging, rocking, whirling, and hand flapping. He tends to avoid using sight and hearing to interact with the environment.

A child who’s autistic may exhibit additional behavioral abnormalities, such as:

eating, drinking, and sleeping problems, for example, limiting his diet to just a few foods, excessive drinking, or repeatedly waking during the night and rocking
mood disorders, including labile mood, giggling or crying without reason, lack of emotional responses, no fear of real danger but excessive fear of harmless objects, and generalized anxiety

Treatment

The difficult and prolonged treatment of autistic disorder must begin early, continue for years (through adolescence), and coordinate efforts to encourage social adjustment and speech development and to reduce self-destructive behavior.

Behavioral techniques are used to decrease symptoms and increase the child’s ability to respond. Positive reinforcement, using food and other rewards, can enhance language and social skills. Providing pleasurable sensory and motor stimulation (such as jogging or playing with a ball) encourages appropriate behavior
and helps eliminate inappropriate behavior. Drug therapy with an agent, such as haloperidol, may be helpful. Risperidone has been used successfully to diminish aggressiveness and hyperactivity.

Treatment may take place in a psychiatric institution, in a specialized school, or in a daycare program; however, the current trend is toward home treatment. Family members may benefit from counseling, respite services, and interdisciplinary team coordination of care. Until the causes of infantile autism are known, prevention isn’t possible.

Special considerations

Reduce self-destructive behaviors. Physically stop the child from harming himself, while firmly saying “no.” When he responds to your voice, first give a primary reward (such as food); later, substitute verbal or physical reinforcement (such as saying “good” or giving the child a hug or a pat on the back). Work to identify positive ways for the child to channel his energy.
Foster appropriate use of language. Provide positive reinforcement when the child indicates his needs correctly. Give verbal reinforcement at first (e.g., by saying “good” or “great”); later, give physical reinforcement (such as a hug or a pat on the hand or shoulder).
Encourage development of self-esteem. Show the child that he’s acceptable as a person.
Encourage self-care. For example, place a brush in the child’s hand and guide his hand to brush his hair. Similarly, teach him to wash his hands and face.
Encourage acceptance of minor environmental changes. Prepare the child for the change

by telling him about it beforehand. Make initial changes minor; for example, change the color of his bedspread or the placement of food on his plate. When he has accepted minor changes, move on to bigger ones.
Provide emotional support to the parents, and refer them to the Autism Society of America.

Teach the parents how to physically care for the child’s needs.
Teach the parents how to identify signs of excessive stress and the coping skills to use under these circumstances. Emphasize that they’ll be ineffective caregivers if they don’t take the time to meet their own needs in addition to those of their child.
Help the parents understand that they aren’t responsible for their child’s condition and shouldn’t feel guilty about it.

Attention deficit hyperactivity disorder

The patient with attention deficit hyperactivity disorder (ADHD) has difficulty focusing his attention; engaging in quiet, passive activities; or both. Although the disorder is present at birth, diagnosis before age 4 or 5 is difficult unless the child shows severe symptoms. In some cases, however, the patient isn’t diagnosed until adulthood.

Causes and incidence

ADHD is thought to be a physiologic brain disorder with a familial tendency. Some studies indicate that it may result from disturbances in neurotransmitter levels in the brain caused by reduced blood flow in the striated area of the brain. It affects 3% to 5% of school-age children and is three times more common in boys than in girls.

Signs and symptoms

The principal sign of ADHD is hyperactivity that’s present over a long period, in at least two settings (such as school and home), and is accompanied by easy distractibility. The patient may be impulsive, emotionally labile, explosive, or irritable. Although he may be highly intelligent, his school or work performance patterns are sporadic. He may jump from one partly completed project, thought, or task to another. The patient may have an attention deficit without hyperactivity; if so, he’s less likely to be diagnosed and treated.

In a younger child, signs and symptoms include an inability to wait in line, remain seated, wait his turn, or concentrate on one activity until its completion. An older child or an adult may be described as impulsive and easily distracted by irrelevant thoughts, sounds, or sights. He may also be characterized as emotionally labile, inattentive, or prone to daydreaming. His disorganization becomes apparent as he has difficulty meeting deadlines and keeping track of school or work tools and materials.

Diagnosis

The child is usually referred for evaluation by the school. (See Diagnosing attention deficit hyperactivity disorder, page 1120.) Diagnosis of
ADHD usually begins by obtaining data from several sources, including the parents, teachers, and the child himself. Complete psychological, medical, and neurologic evaluations rule out other problems. Then the child undergoes tests that measure impulsiveness, attention, and the ability to sustain a task. The combined findings portray a clear picture of the disorder and of the areas of support the child will need.

Diagnosing attention deficit hyperactivity disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, groups certain signs and symptoms into inattention and hyperactivity-impulsivity categories. The diagnosis of attention deficit hyperactivity disorder is based on the person demonstrating at least six signs or symptoms from the inattention group or at least six from the hyperactivity-impulsivity group. They must have persisted for at least 6 months to a degree that’s maladaptive and inconsistent with the person’s developmental level.

Symptoms of inattention

The person manifesting inattention:

often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
often has difficulty sustaining attention in tasks or play activities
often doesn’t seem to listen when spoken to directly
often doesn’t follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not because of oppositional behavior or failure to understand instructions)
often has difficulty organizing tasks and activities
often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
often loses things needed for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
often becomes distracted by extraneous stimuli
often demonstrates forgetfulness in daily activities

Symptoms of hyperactivityimpulsivity

The person manifesting hyperactivity:

often fidgets with hands or feet or squirms in seat
often leaves his seat in the classroom or in other situations in which remaining seated is expected
often runs about or climbs excessively in situations in which remaining seated is expected
often has difficulty playing or engaging in leisure activities quietly
often is characterized as “on the go” or acts as if “driven by a motor”
often talks excessively

Symptoms of impulsivity

The person manifesting impulsivity:

often blurts out answers before questions have been completed
often has difficulty awaiting his turn
often interrupts or intrudes on others

Additional features

Some symptoms that caused impairment were evident before age 7.
Some impairment from the symptoms is present in two or more settings.
Clinically significant impairment in social, academic, or occupational functioning must be clearly evident.
The symptoms don’t occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder and aren’t better accounted for by another mental disorder.

Treatment

Education is the first step in effective treatment. The entire treatment team (which ideally includes parents, teachers, and therapists as well as the patient and the physician) must understand the disorder and its effect on the individual’s functioning.

Treatment varies, depending on the severity of symptoms and their effects on the child’s ability to function. Behavior modification, coaching, external structure, use of planning and organizing systems, and supportive psychotherapy help the patient cope with the disorder.

The patient may benefit from medication to relieve symptoms. Ideally, the treatment team identifies the symptoms to be managed, selects appropriate medication, and then tracks the patient’s symptoms carefully to determine the drug’s effectiveness. Stimulants are the most commonly used drugs. Antipsychotics may sometimes be
used in combination with stimulants. However, other drugs, including tricyclic antidepressants, mood stabilizers, and beta-adrenergic blockers, sometimes help control symptoms.

Conduct disorder

Aggressive behavior is the hallmark of conduct disorder. A child with this disorder fights, bullies, intimidates, and assaults others physically or sexually, and is truant from school at an early age. Typically, the patient has poor relationships with peers and adults and violates others’ rights and society’s rules. Conduct disorder evolves slowly over time until a consistent pattern of behavior is established.

Causes and incidence

Studies have suggested that the disorder has biological (including genetic) and psychosocial components. Roughly 30% to 50% of clinical populations with conduct disorder also have attention deficit hyperactivity disorder (ADHD). Social risk factors that may predispose a child to conduct disorder include socioeconomic deprivation; harsh, punitive parenting with verbal or physical aggression; separation from parents; early institutionalization; family neglect, abuse, or violence; frequent verbal abuse from parents, teachers, or other authority figures; parental psychiatric illness, substance abuse, or marital discord; large family size, crowding, and poverty; and divorce with persistent hostility between the parents. Other risk factors include child abuse and neglect, neurologic damage caused by low birth weight or birth complications, underarousal of the autonomic nervous system, learning impairments, insensitivity to physical pain and punishment, and impaired functioning of the nonadrenergic system.

The prevalence of conduct disorder among people ages 9 to 17 is about 1% to 4%. An estimated 6% to 16% of boys and 2% to 9% of girls younger than age 18 have the disorder. The prognosis is worse in children with an earlier onset; these children are more likely to develop antisocial personality disorder as adults.

Signs and symptoms

Sexual abuse of others
Cheating in school
Cruelty to animals
Engaging in precocious sexual activity
Fighting with family members and peers
Skipping classes
Smoking cigarettes
Speaking to others in a hostile manner
Stealing or shoplifting Using drugs or alcohol
Vandalizing or destroying property

Treatment

Treatment focuses on coordinating the child’s psychological, physiologic, and educational needs. A structured living environment with consistent rules and consequences can help reduce many symptoms. Parents need to be taught how to deal with the child’s demands. Juvenile justice interventions may also be used. Medication can be useful as an adjunct to treatment. Overt aggression responds to many medications, such as antipsychotics, lithium, clonidine, and selective serotonin reuptake inhibitors. ADHD, if present, must also be addressed.

Special considerations

Work to establish a trusting relationship with the child.
Provide clear behavioral guidelines, including consequences for disruptive and manipulative behavior.
Teach the child effective coping skills, social skills, and problem-solving skills, and have him demonstrate them in return.

Diagnosing conduct disorder

A patient with conduct disorder must meet at least three of the criteria from any of the categories below; these criteria must have been noted within the year before the time of examination, and at least one criterion must have been present within the past 6 months.

Aggression to people and animals

Bullies, threatens, or intimidates others
Commonly starts physical fights
Has used a weapon that can cause serious physical harm to others
Has been physically cruel to people
Has stolen while confronting a victim
Has forced someone into sexual activity

Destruction of property

Has deliberately set fire with the intention of causing serious damage
Has deliberately destroyed others’ property

Deceitfulness

Has broken into someone else’s house, car, or building
Commonly lies to obtain goods or favors or to avoid obligations
Has stolen items of nontrivial value without confronting a victim

Serious violations of rules

Often stays out at night despite parental prohibitions, starting before age 13
Has run away from home overnight at least twice while living in the parents’ or surrogate parents’ home
Commonly skips school, beginning before age 13

Additional criteria

The behavior disturbance must cause clinically significant impairment in social, academic, or occupational functioning.
The patient is age 18 or older and doesn’t meet the criteria for antisocial personality disorder.

Other features

Conduct disorder is considered mild if the person exhibits few if any conduct problems beyond those required to make the diagnosis and if the conduct problems cause only minor harm to others.
The disorder is considered moderate if the conduct problems and their effects on others are intermediate between mild and severe.
The condition is considered severe if the person has many conduct problems beyond those needed to make the diagnosis, or if the conduct problems cause considerable harm to others.

Teach the child to express anger appropriately through constructive methods to release negative feelings and frustrations.
Help the child accept responsibility for behavior rather than blaming others, becoming defensive, and wanting revenge.
Use role-playing to help the child practice handling stress and gain skill and confidence in managing difficult situations.
Support the parents in setting firm, appropriate limits for the child.

SUBSTANCE-RELATED DISORDERS

Alcohol-related disorder

The patient with alcohol-related disorder experiences a need for the daily intake of large amounts of alcohol for day-to-day functioning. A regular pattern of heavy drinking limited to weekends, with periods of sobriety between weekends, also suggests a pattern of abuse. People with these patterns of drinking usually show impaired social and occupational functioning.

Causes and incidence

Numerous biological, psychological, and sociocultural factors appear to be involved in alcohol addiction. An offspring of one parent with alcohol-related disorder is seven to eight times more likely to become an alcoholic than is a peer without such a parent. Biological factors may include genetic or biochemical abnormalities, nutritional deficiencies, endocrine imbalances, and allergic responses.

Psychological factors may include the urge to drink alcohol to reduce anxiety or symptoms of mental illness; the desire to avoid responsibility in familial, social, and work relationships; and the need to bolster self-esteem.

Sociocultural factors include the availability of alcoholic beverages, group or peer pressure,
an excessively stressful lifestyle, and social attitudes that approve of frequent drinking.

Complications of alcohol use

Alcohol can damage body tissues by its direct irritating effects, by changes that take place in the body during its metabolism, by aggravation of existing disease, by accidents occurring during intoxication, and by interactions between the substance and drugs. Such tissue damage can cause these complications.

Cardiopulmonary complications

Cardiac arrhythmias
Cardiomyopathy
Chronic obstructive pulmonary disease
Essential hypertension
Increased risk of tuberculosis
Pneumonia

GI complications

Chronic diarrhea
Esophageal cancer
Esophageal varices
Esophagitis
Gastric ulcers
Gastritis
GI bleeding
Malabsorption
Pancreatitis

Hematologic complications

Anemia
Leukopenia
Reduced number of phagocytes

Hepatic complications

Alcoholic hepatitis
Cirrhosis
Fatty liver

Neurologic complications

Alcoholic dementia
Alcoholic hallucinosis
Alcohol withdrawal delirium
Korsakoff’s syndrome
Peripheral neuropathy
Seizure disorders
Subdural hematoma
Wernicke’s encephalopathy

Psychiatric complications

Amotivational syndrome
Depression
Fetal alcohol syndrome
Impaired social and occupational functioning
Multiple substance abuse
Suicide

Other complications

Beriberi
Hypoglycemia
Infertility
Leg and foot ulcers
Impaired respiratory diffusion
Increased incidence of pulmonary infections
Myopathies
Prostatitis
Sexual performance difficulties

More than 15% of American adults have a problem with alcohol use, and about 5% to 10% of male and 3% to 5% of female drinkers are alcohol dependent, accounting for about 12.5 million people. Alcohol-related disorder cuts across all social and economic groups, involves both sexes, and occurs at all stages of the life cycle, beginning as early as elementary school.

Signs and symptoms

Because the person with alcohol dependence may hide or deny his addiction, and may temporarily manage to maintain a functional life, assessing for alcohol-related disorder can be difficult. Note physical and psychosocial symptoms that suggest alcohol-related disorder. For example, the patient’s history may suggest a need for daily or episodic alcohol use to maintain adequate functioning, an inability to discontinue or reduce alcohol intake, episodes of anesthesia or amnesia (blackouts) during intoxication, episodes of violence during intoxication, and interference with social and familial relationships and occupational responsibilities. Many minor complaints may be alcohol-related. The patient may report malaise, dyspepsia, mood swings or depression, and an increased incidence of infection. Observe the patient for poor personal
hygiene and untreated injuries, such as cigarette burns, fractures, and bruises, that he can’t fully explain. Note any evidence of an unusually high tolerance of sedatives and opioids.

Although each person abusing alcohol may present in his own unique way, secretive or manipulative behavior may be a manifestation of the patient’s denial of the severity of his addiction. Suspect alcohol-related disorder if the patient uses inordinate amounts of aftershave or mouthwash. When confronted, the patient may deny or rationalize the problem. Or, he may be guarded or hostile in his response and may even sign out of the hospital against medical advice. He also may project his anger or feelings of guilt or inadequacy onto others to avoid confronting his illness.

After abstinence or reduction of alcohol intake, signs and symptoms of withdrawal— which begin shortly after drinking has stopped and last for 5 to 7 days—may vary. The patient initially experiences anorexia, nausea, anxiety, fever, insomnia, diaphoresis, and tremor, progressing to severe tremulousness, agitation and, possibly, hallucinations and violent behavior. Major motor seizures (alcohol withdrawal seizures) can occur during withdrawal. Suspect alcohol-related disorder in any patient with unexplained seizures. (See Signs and symptoms of alcohol withdrawal.)

Diagnosis

For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 1126.

Clinical findings may help support the diagnosis of alcohol-related disorder. For example, laboratory tests can confirm alcohol use and complications and document recent alcohol ingestion. A blood alcohol level ranging from 0.08% to 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication, depending on the state or country. The blood alcohol level in a physically dependent and tolerant drinker may exceed levels that would cause severe dysfunction or death in a nontolerant drinker. For example, a tolerant drinker might have a blood alcohol level of more than 0.5 mg (the usual lethal level) and still be alive, talking, and moving.

In severe hepatic disease, the blood urea nitrogen level is increased, and the serum glucose level is decreased. Further testing may reveal increased serum ammonia and amylase levels. Urine toxicology studies may help determine if the patient with alcohol withdrawal delirium or another acute complication abuses other drugs as well.

Liver function studies revealing increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine kinase may point to liver damage, and elevated serum amylase and lipase levels point to acute pancreatitis. A hematologic workup can identify anemia, thrombocytopenia, prolonged prothrombin time, and prolonged partial thromboplastin time.

Treatment

Total abstinence from alcohol is the only effective treatment. Supportive programs that offer detoxification, rehabilitation, and aftercare, including continued involvement in Alcoholics Anonymous (AA), may produce good long-term results.

Acute intoxication is treated symptomatically by supporting respiration, preventing aspiration of vomitus, replacing fluids, administering I.V. glucose to prevent hypoglycemia, correcting hypothermia or acidosis, and initiating emergency treatment for trauma, infection, or GI bleeding.

Treatment of chronic alcohol abuse requires a varied approach that may include medications to deter alcohol use and treat effects of withdrawal; psychotherapy, consisting of behavior modification techniques, group therapy, and family therapy; and appropriate measures to relieve associated physical problems.

Aversion, or deterrent, therapy involves a daily oral dose of disulfiram to prevent compulsive drinking. This drug interferes with alcohol metabolism and allows toxic levels of acetaldehyde to accumulate in the patient’s blood, producing immediate and potentially fatal distress in the event he consumes alcohol up to 2 weeks after taking it. Disulfiram is contraindicated during pregnancy and in the patient with diabetes, heart disease, severe hepatic disease, or any disorder in which such a reaction could be especially dangerous. Another form of aversion therapy attempts to induce aversion by administering alcohol with an emetic.

The first drug approved by the U.S. Food and Drug Administration for the treatment of alcohol-related disorder since disulfiram is naltrexone, an opiate antagonist that effectively reduces the amount of intake, severity of craving, and relapse incidence. It’s believed to work by preventing the effects of increased endorphins produced as a product of increased alcohol intake.

Signs and symptoms of alcohol withdrawal

Alcohol withdrawal signs and symptoms may vary in degree from mild (morning hangover) to severe (alcohol withdrawal delirium). Formerly known as delirium tremens, alcohol withdrawal delirium is marked by acute distress following abrupt withdrawal after prolonged or massive use.

Signs and symptoms	Mild	Moderate	Severe
Anxiety	Mild restlessness	Obvious motor restlessness and anxiety	Extreme restlessness and agitation with intense fearfulness
Appetite	Impaired appetite	Marked anorexia	Rejection of all food and fluid except alcohol
Blood pressure	Normal or slightly elevated systolic	Usually elevated systolic	Elevated systolic and diastolic
Confusion	None	Variable	Marked confusion and disorientation
GI symptoms	Nausea	Nausea and vomiting	Dry heaves and vomiting
Hallucinations	None	Vague, transient visual and auditory hallucinations and illusions (commonly nocturnal)	Visual and occasionally auditory hallucinations, usually of fearful or threatening content; misidentification of people and frightening delusions related to hallucinatory experiences
Seizures	None	Possible	Common
Sleep disturbance	Restless sleep or insomnia	Marked insomnia and nightmares	Total wakefulness
Sweating	Slight	Obvious	Marked hyperhidrosis

For long-term success, the recovering individual must learn to fill the place alcohol once occupied in his life with something constructive. Therapy using disulfiram or naltrexone may only substitute one drug dependence for another, so it should be used prudently.

Benzodiazepine isn’t recommended during rehabilitation due to its addictive nature and the potential for reinforcing the substance abuse behavior.

Supportive counseling or individual, group, or family psychotherapy may help. Ongoing support groups are helpful. In AA, a self-help group with more than 1 million members worldwide, the alcoholic finds emotional support from others with similar problems. About 40% of AA’s members stay sober as long as 5 years, and 30% stay sober longer than 5 years.

Special considerations

During acute intoxication or withdrawal, carefully monitor the patient’s mental status, heart rate, breath sounds, blood pressure, and temperature every 30 minutes to 6 hours.

Diagnosing substance dependence and related disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, identifies these diagnostic criteria for substance dependence, abuse, intoxication, and withdrawal.

Substance dependence

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period:

Tolerance, as defined by either of the following: the need for increased amounts of the substance to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of the substance.
Withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for the substance or the same, or similar, substance is taken to relieve or avoid withdrawal symptoms.
The person commonly takes the substance in larger amounts or over a longer period than was intended.
The person experiences a persistent desire or unsuccessful efforts to cut down or control substance use.
The person spends a lot of time in activities needed to obtain the substance, use the substance, or recover from its effects.
The person abandons or reduces important social, occupational, or recreational activities because of substance use.
The person continues using the substance despite knowledge of having a persistent or recurrent physical or psychological problem that’s likely to have been caused or worsened by the substance.

Substance abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:

recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
recurrent substance use in situations in which using the substance is physically hazardous
recurrent substance-related legal problems
continued substance use despite having persistent or recurrent social or interpersonal problems caused or worsened by the effects of the substance

The symptoms have never met the criteria for substance dependence for this class of substance.

Substance intoxication

The development of a reversible substancespecific syndrome resulting from recent ingestion of, or exposure to, a substance.
Clinically significant maladaptive behavioral or psychological changes, resulting from the effect of the substance on the central nervous system and developing during or shortly after use of the substance.
Symptoms aren’t caused by a general medical condition, and aren’t better accounted for by another mental disorder.

Substance withdrawal

Development of a substance-specific syndrome resulting from the cessation or reduction of substance use that has been heavy and prolonged.
The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms aren’t caused by a general medical condition and aren’t better accounted for by another mental disorder.

Assess the patient for signs of inadequate nutrition and dehydration. Start seizure precautions and administer drugs prescribed to treat the signs and symptoms of withdrawal in chronic alcohol abuse.
During withdrawal, orient the patient to reality because he may have hallucinations and may try to harm himself or others. Maintain a calm environment, minimizing noise and shadows to reduce the incidence of delusions and hallucinations. Avoid restraining the patient unless necessary to protect him or others.
Approach the patient in a nonthreatening way. Limit sustained eye contact. Even if he’s verbally abusive, listen attentively and respond with empathy. Explain all procedures.
Monitor the patient for signs of depression or impending suicide.
In chronic alcohol-related disorder, help the patient accept his drinking problem and the necessity for abstinence. Confront him about his behavior, urging him to examine his actions more realistically.
If the patient is taking disulfiram (or has taken it within the past 2 weeks), warn him of the effects of alcohol ingestion, which may last from 30 minutes to 3 hours or longer. The reaction includes nausea, vomiting, facial flushing, headache, shortness of breath, red eyes, blurred vision, sweating, tachycardia, hypotension, and fainting. Emphasize that even a small amount of alcohol will induce this adverse reaction and that the longer he takes the drug, the greater his sensitivity to alcohol will be. Even medicinal sources of alcohol, such as mouthwash, cough syrups, liquid vitamins, and cold remedies, must be avoided.
Refer the patient to AA and offer to arrange a visit from an AA member. Stress the effectiveness of this organization.
For the individual who has lost all contact with his family and friends and who has a long history of unemployment, trouble with the law, or other problems associated with alcohol abuse, rehabilitation may involve job training, sheltered workshops, halfway houses, and other supervised facilities.
Refer the spouse of an alcoholic to Al-Anon and children of an alcoholic to Alateen. By participating in these self-help groups, family members learn to relinquish responsibility for the individual’s drinking. Point out that family involvement in rehabilitation can reduce family tensions.
Refer adult children of an alcoholic to the National Association for Children of Alcoholics.

Substance abuse and induced disorders

Substance abuse and dependence causes physical, mental, emotional, or social harm. Examples of abused drugs include opioids, stimulants, depressants, anxiolytics, and hallucinogens. (See Understanding commonly abused substances, pages 1128 to 1132.) Chronic drug abuse, especially I.V. use, can lead to lifethreatening complications, such as cardiac and respiratory arrest, intracranial hemorrhage, acquired immunodeficiency syndrome, tetanus, subacute infective endocarditis, hepatitis, vasculitis, septicemia, thrombophlebitis, pulmonary emboli, gangrene, malnutrition and GI disturbances, respiratory infections, musculoskeletal dysfunction, trauma, depression, increased risk of suicide, and psychosis. Materials used to “cut” street drugs also can cause toxic or allergic reactions.

Psychoactive drug abuse can occur at any age. Experimentation with drugs commonly begins in adolescence or even earlier. In many cases, drug abuse leads to addiction, which may involve physical or psychological dependence or both. The most dangerous form of abuse occurs when users mix several drugs simultaneously-including alcohol.

Causes and incidence

Psychoactive drug abuse commonly results from a combination of low self-esteem, peer pressure, inadequate coping skills, and curiosity. Most people who are predisposed to drug abuse have few mental or emotional resources against stress, an overdependence on others, and a low tolerance for frustration. Taking the drug gives them pleasure by relieving tension, abolishing loneliness, allowing them to achieve a temporarily peaceful or euphoric state, or simply relieving boredom.

Drug dependence may follow experimentation with drugs in response to peer pressure. It also may follow the use of drugs to relieve physical pain, but this is uncommon.

Signs and symptoms

The signs and symptoms of acute intoxication vary, depending on the drug. The drug user seldom seeks treatment specifically for his drug problem. Instead, he may seek emergency treatment for drug-related injuries or complications, such as a motor vehicle accident, burns from freebasing, an overdose, physical deterioration from illness or malnutrition, or symptoms of withdrawal. Friends, family members, or law enforcement officials may bring the patient to the hospital because of respiratory depression, unconsciousness, acute injury, or a psychiatric crisis.

Examine the patient for signs and symptoms of drug use or drug-related complications as well as for clues to the type of drug ingested. For example,

fever can result from stimulant or hallucinogen intoxication, from withdrawal, or from infection caused by I.V. drug use.

Understanding commonly abused substances

Substance

Signs and symptoms

Interventions

Cannabinoids

Marijuana

▪ Street names: pot, grass, weed, Mary Jane, roach, reefer, joint, muggles, Acapulco gold, Texas tea, Yesca, hemp

▪ Routes: ingestion, smoking

▪ Dependence: psychological

▪ Duration of effect: 2 to 3 hours

▪ Medical uses: antiemetic for chemotherapy

▪ Of use: acute psychosis; agitation; amotivational syndrome; anxiety; asthma; bronchitis; conjunctival reddening; decreased muscle strength; delusions; distorted sense of time and self-perception; dry mouth; euphoria; hallucinations; impaired cognition, short-term memory, and mood; incoordination; increased hunger; increased systolic pressure when supine; orthostatic hypotension; paranoia; spontaneous laughter; tachycardia; and vivid visual imagery

▪ Of withdrawal: chills, decreased appetite, increased rapid-eye-movement sleep, insomnia, irritability, nervousness, restlessness, tremors, and weight loss

▪ Place the patient in a quiet room.

▪ Monitor his vital signs.

▪ Give supplemental oxygen for respiratory depression and I.V. fluids for hypotension.

▪ Give diazepam, as ordered, for extreme agitation and acute psychosis.

Depressants

Alcohol

▪ Found in: beer, wine, and distilled spirits; also contained in cough syrup, after-shave, and mouthwash

▪ Route: ingestion

▪ Dependence: physical and psychological

▪ Duration of effect: varies according to individual and amount ingested; metabolized at rate of 10 ml/hour

▪ Medical uses: neurolysis (absolute alcohol); emergency tocolytic; and treatment of ethylene glycol and methanol poisoning

▪ Of acute use: coma, decreased inhibitions, euphoria followed by depression or hostility, impaired judgment, incoordination, respiratory depression, slurred speech, unconsciousness, and vomiting

▪ Of withdrawal: delirium, hallucinations, seizures, and tremors

▪ Place the patient in a quiet room.

▪ If alcohol was ingested within 4 hours, induce vomiting or perform gastric lavage; give activated charcoal and a saline cathartic.

▪ Monitor his vital signs.

▪ As ordered, give chlordi-azepoxide every 4 hours to prevent withdrawal seizures, tremors, diaphoresis, anxiety, tachycardia, and hypertension. Diazepam may be used if an I.V. route needs to be used.

▪ Institute seizure precautions.

▪ Provide I.V. fluid replacement as well as dextrose, thiamine, B-complex vitamins, and vitamin C to treat dehydration, hypoglycemia, and nutritional deficiencies.

▪ Assess for aspiration pneumonia.

▪ Prepare for dialysis if patient’s vital functions are severely depressed.

Barbiturates (amobarbital, phenobarbital, secobarbital)

▪ Street names: for barbiturates—barbs and downers; for amobarbital—blue angels and blue devils; for phenobarbital— goofballs and purple hearts; and for secobarbital—reds and red devils

▪ Routes: ingestion and injection

▪ Dependence: physical and psychological

▪ Duration: 1 to 16 hours

▪ Medical uses: anesthetic, anticonvulsant, sedative, hypnotic

▪ Of use: absent reflexes, blisters or bullous lesions, cyanosis, depressed level of consciousness (LOC) (from confusion to coma), fever, flaccid muscles, hypotension, hypothermia, nystagmus, paradoxical reaction in children and elderly people, poor pupil reaction to light, and respiratory depression

▪ Of withdrawal: agitation, anxiety, fever, insomnia, orthostatic hypotension, tachycardia, and tremors

▪ Of rapid withdrawal: anorexia, apprehension, hallucinations, orthostatic hypotension, tonic-clonic seizures, tremors, and weakness

▪ If ingestion was recent, induce vomiting or perform gastric lavage. Follow with activated charcoal.

▪ Monitor the patient’s vital signs and perform frequent neurologic assessments.

▪ As ordered, give an I.V. fluid bolus for hypotension and alkalinized urine.

▪ Institute seizure precautions.

▪ Relieve withdrawal symptoms as ordered.

▪ Use a hypothermia or hyperthermia blanket for temperature alterations.

Benzodiazepines (alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, flurazepam, halazepam, lorazepam, midazolam, oxazepam, prazepam, quazepam, temazepam, triazolam)

▪ Street names: dolls and yellow jackets

▪ Routes: ingestion and injection

▪ Dependence: physical and psychological

▪ Duration of effect: 4 to 8 hours

▪ Medical uses: anxiolytic, anticonvulsant, sedative, hypnotic

▪ Of use: ataxia, drowsiness, hypotension, increased selfconfidence, relaxation, and slurred speech

▪ Of overdose: confusion, coma, drowsiness, and respiratory depression

▪ Of withdrawal: abdominal cramps, agitation, anxiety, diaphoresis, hypertension, tachycardia, tonic-clonic seizures, tremors, and vomiting

▪ If the drug was ingested, induce vomiting or perform gastric lavage. Follow with activated charcoal and a cathartic.

▪ Monitor the patient’s vital signs.

▪ Give supplemental oxygen for hypoxia-induced seizures.

▪ As ordered, give I.V. fluids for hypertension, and physostigmine salicylate for respiratory or central nervous system (CNS) depression. Flumazenil, a specific benzodiazepine antagonist, can be used in cases of overdose to reverse the effects of the benzodiazepine.

Opiates (codeine, heroin, morphine, meperidine, and opium)

▪ Street names: for heroin— junk, horse, H, smack, Chinese White, and Mexican mud; for morphine—morph, M, and microdots

▪ Routes: for codeine, meperidine, and morphine—ingestion, injection, and smoking; for heroin—ingestion, injection, inhalation, and smoking; for opium—ingestion and smoking

▪ Dependence: physical and psychological

▪ Duration of effect: 3 to 6 hours

▪ Medical uses: for codeine— analgesia and antitussive; for heroin—none; for morphine and meperidine—analgesia; for opium—analgesia and antidiarrheal

▪ Of use: anorexia, arrhythmias, clammy skin, constipation, constricted pupils, decreased LOC, detachment from reality, drowsiness, euphoria, hypotension, impaired judgment, increased pigmentation over veins, lack of concern, lethargy, nausea, needle marks, respiratory depression, seizures, shallow or slow respirations, skin lesions or abscesses, slurred speech, swollen or perforated nasal mucosa, thrombotic veins, urine retention, and vomiting

▪ Of withdrawal: abdominal cramps, anorexia, chills, diaphoresis, dilated pupils, hyperactive bowel sounds, irritability, nausea, panic, piloerection, runny nose, sweating, tremors, watery eyes, and yawning

▪ If the drug was ingested, induce vomiting or perform gastric lavage.

▪ As ordered, give naloxone until CNS effects are reversed.

▪ Give I.V. fluids to increase circulatory volume.

▪ Use extra blankets for hypothermia; if ineffective, use a hyperthermia blanket.

▪ Reorient the patient to time, place, and person.

▪ Assess breath sounds to monitor for pulmonary edema.

▪ Monitor for signs and symptoms of withdrawal.

▪ Naltrexone is an opiate antagonist that reverses the effects of the opiate.

Hallucinogens

Lysergic acid diethylamide

▪ Street names: LSD, acid, blue dots, cube, D, Owsleys, gel tabs, and microdot

▪ Routes: ingestion, smoking

▪ Dependence: possibly psychological

▪ Duration of effect: 8 to 12 hours

▪ Medical uses: none

▪ Of use: abdominal cramps, arrhythmias, chills, depersonalization, diaphoresis, diarrhea, distorted visual perception and perception of time and space, dizziness, dry mouth, fever, grandiosity, hallucinations, heightened sense of awareness, hyperpnea, hypertension, illusions, increased salivation, muscle aches, mystical experiences, nausea, palpitations, seizures, tachycardia, and vomiting

▪ Of withdrawal: none

▪ Place the patient in a quiet room.

▪ If the drug was ingested, induce vomiting or perform gastric lavage. Follow with activated charcoal and a cathartic.

▪ Monitor his vital signs, and give diazepam for seizures as ordered.

▪ Reorient the patient to time, place, and person, and restrain him as needed.

Phencyclidine

▪ Street names: PCP, hog, angel dust, peace pill, dummy mist, aurora, bust bee, guerrilla, rocket fuel

▪ Routes: ingestion, injection, and smoking

▪ Dependence: possibly psychological

▪ Duration of effect: 30 minutes to several days

▪ Medical uses: veterinary anesthetic

▪ Of use: amnesia; blank stare; cardiac arrest; decreased awareness of surroundings; delusions; distorted body image; distorted sense of sight, hearing, and touch; drooling; euphoria; excitation and psychoses; fever; gait ataxia; hallucinations; hyperactivity; hypertensive crisis; individualized unpredictable effects; muscle rigidity; nystagmus; panic; poor perception of time and distance; possible chromosomal damage; psychotic behavior; recurrent coma; renal failure; seizures; sudden behavioral changes; tachycardia; and violent behavior

▪ Of withdrawal: none

▪ Place the patient in a quiet room.

▪ If the drug was ingested, induce vomiting or perform gastric lavage. Follow with activated charcoal.

▪ Add ascorbic acid to I.V. solution to acidify urine.

▪ Monitor the patient’s vital signs and urine output.

▪ If ordered, give a diuretic; propranolol for hypertension or tachycardia; nitroprusside for severe hypertensive crisis; diazepam for seizures; diazepam or haloperidol for agitation or psychotic behavior; and physostigmine, diazepam, chlordiazepoxide, or chlorpromazine for a “bad trip.”

Stimulants

Amphetamines (amphetamine sulfate, methanephetamine, dextroamphetamine)

▪ Street names: for amphetamine sulfate—bennies, cartwheels, and grennies; for methamphet-amine—speed, meth, and crystal; and for dextroamphetamine sulfate—dexies, hearts, and oranges

▪ Routes: ingestion and injection

▪ Dependence: psychological

▪ Duration of effect: 1 to 4 hours

▪ Medical uses: hyperkinesis, narcolepsy, and weight control

▪ Of use: altered mental status (from confusion to paranoia), coma, diaphoresis, dilated reactive pupils, dry mouth, exhaustion, hallucinations, hyperactive deep tendon reflexes, hypertension, hyperthermia, paradoxical reaction in children, psychotic behavior with prolonged use, seizures, shallow respirations, tachycardia, and tremors

▪ Of withdrawal: abdominal tenderness, apathy, depression, disorientation, irritability, long periods of sleep, and muscle aches, or suicide (with sudden withdrawal)

▪ Place the patient in a quiet room.

▪ If the drug was ingested, induce vomiting or perform gastric lavage; give activated charcoal and a saline or magnesium sulfate cathartic.

▪ Add ammonium chloride or ascorbic acid to I.V. solution to acidify urine to a pH of 5. Also, administer mannitol to induce diuresis, as ordered.

▪ Monitor the patent’s vital signs.

▪ As ordered, give a short-acting barbiturate, such as pentobarbital, for seizures; haloperidol for assaultive behavior; phentolamine for hypertension; propranolol for tachyarrhythmias; and lidocaine for ventricular arrhythmias.

▪ Restrain the patient if he’s experiencing hallucinations or paranoia.

▪ Give a tepid sponge bath for fever.

▪ Institute suicide precautions.

Cocaine

▪ Street names: coke, flake, snow, nose candy, hits, gold dust, toot, crack (hardened form), rock, and crank

▪ Routes: ingestion, injection, sniffing, and smoking

▪ Dependence: psychological

▪ Duration of effect: 15 minutes to 2 hours; with crack, rapid high of short duration followed by down feeling

▪ Medical uses: local anesthetic

▪ Of use: abdominal pain; alternating euphoria and fear; anorexia; cardiotoxicity, such as ventricular fibrillation or cardiac arrest; coma; confusion; diaphoresis; dilated pupils; excitability; fever; grandiosity; hyperpnea; hypotension or hypertension; insomnia; irritability; nausea and vomiting; pallor or cyanosis; perforated nasal septum with prolonged use; pressured speech; psychotic behavior with large doses; respiratory arrest; seizures; spasms; tachycardia; tachypnea; visual, auditory, and olfactory hallucinations; and weight loss

▪ Of withdrawal: anxiety, depression, and fatigue

▪ Place the patient in a quiet room.

If cocaine was ingested, induce vomiting or perform gastric lavage. Follow with activated charcoal and a saline cathartic.

▪ If cocaine was sniffed, remove residual drug from mucous membranes.

▪ Monitor the patient’s vital signs.

▪ Give propranolol for tachycardia.

▪ Perform cardiopulmonary resuscitation for ventricular fibrillation and cardiac arrest, as indicated.

▪ Give a tepid sponge bath for fever.

▪ Administer an anticonvulsant, as ordered, for seizures.

Inspect the eyes for lacrimation from opiate withdrawal, nystagmus from central nervous system (CNS) depressants or phencyclidine intoxication, and drooping eyelids from opiate or CNS depressant use. Constricted pupils occur with opiate use or withdrawal; dilated pupils, with the use of hallucinogens or amphetamines.

Examine the nose for rhinorrhea from opiate withdrawal and the oral and nasal mucosa for signs of drug-induced irritation. Drug sniffing can result in inflammation, atrophy, or perforation of the nasal mucosa. Dental conditions commonly result from the poor oral hygiene associated with chronic drug use. Also inspect under the tongue for evidence of I.V. drug injection.

Inspect the skin. Sweating, a common sign of intoxication with opiates or CNS stimulants, also accompanies most drug withdrawal syndromes. Drug use sometimes induces a sensation of bugs crawling on the skin, known as formication; as a result, the patient’s skin may be excoriated from scratching.

Needle marks or tracks are an obvious sign of I.V. drug abuse. Keep in mind that the patient may attempt to conceal or disguise injection sites with tattoos or by selecting an inconspicuous site such as under the nails. In addition, self-injection can sometimes cause cellulitis or abscesses, especially in the patient who also is a chronic alcoholic. Puffy hands can be a late sign of thrombophlebitis or of fascial infection due to self-injection on the hands or arms.

Auscultation may disclose bilateral crackles and rhonchi caused by smoking and inhaling drugs or by opiate overdose. Other cardiopulmonary signs of overdose include pulmonary edema, respiratory depression, aspiration pneumonia, and hypotension. CNS stimulants and some hallucinogens may cause refractory acute-onset hypertension or cardiac arrhythmias. Withdrawal from opiates or depressants also can provoke arrhythmias and, occasionally, hypotension.

During opiate withdrawal, the patient may report abdominal pain, nausea, or vomiting. He may also complain of hemorrhoids, a consequence of the constipating effects of these drugs. Palpation of an enlarged liver, with or without tenderness, may indicate hepatitis.

Neurologic symptoms of drug abuse include tremors, hyperreflexia, hyporeflexia, and seizures.
Abrupt withdrawal may precipitate signs of CNS depression (ranging from lethargy to coma), hallucinations, or signs of overstimulation, including euphoria and violent behavior.

Carefully review the patient’s medical history. Suspect drug abuse if he reports a painful injury or chronic illness but refuses a diagnostic workup. In his attempt to obtain drugs, the dependent patient may feign illnesses, such as migraine headaches, myocardial infarction, and renal colic; claim an allergy to over-thecounter analgesics; or even request a specific medication. Also be alert for a history of overdose or a high tolerance for potentially addictive drugs. An I.V. drug user may have a history of hepatitis or human immunodeficiency virus (HIV) infection from sharing dirty needles. A female drug user may report a history of amenorrhea.

A patient who abuses drugs may give you a fictitious name and address, be reluctant to discuss previous hospitalizations, or seek treatment at a medical facility across town rather than in his own neighborhood. If possible, obtain the patient’s previous medical records and interview family members to verify his responses.

If the patient admits to drug use, try to determine the extent to which this behavior interferes with his normal functioning. Note whether he expresses a desire to overcome his dependence on drugs. If possible, obtain a drug history consisting of substances ingested, amount, frequency, and last dose. Expect incomplete or inaccurate responses. Drug-induced amnesia, a depressed level of consciousness, or ignorance may distort the patient’s recollection of the facts; he also may fabricate answers to avoid arrest or to conceal a suicide attempt.

The abuse of psychoactive substances may cause a need for dosage adjustments to prescribed medications. Cross-tolerance occurs when one drug that has particular properties results in tolerance of another drug. Drugs with similar pharmacologic properties, such as CNS depressants, will cause the need for more of a similar class of drug to get the same response. This may occur, for example, when a patient on an opiate goes to surgery. More anesthesia is needed for this patient than is needed for an opiate-naive patient.

The hospitalized drug abuser is likely to be uncooperative, disruptive, or even violent. He may experience mood swings, anxiety, impaired memory, sleep disturbances, flashbacks, slurred speech, depression, and thought disorders. He may resort to plays on sympathy, bribery, or threats to obtain drugs, or he may try to pit one caregiver against another.

Psychoactive substances may be used in cultural practices. For instance, some Native Americans use hallucinatory drugs to help achieve spiritual experiences. Therefore, use and abuse must be carefully distinguished.

Diagnosis

For characteristic findings in patients with this condition, see Diagnosing substance dependence and related disorders, page 1126. Various tests can confirm drug use, determine the amount and type of drug taken, and reveal complications. For example, a serum or urine drug screen can detect recently ingested substances.

Characteristic findings in other tests include elevated serum globulin levels, hypoglycemia, leukocytosis, liver function abnormalities, positive Venereal Disease Research Laboratory test results, positive rapid plasma reagin test results due to elevated protein fractions, an elevated mean corpuscular hemoglobin level, elevated uric acid levels, and reduced blood urea nitrogen levels.

Treatment

The patient with acute drug intoxication should receive symptomatic treatment based on the drug ingested. Measures include fluid replacement therapy and nutritional and vitamin supplements, if indicated; detoxification with the same drug or a pharmacologically similar drug (exceptions include cocaine, hallucinogens, and marijuana, which aren’t used for detoxification); sedatives to induce sleep; anticholinergics and antidiarrheals to relieve GI distress; anxiolytics for severe agitation, especially in cocaine abusers; and symptomatic treatment of complications. Depending on the dosage and time elapsed before admission, additional treatment may include gastric lavage, induced emesis, activated charcoal, forced diuresis and, possibly, hemoperfusion or hemodialysis.

Treatment of drug dependence commonly involves a triad of care: detoxification, short- and long-term rehabilitation, and aftercare; the latter means a lifetime of abstinence, usually aided by participation in Narcotics Anonymous (NA) or a similar self-help group.

Detoxification, the controlled and gradual withdrawal of an abused drug, is achieved through substituting a drug with a similar action. Such gradual replacement of the abused drug controls the effects of withdrawal, thereby reducing the patient’s discomfort and associated risks.

Depending on which drug the patient has abused, detoxification may be managed on an inpatient or outpatient basis. For example, withdrawal from depressants can produce hazardous adverse reactions, such as generalized tonic-clonic seizures, status epilepticus, and hypotension. The severity of these reactions determines whether the patient can be safely treated as an outpatient or if he requires hospitalization. Withdrawal from depressants usually requires detoxification because abrupt or poorly managed withdrawal from barbiturates can cause death.

Opioid withdrawal causes severe physical discomfort and can be life threatening. To minimize these effects, chronic opioid abusers commonly are detoxified with methadone.

To ease withdrawal from opioids, depressants, and other drugs, useful nonchemical measures may include psychotherapy, exercise, relaxation techniques, and nutritional support. Sedatives and tranquilizers may be administered temporarily to help the patient cope with insomnia, anxiety, and depression.

Buprenorphine with naloxone is another drug that’s being used to lessen craving in opiateaddicted patients. Naloxone is an opiate antagonist; it blocks opiate receptors. A person taking buprenorphine with nalorone won’t respond to the effects of other opioids.

After withdrawal, the patient needs to participate in a rehabilitation program to prevent a recurrence. Rehabilitation programs are available for inpatients and outpatients; they usually last a month or longer and may include individual, group, and family psychotherapy. During and after rehabilitation, participation in a drug-oriented self-help group may be helpful. The largest such group is NA.

Special considerations

Focus on restoring the patient’s physical health, educating him and his family about drug abuse and dependence, providing support, and encouraging participation in drug treatment programs and self-help groups.

During an acute episode:

Continuously monitor the patient’s vital signs, and observe for complications of overdose and withdrawal, such as cardiopulmonary arrest, seizures, and aspiration.
Based on standard hospital policy, institute appropriate measures to prevent suicide attempts.
Give medications, as ordered, to decrease withdrawal symptoms; monitor and record their effectiveness.
Maintain a quiet, safe environment during withdrawal from any drug because excessive noise may agitate the patient.
Remove harmful objects from the patient’s room, and use restraints only if you suspect that he might harm himself or others. Institute seizure precautions.

After an acute episode:

Learn to control your reactions to the patient’s undesirable behaviors—commonly, psychological dependency, manipulation, anger, frustration, and alienation.
Set limits for dealing with demanding, manipulative behavior.
Promote adequate nutrition and monitor the patient’s nutritional intake.
Administer medications carefully to prevent hoarding by the patient. Check the patient’s mouth to ensure that he has swallowed the medication. Closely monitor visitors who might supply the patient with drugs.
Refer the patient for detoxification and rehabilitation, as appropriate. Give him a list of available resources.
Encourage family members to seek help whether or not the abuser seeks it. You can suggest private therapy or community mental health clinics.

If the patient refuses to participate in a rehabilitation program, teach him how to minimize the risk of drug-related complications, as follows:
Review measures for preventing HIV infection and hepatitis. Stress that these infections are readily transmitted by sharing needles with other drug users and by having unprotected sexual intercourse.
Advise the patient to use a new needle for every injection or to clean needles with a solution of chlorine bleach and water.
Emphasize the importance of using a condom during intercourse to prevent disease transmission and pregnancy. If necessary, teach the female drug abuser about other methods of birth control. Explain the devastating effects of drugs on the developing fetus.

PSYCHOTIC DISORDERS

Schizophrenia

Schizophrenia is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, sense of self, volition,
interpersonal relationships, and psychomotor behavior. (See Phases of schizophrenia.) The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), recognizes paranoid, disorganized, catatonic, undifferentiated, and residual schizophrenia. Onset of symptoms usually occurs during adolescence or early adulthood. The disorder produces varying degrees of impairment. Up to one-third of patients with schizophrenia have just one psychotic episode and no more. Some patients have no disability between periods of exacerbation; others need continuous institutional care. The prognosis worsens with each episode.

Phases of schizophrenia

Schizophrenia usually occurs in three phases: prodromal, active, and residual.

Prodromal phase

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Tags: Professional Guide to Diseases

Aug 27, 2016 | Posted by drzezo in PATHOLOGY & LABORATORY MEDICINE | Comments Off

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