|
|
|
|
|
|
|
|
INTRODUCTION: General Considerations: a. Similarities and differences of symptomatology b. Problems of differentiation: very often, the same symptoms underlie different disorders. c. Complication stemming from the issues of the primary and secondary diagnosis and causative factors of the problems. Which problem is primary and which is secondary due to the first one? d. Difficulties in making the immediate diagnosis e. The complication of the issues by the polysubstance abuse f. Complication of the dual diagnosis individuals g. The physiological issues of the type of addictions and mental illness as seen in the production of the neurotransmitting substances in the human brain (dopamine, endorphine, etc). - those who are allegedly born with inability of the brain to produce these substances to maintain balance; those who by the prolonged use destroy the ability of the brain to produce them any longer (if you do not use it, you will lose it); those who abuse substances because of self-medication (majority of mentally ill); and those who use it only occasionally.
a. Use: Occasional use of alcohol and other drugs without development of any tolerance or withdrawal symptoms. Individual is using no more than several times a year during the holidays and vacation days. b. Abuse: Continued use of alcohol and other drugs despite knowledge of having a persistent or recurring social, occupational, psychological, or physical problems. c. Dependence: In order to diagnose substance dependence, at least three of the following must be present:
CENTRAL NERVOUS SYSTEM DEPRESSANTS This is a very broad category of substances that has a variety of effects, duration, addictive potentials, severity of tolerance and withdrawal symptoms and length of detoxification. The major subcategories of this category are:
The essential and associates features of these substances are very similar to those of alcohol intoxication. Because of that, they have a cross-tolerance to each other and to alcohol, that is, taking them together potentiate their effect manifoldly. However, intoxication with this class of substances is less likely to result in displaying of aggression or violence than is the case with alcohol intoxication. As with alcohol, the initial behavioral effects of this class are usually disinhibitory. If the person continues to use these substances, inhibitory effects will supervene. The essential features of this disorder are maladaptive behavioral changes, manifested in disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning. Characteristic physical signs are:
Cessation of prolonged (several weeks or more) moderate or heavy use of this class of substances, or reduction in the amount of substance used, leads to at least three of the following:
Approximate detectability time in urine for minor tranquilizers is 14 days after last usage. For short-acting barbiturate (Secobarbital) 24 hours. All others 2-3 weeks. CENTRAL NERVOUS SYSTEM STIMULANTS This class of substances is represented by Cocaine, Crack, Amphetamine (Benzedrine), Methamphetamine (Desoxyn), Ice, Phenmetrazine (Preludine), Ritaline, etc. MDMA (ecstasy) shares these properties and properties of Hallucinogens. The course of intoxication by this class of substances is self-limited, with full recovery within 48 hours. Behavioral Changes: Euphoria, grandiosity, hypervigilance, fighting, psychomotor agitation, impaired judgment, impaired social or occupational functioning. The Physical Symptoms: Pupillary dilation; elevated blood pressure; perspiration or chills; nausea or vomiting. Withdrawal Symptoms: Severe depression ("crash"); irritability; anxiety; fatigue; insomnia or hypersomnia; psychomotor agitation; intense craving for the substance. These symptoms usually reach a peak in two to four days, although depression and irritability may persists for months. Complications: Delirium may develop within 24 hours of use. Delusional disorder occurs - rapidly developing persecutory delusions - paranoid state. Distortion of body image and misperception of people's faces may occur. Initially, suspiciousness and curiosity may be experienced with pleasure, but may later induce aggressive or violent action against "enemies." The hallucination of bugs or vermin crawling in or under the skin (formication) can lead to scratchy and extensive skin damage. These delusions can linger for a week or more but occasionally last for over a year. With use of this class of substance syncope or chest pain may occur. There may be seizures following large doses. Death may result from cardiac arrythmia or respiratory paralysis. Approximate detectability time in urine 24-48 hours. For Cocaine 24-72 hours. OPIATES AND OTHER ANALGESICS The following substances are representatives of this class: Opium, Morphine, Heroin, Methadone, Codeine, Darvon, Demerol, Fentanyl (China White), etc. The course of action of this substances depends on the type. It varies from the short term (several minutes) to long term (several hours). Behavioral Changes: Initial euphoria followed by apathy, dysphoria, psychomotor retardation, impairedjudgment, impaired social or occupational functioning. Physical Symptoms: pupillary constriction (if severe overdose resulting in anoxia - pupillary dilation); drowsiness; slurred speech; impaired attention or memory. Withdrawal Symptoms: craving for opiates; nausea or vomiting; muscle aches; lacrimation (wet eyes) or rhinorrhea (runny nose); pupillary dilation; piloerection; sweating; diarrhea; yawning; fever; insomnia (these are all typical influenza symptoms). Course: For Heroin and Morphine the first signs of withdrawal are usually noted within six to eight hours after last use, reach a peak on the second or third day, and disappear in seven to ten days. For Demerol withdrawal symptoms begin more quickly, reach a peak within 8 to 12 hours, and are over within 4 or 5 days. Methadone withdrawal may not begin for one to three days after the last dose, and its severity depends on the degree of dependence. The symptoms are usually over by the 10th to 14th day. Approximate detectability time in urine for Methadone is 72 hours. For other opiates 48-72 hours. HALLUCINOGENS OR PSYCHEDELICS The representatives of this class of substances are LSD, Psilocybin (mushrooms), Mescaline (peyote), MDMA (ecstasy) - shared with Amphetamines. Course: The onset is usually within an hour of use. In the case of LSD, the most commonly used hallucinogen, the disorder lasts from 8 to 12 hours. For others the duration may range from under an hour to a day or two - at most, three days. Behavioral Changes: An increased awareness of sensory input with vivid colors and a sharpened sense of hearing; depersonalization; illusions; hallucinations; synesthesia (seeing colors when loud sound occurs). The hallucinations are usually visual, often of geometric forms and figures, sometimes of persons and objects. Auditory hallucinations are rare. Euphoria is common. Mystical or religious experiences are present. Physical Symptoms: Pupillary dilation; tachycardia; sweating; palpitations; blurring of vision; tremors; incoordination. Bad Trip: Marked anxiety and depression; ideas of reference; fear of loosing one's mind; paranoid ideation; impaired judgment, or impaired social or occupational functioning. In most instances, every person using this class of substances realizes that the perceptual changes he/she is experiencing are due to the effect of the hallucinogen. Complications: Hallucinogen Delusional Disorder may develop. It is the same as above, except the person has a delusional conviction that the disturbed perceptions and thoughts correspond to reality. Course: variable - from a brief, transitory experience to a long-lasting psychotic episode that is difficult to distinguish from a schizophrenic disorder. Hallucinogen Mood Disorder: Appearance of Depression or anxiety; elation is rare. The depressive features include feelings of self-reproach or excessive or inappropriate guilt, accompanied by fearfulness, tension, and physical restlessness. Course: variable, and may range from a brief, transient experience to a long-lasting episode that is difficult to distinguish from a Mood Disorder. Posthallucinogen Perception Disorder: Flash back. Reexperiencing the symptoms of hallucinogen taking without actual taking any of these substances. The disturbance causes marked distress. Complications of this disorder include suicidal behavior, Major Depression, and Panic Disorder. Approximate detectability time in urine is 8 days. SOLVENTS AND INHALANTS The representatives of this class of substances are Glues, Aerosols, Cleaning Solutions, Nail Polish Removal, lighter Fluids, Paints and Paint Thinners; other petroleum products (gasoline, etc.) Course: The usual "high" begins within minutes and lasts a quarter to three quarters of an hour, during which the user feels giddy and light-headed. The symptoms of mild to moderate intoxication by these class of substances are very similar to those of Alcohol and Sedatives or Hypnotic Intoxication. Behavioral Changes: may include belligerence, assaultiveness, apathy, impaired judgment, etc. Physical Signs: include dizziness; nystagmus; slurred speech; unsteady gait; lethargy; depressed reflexes; tremor; blurred vision; stupor or coma. High acute doses or chronic heavy use of this class may induce characteristic neurological signs, such as incoordination, generalized muscle weakness, and psychomotor retardation. This class of substances often leave visible external signs of use, including a rash around the nose and mouth, breath odors, and residue on the face, hands, and clothing. Eye irritation is common (redness, swelling, tearing), and there may be irritation of the throat, lungs, and nose (coughing, gagging, or sinus discharge). Nausea and headache are common. OTHERS The main representative of this category is Phencyclidine, also known as PCP or Angel Dust. Course: In most cases, people are alert and oriented within three to four hours following the use of PCP. Chronic users of PCP report feeling intoxicated for four to six hours. Effects may last for several days and even years. Complication: Death from respiratory depression can occur following a high dose. The Behavioral Changes: The symptoms begin within one hour of oral use of PCP; if smoked, snored or taken intravenously, onset may be within fiveminutes. They are: belligerence; assaultiveness; impulsiveness; unpredictability; psychomotor agitation. The Physical Symptoms: Vertical and horizontal nystagmus (an involuntary spasmodic motion of the eyeball); increased blood pressure and heart rate; numbness or diminished responsiveness to pain; ataxia ( inability to coordinate voluntary muscle movements); muscle rigidity and seizures. Intoxication may be accompanied by repetitive motor movements, facial grimacing, muscle rigidity on stimulation, and repeated episodes of vomiting. There may be also hallucination, paranoid ideations and bizarre and violent behavior. Complications and Course: Similar as with the Hallucinogens (delirium, delusional disorder and mood disorder with the same possible outcome). PCP can be stored within the fatty tissues or lipids of the brain for up to two years and, unpredictably, may be released into the blood stream causing reoccurrence of the above-described symptoms without any additional use. Detectable in urine for 8 days. |