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Substance Abuse

There is currently a debate about whether some women are beaten because their own substance abuse renders them vulnerable to attack or whether they self-medicate in response to being abused over a period of years. These may be two distinct groups of women. Either way, many abused women suffer from addiction to drugs or alcohol. Recent studies have shown that a far greater percentage of substance-abusing battered women did not use or abuse substances before the start of the battering. Some women have reported that the batterer encouraged them to drink or to use drugs. Others have noted that the batterer forced them to use alcohol or drugs along with him. Nonetheless, many shelters address the issues of drug and alcohol dependency in their efforts to help battered women survive. These efforts can take the form of classes, support groups, or transportation to existing programs in the community.

Acquired immunodeficiency syndrome

Generally the most severe but neurological problems such as dementia resulting from HIV infection of the brain cells can also occur. The disease is almost always fatal. It is generally transmitted through blood and body fluids, usually through unprotected sexual intercourse, but vertical and or perinatal transmission is also very common. AIDS is prevalent among injecting drug addicts and in patients receiving blood transfusions. It can be partly controlled by antiretroviral drugs such as AZT (azidothymidine) or non-nucleoside reverse transcriptase inhibitors such as nevirapine combined with protease inhibitors (See HAART therapy), but the side-effects of the drugs are not negligible.

Pharmacology Benzodiazepines

IV midazolam has been associated with respiratory depression, especially when combined with a narcotic. Other adverse effects include hiccoughs, nausea and vomiting, and tenderness at the IV site. Paradoxical reactions, such as agitation, hyperactivity, and combativeness, have been reported in patients with alcohol and substance abuse.

Assessment of Mental Health in Older Adults

ASSESSMENT OF MENTAL HEALTH processes in the elderly can be particularly challenging, in part due to the fact that many assessment instruments were developed on younger populations and may not provide as accurate a picture in older populations, who vary greatly in their levels of cognitive, sensory, and motor abilities. In addition, many physical and mental illnesses in late life can present similar symptoms, and differentiating between the two is the focus of much of the assessment research in late life. Finally, the elderly may be less likely to disclose certain types of problems, and thus special techniques may be necessary to assess sources of psychological distress, including substance abuse and life events. However, less is known about what constitutes positive mental health in late life.

Behavioral Medicine

Chronic diseases have replaced acute, infectious diseases as the leading causes of death. Those chronic diseases often have cause effect behavioral relationships with unhealthy behavioral habits such as cigarette smoking, lack of exercise, poor eating habits, substance abuse, and so on. Those facts are the main reasons behavioral medicine is one of the most clinically valuable, recent byproducts of comprehensive behavior therapy. Behavioral medicine has already demonstrated great clinical value in preventing and treating health problems. For example, in recent decades there has been a significant decrease in the death rate for cardiovascular diseases. That decrease resulted largely from people making healthy changes in their personal habits and learning healthier techniques of emotional distress management. See Behavioral Medicine.

WA HoogerwerfMD and P Jay PasrichaMD

Pain is a subjective experience there are no diagnostic tests that can determine the quality or intensity of an individual's pain. Regardless of whether there is an apparent so-called organic cause of the pain or not, the physician should bear in mind that pain often dominates the lives of patients in a negative fashion. Unfortunately, the patient with chronic abdominal pain is increasingly perceived as a clinical liability by the busy practitioner, with his or her symptoms either trivialized or perhaps worse, dismissed as representative of either malingering , psychosomatic , or drug-seeking behavior. These and various other, rather unscientific euphemisms of a similar nature are reflective of the physician's lack of understanding of the biological basis, as well as the psychosocial dimensions, of chronic pain and the consequent frustration of not being able to place the symptom in a conceptually familiar frame of reference (as compared with a symptom such as hematochezia). This has...

Fears Due to Inadequate Understanding

Unrealistic fears of the diagnosis and treatment are also a problem for many, and those who do not understand that ADHD is a complicated and significantly impairing problem are not likely to learn enough about the disorder to alleviate those fears. For example, many parents worry that if they provide stimulant treatment for their son or daughter with ADHD, the child might have an increased risk of drug addiction later in life. Ironically, by not seeking information about ADHD treatment, they are not likely to find out that a child who has ADHD, if untreated or inadequately treated, has double the risk of suffering, at some point in life, from substance abuse severe enough to warrant diagnosis. Indeed, five scientific studies involving almost a thousand children with ADHD have demonstrated that children whose ADHD is consistently treated with appropriate medications during childhood and adolescence have their elevated risk of substance abuse reduced, essentially to that of a child...

Substance Use Disorders

Among individuals diagnosed with ADHD, there is a markedly elevated incidence and severity of abuse and dependence on alcohol and other drugs over the lifetime. This difference does not become clear in group data until after mid-adolescence, however, when many of those with ADHD tend to become caught up in escalating problems with substance abuse. Joseph Biederman and Timothy Wilens (1997) published data comparing ADHD boys' and normal controls' use of drugs and alcohol at baseline and four years later. They found no difference between the ADHD adolescents and controls in rates of substance use disorders up to age fifteen years. Yet an earlier study of adults indicated that 52 percent of those diagnosed with ADHD had qualified for diagnosis of substance abuse or dependence at some point in their lives, while only half that percentage (27 percent) of adults without ADHD met the diagnostic criteria for substance use disorder. stance use before remission. Apparently those with ADHD tend...

Rates of Retention and Recidivism

A major problem with samples in research studies includes subject attrition, or dropping out of the research program before the end of the study. We do know that batterers who drop out of treatment are more likely to be young, to have substance abuse problems, and to have a longer history of abuse. Yet some offenders are so violent as to be considered un-treatable and thus are not referred for intervention by courts, probation officers, or community agencies. They are seldom included in treatment outcome studies. In addition, women may not want to participate initially or to continue in research studies for a number of reasons, including deciding to return to the abuser, lack of interest, or out of fear for their safety.

Diagnosis Combined Type Inattentive Type

Substance Abuse It should be emphasized that the percentages in this table are lifetime rates. For example, a forty-seven-year-old businessman with combined-type ADHD who had smoked marijuana heavily for a year during college and then had abstained from any marijuana use for the following quarter-century would be included in the 69 percent with a history of substance abuse or dependence.

Reviewing Resources and Obstacles

Limited influence over environmental circumstances may pose an obstacle. Child maltreatment is related to poverty. Unemployment is related to substance abuse and spouse violence. Agency policies and practices influence options. Lack of coordination of services may limit access to resources. Clients may receive fragmentary, overlapping, or incompatible services.

More Specialized Treatments

As mentioned earlier, some persons with ADD syndrome also suffer from severe learning disorders such as reading disorder, math disorder, or disorder of written expression. During the school years, they are likely to need special education services in addition to treatment for ADD impairments. Others with ADD syndrome are actively caught up in abuse or dependence on alcohol, marijuana, or other drugs for them, effective treatment of their substance abuse will be required before their ADD impairments can adequately be alleviated. Still others with ADD syndrome may have chronic and severe problems with panic attacks or OCD. And severe social impairments on the Asperger's autistic spectrum or severe problems with mood regulation, depression, or bipolar disorder can also complicate the patient's struggles with ADD syndrome. Detailed information about treatment options for ADHD in combination with these various comorbid disorders is the primary focus of my edited textbook Attention Deficit...

Who Are the Batterers

Abused as children than other types of batterers. Substance abuse is associated with their violence only about half of the time. Within-family abusers do not appear to have clinical levels of depression or anger, but do appear to be jealous and to minimize their violent behavior. Approximately half of all batterers who enter treatment programs match the description of the family-only batterer. The second categorical dimension is the pan-violent or antisocial batterer. Approximately one-fourth of batterers in treatment programs fit this description. Generally, pan-violent batterers have the highest rates of severe physical assault to their partners and are most likely to behave in violent ways in settings outside of the family. Not surprisingly, they have high rates of substance abuse, arrest, and involvement with the legal system. They are likely to have been severely abused as children and show only moderate levels of marital satisfaction, anger, and depression. Yet they are most...

The Nature of Behavioral Disorders

AN and BN are driven, repetitive behavioral disorders that are difficult to interrupt. They share characteristics with other pathological behavioral conditions, such as substance abuse. Excuses are made for not eating, and vomiting or hiding food is done surreptitiously. Disturbed eating and dieting behaviors gradually come to dominate the person's life, impairing physical, psychological, or social function. Persons with disorders of behavior frequently attribute their difficulties to various causes (eg, conflicts with others or circumstantial stressors) and minimize the extent to which they engage in the disturbed behavior because it is increasingly rewarding to them. Although stressors, social pressures, and individual vulnerabilities can be predisposing factors, they become irrelevant as secondary sustaining factors emerge and maintain the behavioral cycle. It is these secondary sustaining factors that account for continued engagement in the behavior in the face of mounting costs....

Psychiatric Comorbidity Alcoholism Mood and Personality

Of particular concern to the gastroenterologist is the high comorbidity between eating disorders and substance abuse, especially alcoholism. The overall rate of all substance use disorders among eating disordered patients was 37 in one study, and rates of alcoholism among bulimics were 40 (Braun et al, 1994). Patients abusing alcohol exhibit high rates of GI comorbidity, and women suffer adverse consequences, such as cirrhosis, from consumption of alcohol more quickly than do men. We recommend screening all eating disordered patients for alcohol abuse behaviors (Redgrave et al,2003).

Management options

General management is directed at any specific organ impairment (including central nervous system depression) and providing appropriate nutrition and psychological support and counselling. Substance abuse should always be considered in the differential diagnosis of any atypical case, e.g. unexplained collapse or acute confusion.

Are the Symptoms Truly Caused by ADHD

Such stressors, especially when more than one is present, may be the primary cause of the child's apparent ADHD impairments, or they may simply be exacerbating ADHD impairments that have been present since birth. The incidence of unemployment, marital conflict, substance abuse, and frequent changes of residence is elevated among individuals with ADHD. The presence of environmental stressors, even if they are many and severe, does not rule out a diagnosis of ADHD any more than such stressors would rule out a diagnosis of asthma.

Generalized Psychiatric Samples

Point Verbal superiority for Page and Steffy's group of patients with schizophrenia was reported previously, but these investigators also observed a 7 J4-point V P profile for 46 patients described as neurotics, although they found a V-P difference of less than 1 point for 108 inpatients with personality disorders. In contrast to these V P profiles, Hawkins, Sullivan, and Choi (1997) found a P V profile for a mixed psychiatric group of 33 patients (18 with major depression or bipolar disorder, 8 with substance abuse problems, 4 with impulse control disorders, and three with assorted other disorders). The lack of a V P pattern in Hawkins et al.'s mixed psychiatric group may be related to the diversity of diagnoses in the sample.

Screening and Referral

Tory should include careful questions about dieting and eating behavior, and screening for comorbid mood and substance abuse problems, because these often complicate the presentation of patients with eating disorders (see Table 381 for eating disorder-related questions we ask during an initial examination). Besides standard questions used to screen for eating disorder symptoms, we have found the following three questions to be sensitive in cases marked by denial of illness (1) How much would you like to weigh (desired weight) (2) Exactly what (and how much) did you eat yesterday and (3) in the case of excessive exercisers, If exercise did not burn calories how much time would you spend exercising Although emaciated anorectics will acknowledge they are too thin and express a desire to gain weight, their desired weight is usually around a BMI of 18, reflecting fear of fatness despite their insistence that they wish to weigh more. A description of the prior day's intake helps uncover...

Anaesthetic and resuscitative problems

Difficulties in resuscitation from the arrested state. In most individuals, sudden death occurs because of the absence of resuscitation facilities. In those reached before death,VF seems to be the commonest arrest arrhythmia, although asystolic cardiac arrest has also been documented after butane inhalation (Roberts et al 1990). Out of hospital defibrillation was performed in a 15-year-old girl, but she had a severe residual neurological deficit (Williams & Cole 1998). It has been suggested that the use of high-dose epinephrine (adrenaline) for resuscitation from VF caused by volatile substance abuse may be harmful (Adgey et al 1995).A 17 year old man, after collapse following the use of butane lighter fuel, had recurrent episodes of VF for which he required 27 DC shocks. Circulation returned 10 min after receiving amiodarone 300 mg iv (Edwards & Wenstone 2000).After a stormy ITU course, with a myocardial infarction, recurrent pulmonary oedema and renal failure, he recovered without...

Multiple Routes to Impaired Executive Functions

These studies show that many impairments of executive function seen in ADD syndrome can occur in persons who did not have ADHD in their earlier years. For some, head injuries, the hormonal changes of menopause, or cognitive changes of old age create a cluster of impairments that looks very much like ADD without the lifespan history of symptoms. It seems likely that severe chronic substance abuse and a variety of other psychiatric or medical disorders may have similar damaging effects on executive functions. It also seems likely that external challenges like these would cause some individuals who have a lifelong history of ADD syndrome to experience a worsening of their ADD symptoms.

Medication Alone May Not Be Enough

For those whose ADD impairments are complicated by symptoms of depression, anxiety, dyslexia, substance abuse, or other disorders, treatment with medications effective for ADD symptoms may be helpful, but not helpful enough. Treatment in these situations often requires very skilled diagnosis and multiple treatment interventions, possibly including careful trials of two or more different medications used in combination. Psychosocial or educational interventions may also play a crucially important role.

Sexual Feelings and Relationships

As she spent more time with her older boyfriend and his friends, the girl also joined in the beer drinking and marijuana smoking that often occurred at their weekend parties. Joseph Biederman, Timothy Wilens, and others (1998) have shown that individuals with ADHD not only have a twofold increased lifetime risk of substance use disorders than those without ADHD, but also tend to begin substance abuse earlier and continue it longer. Elizabeth Disney and colleagues (1999) found that girls with ADHD often begin substance abuse earlier than boys with ADHD, possibly because they tend to associate with older boys whose patterns of substance abuse may be more fully developed. Another question that might be raised is Where might this girl have ended up if her ADD syndrome had not been identified and treated when it was She came for evaluation because she was severely depressed and a heavy abuser of alcohol and marijuana. She did not come for treatment immediately after she had aborted the...

Cognitive Therapy And Mental Health

The cognitive model of depression has found support for descriptive aspects of its theory and for its treatment efficacy. Cognitive therapy has also been applied to a number of other psychological disorders, including anxiety, personality disorders, substance abuse, eating disorders, stress, and marital conflict. More recently, it has been applied to nonclinical problems, such as management problems in business and conflict resolution in schools.

Dealing with the extremes

The other broad area of consideration that lies behind any treatment that is offered in institutions for those with mental health problems is that of culture and gender. Different ethnic and social groups within a culture appear in such institutions at different rates. Men and women appear at similar rates but for different disorders. For example, men find themselves seeking help more than women for substance abuse and women more than men for mood disorders. There is also a fundamental difference between men and women in Western cultures in that women are far more likely than men to talk to others (particularly their general practitioners) about any mental health problems they might be experiencing. In general, then, the therapist has to be aware of any and all of these ethnic and social differences if he or she is to remain appropriately sensitive to the patient.

Failure or Success Is Not a Good Measure

Like the high school hockey player described in the Chapter 1, this physician is able to perform well under intense, immediate pressures that are exciting and interesting to him. But despite the talents that brought him a college degree, a medical degree, and a license to practice medicine, he suffers from longstanding problems with executive functioning. When not under the immediate pressures of treating critically injured patients, he has great difficulty organizing and prioritizing his work, his time, and his money. He can't sustain focus on important tasks like keeping adequate patient records and communicating with his supervisors and his wife. He can't hold in mind what he has studied to prepare for an important exam. And his impulsive style of spending and driving is currently threatening him with bankruptcy and possible loss of his driver's license. His difficulties were not due to substance abuse or any other psychiatric problem they were the consequence of unrecognized and...

Adulthood Managing Responsibilities Finding a Niche

These bright individuals dropped out or were kicked out of university because they were not able to manage themselves well enough to meet minimal requirements for university study. With just a few exceptions, they did not leave because of substance abuse they failed out because they were unable to make themselves go to classes regularly, take decent notes, complete the assigned readings, study adequately for tests, and finish enough written assignments on time. Most reported that they realized at the time what needed to be done, and tried to push themselves to do it, but just did not have enough willpower to make it happen.

Promotion Of Wellbeing

In New Haven, Weissberg and his associates from Yale University joined together with the superintendent of schools, the Board of Education, parents, community leaders and school staff to develop an organized approach to the promotion of socio-emotional development in the public school system. A Department of Social Development was created with the central element being a comprehensive inoculation program. For every public school in the city, the Social Development Program was incorporated from kindergarten through twelfth grade. This program had from 25 to 50 hours of classroom instruction at each grade level, which focused on problem solving, self-monitoring, conflict resolution, communication skills, respect, responsibility, health, substance abuse, culture, and citizenship. Realizing that there was a need to provide children with activities and outlets outside of the school, and in order to reinforce lessons taught in the classroom, the program moved beyond mere classroom curricula...

Melanie E Bennett And Selvija Gjonbalajmorovic

In recent years, the issue of psychiatric comorbidity has gained increased attention. Research indicates that a substantial percentage of the general population with a lifetime psychiatric disorder has a history of some other disorder (Kessler, 1997 Kessler et al., 1994), and more than half of patients in psychiatric treatment meet criteria for more than one diagnosis (Wolf, Schubert, Patterson, Marion, & Grande, 1988). The issue of comorbidity broadly refers to combinations of any types of psychiatric disorders that co-occur in the same individual. A diagnostic pair that has received significant attention over the last two decades is that of mental illness and substance abuse. The term dual diagnosis describes individuals who meet diagnostic criteria for an Axis I or Axis II mental disorder (or disorders) along with one or more substance use disorders. Since the 1980s, rates of co-occurring mental illness and substance use disorders have been found to have increased sharply. This...

Differentiating Depression from Dementia

Some depressive symptoms mimic cognitive impairment, especially in the elderly. In particular, psycho-motor retardation and memory lapses in the elderly are usually attributed to dementing processes, but actually may reflect depression. Pseudodementias can result from a wide variety of disorders, including nutritional deficiencies, prescribed medications, alcohol and substance abuse, and surgical procedures. Thus, assessment of the occurrence of problems of this type may be an important component in elders presenting with cognitive impairment. In turn, dementia is often associated with difficulty concentrating, loss of en

Disorders of Arousal and Motivation

Pennington (2002) proposed a category called disorders of motivation, which includes (1) depression and dysthymia, (2) anxiety disorders, (3) posttraumatic stress disorder, and (4) bipolar illness. Each of these involves disruptions in the arousal motivation system of the brain. To this category I have added obsessive-compulsive disorder as well as substance abuse and dependence. These two additional disorders are also essentially disruptions in the brain's normal regulation of arousal and motivation. Each of the six disorders in this expanded list occurs more frequently among persons with ADHD.

Community Based Coalitions

The appeal of places of worship as settings for health promotion and disease prevention is based on experience suggesting that such settings are receptive to health-related programs, have access to large numbers of persons from all socioeconomic and ethnic groups, have effective communication and meeting facilities, and are oriented to volunteerism (Lasater et al. 1990 1991 DePue et al. 1990). Since its creation in 1989, the Heart, Body, and Soul Program has evolved in scope to include programs targeted against heart disease, smoking, obesity, violence, crime, substance abuse, and tuberculosis, as well as the promotion of youth education, completion of schooling, and career development. Examples of the effectiveness of this approach include significantly improved rates of identification, care, and control of hypertension, as well as concomitant decreases in related morbidity and mortality and significant improvement in smoking cessation (Levine et al. 1979, 1990 Morisky et al. 1983...

Premenstrual Syndrome Treatment Interventions

Premenstrual Dysphoric Disorder (PMDD), formerly Late Luteal Phase Dysphoric Disorder (LLPDD) Terms that refer to that small percentage of women who have premenstrual syndrome with primarily emotional symptoms severe enough to affect their ability to function at home or in the workplace. Premenstrual Exacerbation Aggravation of such chronic conditions such as asthma, depression, anxiety, eating disorders, substance abuse, headaches, allergies, seizures, or herpes during the premenstrual phase.

Healthy Mood Management A Developmental Perspective

The relationship between negative mood states and smoking and drinking has already been described. It is highly likely that illicit use of drugs follows a similar pattern. Diet and exercise certainly are affected by depressed mood. Deaths from firearms present an interesting illustration of how strong, and yet invisible to most of us, the impact of depression is on our society few people are aware that for several decades over half the deaths from firearms in the United States have been suicides. Unprotected sexual behavior not only exposes individuals to sexually transmitted diseases, but also to unplanned pregnancies. And some proportion of motor vehicle accidents are related to alcohol and other substance abuse, or to reckless driving, which may be the result of desperate states of mind. The proportion of these factors that is attributable to depression is yet unknown, but is likely to be significant.

Adjunct Medications

Adjunct medications enhance the effects of narcotics and sedatives, especially in the narcotic tolerant patient, and patients with a history of alcohol and substance abuse. Most adjunct medications also have antiemetic qualities. Examples of adjunct medications include promethazine (Pherergan), droperidol, and diphenhydramine (Benadryl). Use of adjunct medications for long procedures will decrease the need for larger amounts of narcotic analgesics, thereby reducing risks associated with these doses. These medications should be given early in the procedure because their onset of action is typically longer than narcotic analgesics and benzodiazepines. Therefore, identification of high risk patients and potential for longer therapeutic procedures is useful for optimal sedation practices. It should be noted that in December 2001 the US Food and Drug Administration issued a black box warning for droperidol. This warning is intended to increase

The Editors

Watson, Ph.D., initiated the Specialized Alcohol Research Center at the University of Arizona College ofMedicine and had directed the center for 6 years. Dr. Watson has edited 50 books, including lOon alcohol abuse and 4 on other drugs of abuse. He has worked for several years on research for the U.S. Navy Alcohol and Substance Abuse Program.

Selection Process

Abstinence from drugs and alcohol is a prerequisite for being listed for LT. At our institution we require alcoholics and drug addicts to have completed a preapproved outpatient alcohol or drug rehabilitation program with documented abstinence for at least 6 months prior to being considered for examination. Patients who are found to be using drugs or alcohol while they are on the transplantation list are automatically removed. We believe that transplantation programs should maintain objectivity by stipulating rigid, written criteria agreed to by the members of the team regarding alcohol and other substance abuse. This is one area where bias, culture and preconceived beliefs may cause discrimination and unfair decisions.


Compression at the spiral groove common. During unconsciousness (coma, head injury, substance abuse, sleep paralysis (Saturday night palsy), unusually long pressure to the upper arm (military personnel - shooting, training), tourniquet, neonates (compression by umbilical band, amniotic bands or uterine constriction rings).

Bipolar Disorder

Bipolar disorder (BPD) is also among diagnoses classified by Pennington as disorders of motivation and arousal. Formerly known as manic-depressive disorder, this syndrome is characterized by episodes during which the individual manifests an intense increase in elation, grandiosity, and rapid or racing thoughts, usually with decreased need for sleep and often with hypersexuality or increased frequency of other activities that may be pleasurable, but are likely to create serious difficulties for the individual. Such episodes alternate in longer or shorter intervals with episodes of major depression. Switches between the manic and depressive moods may occur with no clear cause. Individuals with BPD also have elevated risk for substance abuse and suicide.

Administration Time

Lopez, and Werth (1998) recorded the administration times for the WAIS-III subtests, IQs, and indexes in a sample of 62 patients at a Veterans Affairs Medical Center who were referred for routine psychological or neuropsychological assessment. The primary diagnosis for this group of patients was substance abuse disorder, followed by a small number of patients with psychiatric disorders, medical illnesses, and neurological conditions. The sample was nearly all male (2 women) and the mean age was 46.87 (SD 11.68). On average, the 11 subtests that yield the three IQs took 91 minutes to administer to this clinical sample, and the 11 subtests that yield the four WAIS-III indexes took 77 minutes to administer the 13 subtests that permit computation of the IQs and indexes averaged 100 minutes of administration time. All of these values are a little higher than the upper range of estimates reported in the WAIS-III Manual, and substantially higher than the mean values estimated in the manual.

The Need for Ethics

One readily apparent rationale for emphasizing ethics in medical education is the need to prevent misconduct. There are many pitfalls to which physicians are subject, including tampering with medical records to hide error, financial misconduct, exploitation of employees and colleagues, substance abuse, and frank incompetence, among others. Professional organizations, licensing boards, and the legal system may specify what sorts of conduct physicians must avoid and even detail their disciplinary procedures, but the ultimate and best bulwark against misconduct lies not in external controls but in the internal character of physicians. We need to invite learners to discuss the types of misconduct they might encounter in practice and reflect on both the inherent impropriety and the adverse consequences that can flow from them both for themselves, their colleagues, patients, and the community. Unethical actions of even one individual can seriously tarnish the reputation and goodwill...

Mptp Intoxication

Some intravenous drug addicts who use a synthetic heroin-like drug (meperidine) develop chronic parkinsonism as a result of contamination by (MPTP) (193). MPTP is metabolized in the brain to 1-methyl-4-phenylpyridinium (MPP+) (194) and is selectively transported into dopaminergic cells, which it kills by inhibiting mitochondrial function (195). Human postmortem studies reveal severe depletion of pigmented neurons in the substantia nigra without LBs (196). The presence of active gliosis and microglial activity has been interpreted as indicating ongoing neurodegeneration, years after the initial exposure. MPTP-induced parkinsonism in experimental nonhuman primates has become a valuable model for studying idiopathic PD (197). In addition to nerve cell degeneration in both the substantia nigra and the locus ceruleus, these animals develop eosinophilic neuronal inclusions that show both similarities and differences compared with LBs in human disease (198).

Ovarian Sonography

Clinical experience has indicated that the majority of women with signs of virilization (i.e., mas-culinization of body muscular, severe or extreme male-pattern balding or hirsutism, clitoromegaly, etc.) will have androgen excess. Although rarely a sign of PCOS, virilization can be seen in patients with disorders of severe insulin resistance, androgen-secreting tumors, and androgenic substance abuse. Less clear is the predictive ability of less dramatic signs and symptoms. Although reviewed previously (see Chapter 14), it is still noteworthy to briefly summarize the predictive ability of the various historical and clinical features of androgen excess.


Second, definitions of what constitutes dual diagnosis are far from uniform. Studies of dual diagnosis often employ differing definitions of substance use disorders, making prevalence rates diverse and difficult to compare. For example, definitions of substance abuse vary, ranging from problem use of a substance, to abuse or dependence based on DSM criteria. This is a particularly important issue in terms of diagnostic criteria for both mental and substance use disorders. The publication of DSM-IV (American Psychiatric Association, 1994) and the changes in that system from its predecessor may affect dual diagnosis prevalence rates in both community and clinical samples. These changes include a greater focus on determining that a mental disorder is independent from a substance use disorder by determining that the mental disorder either predated the substance use disorder or persists for at least four weeks following cessation of alcohol or drug use. Others do not specify the exact...

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