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III. Clinical evaluation
A. The clinical features of substance abuse are
a maladaptive pattern of use that leads to
significant impairment. Substance abusers
are unable to fulfill work or personal obliga­
tions; they continue to use the substance in
situations where it is physically dangerous;
they have substance-related legal problems,
and continue to use despite resultant inter­
personal problems.
B. Substance abuse is defined as substance
dependence when tolerance and withdrawal
symptoms develop. Tolerance occurs when
the user requires increasing amounts of the
substance in order to become intoxicated.
C. Withdrawal is characterized by physiological
symptoms that develop upon cessation of
use. The initial signs of alcohol withdrawal
are sweating and tachycardia. Tremors or
 shakes, seizures, and auditory and tactile
hallucinations (formication) may also occur
within the first 48 hours of alcohol cessation.
D. Alcohol withdrawal delirium (delirium
tremens) may present two to three days
after cessation, but patients are at risk for
up to one week. Delirium typically occurs
only in people who have abused alcohol
heavily for many years.
E. Other symptoms of substance dependence
include taking larger amounts of a sub­
stance than intended, persistent failed ef­
forts to cut down, and spending an enor­
mous amount of time trying to obtain the
substance.
IV.Treatment
A. Patients with acute alcohol intoxication may
require inpatient admission to prevent the
development of seizures and delirium
tremens, to treat dehydration, monitor
suicidality, or to treat psychotic symptoms.
Inpatient admission is also considered when
outpatient detoxification has failed.
B. Benzodiazepines are used for withdrawal
prophylaxis and acute management of
seizures.
C. Patients are hydrated if necessary and
thiamine is given to prevent the develop­
ment of Wernicke s Encephalopathy. Long­
term inpatient rehabilitation and ongoing
outpatient substance-abuse counseling are
required to prevent relapse.
References, see page 92.
Dissociation - History Taking
History of present illness: Current symptoms,
duration, date of onset, sudden vs. gradual onset
of symptoms, potential triggers, and associated
distress. Ask about losing time, memory gaps,
blackouts, forgetfulness, accumulating posses­
sions without remembering how they were ac­
quired. Ask the patient if he has ever been told
about out-of-character behavior, or if he has ever
found himself in places without knowing how he
arrived. Dissociative Amnesia is assessed by
asking about episodic memory loss, memory loss
for specific intervals of time, or for personal infor­
mation. Consider whether amnestic events are of
a stressful or traumatic nature.
Dissociative Fugue is assessed by asking about
recent travel and identity confusion. If Dissociative
Identity Disorder is suspected, ask about another
person existing inside the patient, voices coming
from inside, and other people taking control of the
patient. Also in dissociative identity disorder, ask
about memory loss for childhood events, flash­
backs, headaches, blank spells, being recognized
by people the patient does not know, or being
called by a different name.
Depersonalization Disorder is assessed by asking
about feeling unreal, being outside one s body,
looking at oneself from overhead or at a distance,
dizziness, perceptual clouding, and perceived
bodily changes like enlarged extremities. Ask
about comorbid symptoms of depression and
anxiety.
Past psychiatric history: Past psychiatric diag­
noses, hospitalizations, and treatments.
Dissociative symptoms can appear in schizophre­
nia, Somatoform Disorders, major depression,
bipolar disorder, obsessive-compulsive disorder,
acute or post-traumatic stress disorder, panic
disorder, borderline personality disorder, and
histrionic personality disorder. A history of anxiety
and depressive symptoms is a predisposing factor
to developing a dissociative disorder.
Substance abuse history: Substance intoxica­
tion can cause dissociative symptoms; therefore,
ask specifically about alcohol, benzodiazepines,
marijuana, hallucinogens, and barbiturates.
Social history: Family relationships, divorce,
marital discord, exposure to domestic violence,
history of physical abuse, sexual abuse or other
traumatic events. Ask about legal history and
possible motivations for secondary gain.
Family history: Psychiatric disorders in family
members, relatives seeing a psychiatrist, or taking
psychiatric medication. Dissociative identity
disorder may occur more frequently among first­
degree relatives.
Past medical history: Neurological disorders,
head trauma, seizures, brain tumors, and migraine
headaches can all cause dissociative symptoms.
Hypothyroidism and hypoglycemia can also cause [ Pobierz całość w formacie PDF ]