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Physical management is necessary if psychological and pharmacologic means are not sufficient It requires the active and visible presence of an adequate number of personnel (five or six) to reinforce the idea that the situation is under control despite the patient s lack of inner controls Such an approach
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often precludes the need for actual physical restraint When adequate personnel are not available, however, two people shielded by a mattress (single-bed size) can usually corner and subdue the patient without injury to anyone Seclusion rooms and restraints should be used only when necessary (ambulatory restraints are an alternative), and the patient must then be observed at frequent intervals Design of corridors and seclusion rooms is important Narrow corridors, small spaces, and crowded areas exacerbate the potential for violence in an anxious patient
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The treatment of victims (eg, battered women) is challenging and often complicated by their reluctance to leave the situation Reasons for staying vary, but common themes include the fear of more violence because of leaving, the hope that the situation may ameliorate (in spite of steady worsening), and the financial aspects of the situation, which are seldom to the woman s advantage Concerns for the children often finally compel the woman to seek help An early step is to get the woman into a therapeutic situation that provides the support of others in similar straits Al-Anon is frequently a valuable asset and quite appropriate when alcohol is a factor The group can support the victim while she gathers strength to consider alternatives without being paralyzed by fear Many cities now offer temporary emergency centers and counseling Use the available resources, attend to any medical or psychiatric problems, and maintain a compassionate interest Some states now require physicians to report injuries caused by abuse to police authorities
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Jonassen JA et al Identification of physician and patient attributes that influence the likelihood of screening for intimate partner violence Acad Med 2003 Oct;78(10 Suppl): S20 3 [PMID: 14557085] McFarlane J et al Abuse during pregnancy and femicide: urgent implications for women s health Obstet Gynecol 2002 Jul; 100(1):27 36 [PMID: 12100800] Walthan CN et al Interventions for violence against women: scientific review JAMA 2003 Feb 5;289(5):589 600 [PMID: 12578492]
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The term drug dependency is used in a broad sense here to include both addictions and habituations It involves the triad of compulsive drug use referred to as drug addiction, which includes: (1) a psychological dependence or craving and the behavior involved in procurement of the drug; (2) physiologic dependence, with withdrawal symptoms on discontinuance of the drug; and (3) tolerance, ie, the need to increase the dose to obtain the desired effects Drug dependency is a function of the amount of drug used and the duration of usage The amount needed to produce dependency varies with the nature of the drug and the idiosyncratic nature of the user The frequency of use is usually daily, and the duration is inevitably greater than 2 3 weeks Polydrug abuse is very
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common Transgenerational continuity of drug abuse is also common There is accumulating evidence that an impairment syndrome exists in many former (and current) drug users It is believed that drug use produces damaged neurotransmitter receptor sites and that the consequent imbalance produces symptoms that may mimic other psychiatric illnesses Kindling repeated stimulation of the brain renders the individual more susceptible to focal brain activity with minimal stimulation Stimulants and depressants can produce kindling, leading to relatively spontaneous effects no longer dependent on the original stimulus These effects may be manifested as mood swings, panic, psychosis, and occasionally overt seizure activity The imbalance also results in frequent job changes, marital problems, and generally erratic behavior Patients with PTSD frequently have treated themselves with a variety of drugs Chronic abusers of a wide variety of drugs exhibit cerebral atrophy on CT scans, a finding that may relate to the above symptoms Early recognition is important, mainly to establish realistic treatment programs that are chiefly symptom-directed The clinician faces three problems with substance abuse: (1) the prescribing of substances such as sedatives, stimulants, or opioids that might produce dependency; (2) the treatment of individuals who have already abused drugs, most commonly alcohol; and (3) the detection of illicit drug use in patients presenting with psychiatric symptoms The usefulness of urinalysis for detection of drugs varies markedly with different drugs and under different circumstances (pharmacokinetics is a major factor) Water-soluble drugs (eg, alcohol, stimulants, opioids) are eliminated in a day or so Lipophilic substances (eg, barbiturates, tetrahydrocannabinol) appear in the urine over longer periods of time: several days in most cases, 1 2 months in chronic marijuana users Sedative drug determinations are quite variable, amount of drug and duration of use being important determinants False-positives can be a problem related to ingestion of some legitimate drugs (eg, phenytoin for barbiturates, phenylpropanolamine for amphetamines, chlorpromazine for opioids) and some foods (eg, poppy seeds for opioids, coca leaf tea for cocaine) Manipulations can alter the legitimacy of the testing Dilution, either in vivo or in vitro, can be detected by checking urine specific gravity Addition of ammonia, vinegar, or salt may invalidate the test, but odor and pH determinations are simple Hair analysis can determine drug use over longer periods, particularly sequential drugtaking patterns The sensitivity and reliability of such tests are considered good, and the method may be complementary to urinalysis
Kosten TR et al Management of drug and alcohol withdrawal N Engl J Med 2003 May 1;348(18):1786 95 [PMID: 12724485] Prochaska JJ et al Addressing nicotine dependence in psychodynamic psychotherapy: perspectives from residency training Acad Psychiatry 2007 Jan Feb;31(1):8 14 [PMID: 17242046] Thom B From alcoholism treatment to the alcohol harm reduction strategy for England: an overview of alcohol policy since 1950 Am J Addict 2005 Oct Dec;14(5):416 25 [PMID: 16257879]
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