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.
superimposed on cyclothymic disorder. A patient also may have a disorder on axes I, II, and III simultaneously.
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)
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.
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?
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.
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.
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
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.
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.
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.
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.
Alcohol (ethyl, isopropyl, and methyl)
Ethchlorvynol
Chlorpromazine
Cocaine
Desmethyldoxepin (metabolite of doxepin)
Heroin (metabolized to and detected as morphine)
Imipramine
Methadone
Morphine
Phencyclidine (PCP)
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
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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)
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.
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.
Physical injury
Retinal detachment
Orthopedic disorders
Self-mutilation
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.
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.
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.
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.
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.)
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.
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
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
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
social interaction
language as used in social communication
symbolic or imaginative play
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
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.
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.
Emotional and social complications
Poor nutrition
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.
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
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
often blurts out answers before questions have been completed
often has difficulty awaiting his turn
often interrupts or intrudes on others
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.
used in combination with stimulants. However, other drugs, including tricyclic antidepressants, mood stabilizers, and beta-adrenergic blockers, sometimes help control symptoms.
Work with the patient and his parents to develop external structure and controls.
Set realistic expectations and limits because the patient with ADHD is easily frustrated (which leads to decreased self-control).
Remain calm and consistent.
Keep instructions short and simple.
Provide praise, rewards, and positive feedback whenever possible.
Poor performance in school
Substance abuse
Higher incidence of other psychosocial disorders such as ADHD, oppositional defiant disorder, mood disorders, anxiety disorders, depression, and learning disabilities
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
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.
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
Has deliberately set fire with the intention of causing serious damage
Has deliberately destroyed others’ property
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
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
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.
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.
an excessively stressful lifestyle, and social attitudes that approve of frequent drinking.
Cardiac arrhythmias
Cardiomyopathy
Chronic obstructive pulmonary disease
Essential hypertension
Increased risk of tuberculosis
Pneumonia
Chronic diarrhea
Esophageal cancer
Esophageal varices
Esophagitis
Gastric ulcers
Gastritis
GI bleeding
Malabsorption
Pancreatitis
Anemia
Leukopenia
Reduced number of phagocytes
Alcoholic hepatitis
Cirrhosis
Fatty liver
Alcoholic dementia
Alcoholic hallucinosis
Alcohol withdrawal delirium
Korsakoff’s syndrome
Peripheral neuropathy
Seizure disorders
Subdural hematoma
Wernicke’s encephalopathy
Amotivational syndrome
Depression
Fetal alcohol syndrome
Impaired social and occupational functioning
Multiple substance abuse
Suicide
Beriberi
Hypoglycemia
Infertility
Leg and foot ulcers
Impaired respiratory diffusion
Increased incidence of pulmonary infections
Myopathies
Prostatitis
Sexual performance difficulties
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.
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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 |
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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.
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.
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 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.
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.
Cardiac and respiratory arrest
Intracranial hemorrhage
Acquired immunodeficiency syndrome
Subacute bacterial endocarditis
Hepatitis
Septicemia
Pulmonary emboli
Gangrene
fever can result from stimulant or hallucinogen intoxication, from withdrawal, or from infection caused by I.V. drug use.
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. |
Abrupt withdrawal may precipitate signs of CNS depression (ranging from lethargy to coma), hallucinations, or signs of overstimulation, including euphoria and violent behavior.
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.
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.
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.
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