Substance Abuse

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Editor: Miranda Herbert Ferrara
Date: 2010
Human Diseases and Conditions
From: Human Diseases and Conditions(Vol. 4. 2nd ed.)
Publisher: Charles Scribner's Sons
Document Type: Disease/Disorder overview
Pages: 10
Content Level: (Level 4)
Lexile Measure: 1200L

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Substance Abuse

Substance abuse is the unhealthy, even dangerous pattern of over consuming alcohol, tobacco, illegal drugs, prescription drugs, and other substances (such as paint thinners or aerosol gasses) that change how the mind and body work. It is possible to abuse some substances without becoming physically, emotionally, or psychologically dependent on them, but continued abuse tends to make people dependent. Dependency on some substances happens very quickly and is difficult to reverse.

What Is Substance Abuse?

Substance abuse is the unhealthy, even dangerous over consumption of various substances such as alcohol and other drugs that usually leads to frequent, serious problems at home, school, or work. People who abuse substances can get sick, ruin their relationships with other people, destroy their lives and the lives of family members, and even die, and while under the influence, they can injure or kill others. In 2007, 19.9 million Americans age 12 and over said they were current users of illegal drugs. In that same year, more than 17 million Americans age 12 or older reported that they drank alcohol heavily. Heavy drinking means that these people binge drank or they drank five or more drinks on five or more days during the previous month. Substance abuse is a serious problem in the United States.

Substance abuse is not the same as occasional alcohol or other drug use. When people are addicted to a substance, they develop a strong physical or psychological need for that drug. One hallmark of addiction is tolerance (TOL-er-uns), which means that over time, people need more and more of the substance to feel a high. Another symptom is withdrawal,


Substance abuse and addiction affect many different parts of the body.

Substance abuse and addiction affect many different parts of the body. Illustration by Frank Forney. Reproduced by permission of Gale, a part of Cengage Learning.

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which means that people who are addicted have physical symptoms and feel sick if they stop using the substance.

Alcohol and other drugs cause “intoxication” (in-TOK-sih-KAY-shun), the medical term for a temporary feeling of being high or drunk that occurs just after using a drug. Intoxication leads to changes in the way people think and act. For example, people may become angry, moody, confused, or uncoordinated. These changes increase the risk that people will make poor choices, have accidents that hurt themselves or others, or behave in a way that they will later regret.

Different substances have different effects on the body. Substances that are commonly abused in the United States include the following:

  • Alcohol
  • Amphetamines
  • Anabolic steroids
  • Cocaine
  • Depressants
  • Hallucinogens
  • Inhalants
  • Marijuana
  • Narcotics
  • Prescription medications
  • Nonprescription (over-the-counter) medications
  • Tobacco

What Causes Substance Abuse?

People give many reasons for starting to drink alcohol or use other drugs. Some people are looking for an easy way to escape problems at home, school, or work. Others hope that alcohol or other drugs will help them fit in or make them appear to be something better than what they are. Some may use substances to “treat” or “self-medicate” depression or boredom. Still others are initially just curious. Whatever the original reason, no one can say for sure which people will go on to have a serious substance abuse problem. However, certain factors raise the risk that abuse will develop. Risk factors for substance abuse problems include the following:

  • Family history of substance abuse
  • Using alcohol or tobacco at a young age
  • Depression
  • Low self-esteem*
  • Feeling like an outsider
  • Poverty
  • Child abuse or neglect
  • Family problems
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Cocaine is a mood-altering drug that interferes with normal transport of the neurotransmitter dopamine, which carries messages from neuron to neuron. When cocaine molecules block dopamine receptors, too much dopamine remains active in the synap

Cocaine is a mood-altering drug that interferes with normal transport of the neurotransmitter dopamine, which carries messages from neuron to neuron. When cocaine molecules block dopamine receptors, too much dopamine remains active in the synaptic gaps between neurons, creating feelings of excitement and euphoria. Illustration by Frank Forney. Reproduced by permission of Gale, a part of Cengage Learning.

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The United States and the World

The World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) accumulate statistics about health problems resulting from substance abuse. Notable facts include the following:

  • In 2004, 19,838 people died as a result of accidental drug overdoses. That number increased from 11,155 in 1999. The abuse of legal drugs among people ages 15 to 24 is likely responsible for the dramatic increase.
  • In 2007, twice as many males (12.5%) as females (5.7%) were categorized as substance abusers; however, abuse rates among males and females ages 12 to 17 was equal.
  • In 2007, 12.5 percent of people over the age of 12 reported that they had driven a vehicle while under the influence of alcohol or other drugs.

Some of these factors can be changed or controlled by the people themselves, but others cannot. However, that does not mean that those who come from troubled families or low income neighborhoods are destined to be substance abusers. Certain other factors raise the odds that young people will be able to cope with problems without turning to alcohol or other drugs. These factors include the following:

  • Learning to do something well
  • Being active at school or in the community
  • Having a caring adult or friend to talk to

Addiction is a special type of dependence in which people have a compulsive need to use the substance no matter what the consequences are. People who are psychologically addicted need to keep using the substance to feel satisfied. People who are physically addicted feel sick and have physical withdrawal symptoms if they stop using the substance. The risk and type of dependence varies by substance. Substance abuse occurs among people of all ages, cultures, sexes, and races.

What Are Some Commonly Abused Substances?

People abuse a wide variety of drugs, both legal and illegal. Legally available substances include alcohol, tobacco, chemicals in certain household products, over-the-counter drugs, and medicines prescribed by a doctor. Illegally sold substances include numerous street drugs.

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Alcohol Although moderate drinking (two to four drinks a day for men and one to two drinks a day for women and older people) is not normally considered harmful, millions of people in the United States abuse alcohol or are alcoholics (people who are physically dependent on alcohol). A 2007 national survey found that 17 million Americans are heavy drinkers and that 57.8 million people engage in binge drinking (more than five drinks on one occasion).

Alcohol affects virtually every organ in the body, and long-term use can lead to a number of medical problems. The immediate effects of drinking too much include slurred speech, poor coordination, unsteady walking, memory problems, poor judgment, and the inability to concentrate. Drinking too much alcohol at one time can cause alcohol poisoning and sudden death. The recklessness that comes from drinking too much is a leading cause of traffic accidents and other injuries. In addition, alcohol drinking by pregnant women is the cause of the most common preventable birth defect fetal alcohol syndrome* . Long-term risks of heavy drinking include liver damage, heart disease* , neurological effects, reduced cognitive functioning, sexual problems for men, and trouble getting pregnant for women.

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Medicinal Marijuana

Marijuana is an illegal drug. In some states, however, it can legally be prescribed for certain medical purposes. Research indicates that marijuana may help in the treatment of glaucoma* , and it may relieve the nausea and wasting away that people with AIDS and cancer sometimes experience as a side effect of medical treatments. But research also shows that marijuana smoke contains more tar than cigarette smoke and may contain high levels of other cancer-causing agents. As of 2009, further research was needed and public policies regarding marijuana remained controversial.

Tobacco Tobacco contains nicotine (NIK-o-teen), a highly addictive chemical. Nicotine is readily absorbed from tobacco smoke in the lungs, whether the smoke comes from cigarettes, cigars, or pipes. Smoking is the number one cause of preventable death in the United States. The long-term health risks include cancer, lung disease, heart disease, and stroke* . Smoking by pregnant women has been linked to miscarriage* , stillbirth* , premature birth* , low birth weight* , and infant death. Nicotine is readily absorbed from smokeless tobacco as well. Like smoking, dipping or chewing tobacco can have serious long-term effects, including cancer of the mouth, gum problems, loss of teeth, and heart disease.

Marijuana Marijuana (mar-ih-HWAH-nuh; nicknames: pot, herb, weed, blunts, Mary Jane) is the most widely used illegal drug. It is typically the first illegal drug tried by teenagers. It is a mixture of dried, shredded flowers and leaves from the cannabis plant. Marijuana usually is smoked in a cigarette, pipe, or water pipe, but some users also mix it with foods or use it to brew tea. Short-term effects of marijuana use include euphoria* , sleepiness, increased hunger, trouble keeping track of time, memory problems, inability to concentrate, poor coordination, increased heart rate, paranoia* , and anxiety. Long-term risks include lung disease, changes in hormone levels, lower sperm counts in men, and infertility.

Hallucinogens Hallucinogens (huh-LOO-sih-no-jenz) are drugs that distort a person's view of reality. They include LSD (lysergic acid diethyl-amide; nickname: acid), PCP (phencyclidine; nicknames: angel dust, love-boat), psilocybin (SY-lo-SY-bin; nickname: magic mushrooms), mescaline (MES-kuh-len), and peyote (pay-YO-tee or pay-YO-tay). People who use Page 1616  |  Top of Articlethese drugs may lose all sense of time, distance, and direction. They may behave strangely or violently, which can lead to serious injuries or death.

Users react differently to hallucinogens, and some individuals have bad experiences with them. LSD is one of the most potent of all mind-altering drugs. It may be taken in the form of paper that has been dipped in the drug, powder, liquid, gelatin, or pills. LSD can last for as long as 12 hours in the body. The physical effects of LSD use include dilated (widened) pupils, increased heart rate, higher blood pressure, sweating, loss of appetite, trouble sleeping, dry mouth, and shaking. The psychological effects are much more dramatic, however. Users may feel several different emotions at once, or they may swing from one emotion to another, from euphoria to paranoia. They may have bizarre or terrifying thoughts, or they may see things that are not really there, like walls melting. Some users later have flashbacks, in which they relive part of what they experienced while taking the drug, even though the drug is no longer active in their bodies. Hallucinogens are not physically addictive, but people using them are at risk for accidents,

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Same Problem, Different Solution

In the United States, using and selling drugs such as marijuana and heroin is illegal, and people who break drug laws go to jail. In the Netherlands, the government is trying a different approach that stresses treatment rather than punishment.

In the mid-1970s, the Netherlands was hit by a sharp upswing in heroin use. In response, the government launched a policy called harm reduction, which aims to lower the harmful effects of drug use for both users and other members of society. The policy is based on the belief that so-called soft drugs, such as marijuana and the related drug hashish (hah-SHESH), are less dangerous than so-called hard drugs, such as heroin, cocaine, amphetamines, and methamphetamine. To encourage people not to try hard drugs, the government tolerates the sale of small amounts of marijuana and hashish in adults-only coffee shops, much the way alcohol is sold in bars. Marijuana is still considered a controlled substance, but the government generally does not enforce the law regarding it.

Much debate in the early 2000s surrounded this policy and how well it was perceived to work. However, the number of drug addicts in the Netherlands was lower than in many countries. In addition, the average age of addicts was rising, which suggested that fewer young people were getting hooked. But the rate of marijuana and hashish use increased in the late 1990s and early 2000s, although it remained lower than in the United States. Furthermore, the policy failed to address the impact on international laws. Substances were brought into the Netherlands from and through countries where the sale and use of marijuana was strictly prohibited.

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violence, panic attacks* , and other consequences of impaired judgment. All of these substances are illegal to use, make, or sell.

PCP can be snorted, smoked, or eaten. It can cause bizarre and sometimes violent behavior. Other possible effects of PCP use include increased or shallow breathing rate, higher blood pressure, flushing, sweating, numbness, poor coordination, and confused or irrational thinking. High doses can lead to seeing or hearing things that are not really there, paranoia, seizures* , coma* , injuries, and suicidal behavior.

Stimulants Stimulants (STIM-yoo-lunts) are drugs that produce a temporary feeling of euphoria, alertness, power, and energy. As the high wears off, however, depression and edginess set in. Stimulants include cocaine (ko-KANE; nicknames: coke, snow, blow, nose candy), crack cocaine, amphetamine (am-FET-uh-mean), methamphetamine (METH-am-FET-uh-mean; nicknames: speed, meth, crank), and crystallized methamphetamine (nicknames: ice, crystal, glass).

Cocaine is a white powder that is either snorted into the nose or injected into a vein. Crack is a form of cocaine that has been chemically changed so that it can be smoked. Both forms are very addictive. Possible physical effects of cocaine and crack use include increased heart rate, higher blood pressure, increased breathing rate, heart attack, stroke, trouble breathing, seizures, and a reduced ability to fight infection. Possible psychological effects include violent or strange behavior, paranoia, seeing or hearing things that are not really there, feeling as if bugs are crawling over the skin, anxiety, and depression. Eventually, cocaine addicts often wind up losing interest in food, sex, friends, family, everything except getting high.

Amphetamines are human-made stimulants that speed up the central nervous system* , creating a sense of euphoria and increased energy. Amphetamines can be taken orally, injected, smoked, or sniffed. They may be legally prescribed to treat attention deficit hyperactivity disorder (ADHD), to suppress appetite, and to combat fatigue or narcolepsy (a disorder that causes uncontrolled falling asleep). Amphetamines include benzedrine, dexedrine, and methedrine. Street names for amphetamines include black beauties, crystal, hearts, bennies, crank, ice, speed, and meth.

People who abuse amphetamines need more and more of the drug to achieve the same effect or high. When they become dependent, amphetamine users may be jittery, lose weight, feel depressed, anxious, restless, hostile, and lack energy. An overdose may cause tachycardia (very fast heartbeat), high blood pressure, seizures, fever, delirium, paranoia, psychosis* , coma, and cardiovascular collapse.

Narcotics Narcotics (nahr-KOT-iks) are addictive painkillers that produce a relaxed feeling and an immediate high, followed by restlessness and an upset stomach. They can also be deadly. Drugs in this class include heroin (HAIR-oh-in; nicknames: smack, H, skag, junk), morphine (MOR-feen), opium (OH-pee-um), and codeine (KO-deen).

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Heroin is made from morphine, a natural substance that comes from the poppy plant. It is a powder that is injected, snorted, or smoked, and it is highly addictive. Immediate effects of heroin use include a heavy feeling in the arms and legs, warm flushing of the skin, dry mouth, clouded thinking, and going back and forth between being wide awake and feeling drowsy. In addition, street heroin varies in strength, and users never know if they are getting a particularly strong dose. If they do, they can overdose (OD) easily, resulting in coma and death. Long-term effects include collapsed veins, infection of the heart lining and valves, liver disease, and HIV* /AIDS from sharing needles.

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The Opium Trade

Ancient Chinese medical texts indicated that opium, imported to the West from China by Arab traders in the 8th century, was used originally for medicinal purposes. When tobacco was introduced to China from the Philippines, the mixing of tobacco with opium became popular. British colonial traders recognized the strong demand for opium. Despite an 18th-century edict by the Chinese government banning the sale of opium and the operation of opium houses, the British continued its sale on the black market. During the late 18th century, opium was at times the largest single commodity in trade.

Sedatives (SED-uh-tivz), sometimes called tranquilizers (TRANK-will-LY-zerz) or sleeping pills, include barbiturates (downers). These drugs produce a calming effect and sleepiness. Physicians prescribe them to relieve anxiety, promote sleep, and treat seizures. When they are abused or taken at high doses, however, many of these drugs can lead to loss of consciousness and death. Combining sedatives with alcohol is particularly dangerous. Possible effects of sedative abuse include poor judgment, slurred speech, staggering, poor coordination, and slow reflexes.

Inhalants

Inhalants are chemical vapors that can be inhaled to produce mind-altering effects. The vapors then enter the lungs. There are three types of inhalants: solvents (such as paint thinners, gasoline, glues, felt-tip marker fluid), gases (such as butane lighters, whipping cream aerosols, spray paints, deodorant sprays, and nitrous oxide or “laughing gas”), and nitrites.

The physical effects of inhalants depend on the chemical being inhaled. Many cause serious, often irreversible health problems, and sometimes cause death. Users can lose consciousness. Other serious, but potentially reversible, effects include liver damage, kidney damage, and depletion of blood oxygen. Irreversible effects of inhalants include hearing loss, loss of muscle control and limb spasms, damage to the central nervous system and brain, damage to the bone marrow* , lung damage, and heart failure.

Club drugs

Club drugs are drugs that are mainly used by young people at parties, clubs, and bars. Although users may think these are harmless, research has shown that they can cause serious health problems and sometimes even death. When combined with alcohol, they can be particularly dangerous. Drugs in this category include MDMA (nicknames: XTC, ecstasy, Adam) GHB (nicknames: liquid ecstasy, Georgia home boy), Rohypnol (nicknames: roofies, roach), and ketamine (nickname: special K).

MDMA combines some of the properties of hallucinogens and stimulants. Possible effects include euphoria, confusion, paranoia, increased heart rate, higher blood pressure, blurred vision, faintness, chills, and sweating. Because this drug is increasingly abused at dances, young people may forget to drink, become dehydrated, and need to be rushed to the Page 1619  |  Top of Articleemergency room for immediate treatment. Possible psychological effects include confusion, depression, sleep problems, anxiety, and paranoia. Research has linked MDMA to long-term damage in parts of the brain that are critical for thought, memory, and pleasure.

GHB, Rohypnol, and ketamine are often colorless, tasteless, and odorless, which makes it easy for someone to slip one of these drugs into another person's drink. As a result, these substances are sometimes called “date rape” drugs, because they have been used against women who were drugged unknowingly and then raped. To make matters worse, people may be unable to remember what happened to them while they were under the influence of one of these drugs.

Prescription and Over-the-Counter Drugs

People can abuse legal medicines by taking more than prescribed, using them for nonmedical reasons, or using them to treat unrelated illnesses. The most commonly abused prescription and over-the-counter medicines are stimulants, pain relievers, depressants (such as sleeping pills), cough and cold medicines, and laxatives.

Abusing these substances can cause physical and psychological dependence. Some prescription medications contain alcohol and narcotics—such as codeine—that are physically addicting. Combining alcohol with prescription and over-the-counter drugs, or mixing drugs, can change the effectiveness of the drugs and cause harmful side effects.

Anabolic steroids

Anabolic steroids (AN-uh-BOL-ik STER-oidz) are drugs that are related to testosterone (tes-TOS-tuh-rone), the major male sex hormone. Although these drugs have medical uses, many athletes and bodybuilders abuse them because they can increase muscle build-up with weight lifting or strength training. Although steroids may seem like a shortcut to improved sports performance and a more muscular body, they carry serious health risks. In boys and men, steroids can reduce sperm production, shrink the testicles, enlarge the breasts, and cause problems with sexual performance. In girls and women, they can lead to unwanted body hair, a deep voice, and irregular periods. Steroids can damage the heart, liver, and kidneys. In teenagers, they can stunt bone growth, making users reach a shorter final height than they would have otherwise. High doses of testosterone can also cause outbursts of aggressive or violent behavior (steroid rage).

What Are Some Other Risks of Substance Abuse?

Abusing drugs leads to unclear thinking and unpredictable behavior. Many drugs also cause poor coordination and slow reflexes. It is little wonder, then, that substance abuse is closely tied to accidents and injuries. In 2006, 25 percent of drivers ages 15 to 20 who were killed in automobile accidents were under the influence of alcohol at the time their deaths.

In the United States, substance abuse is a major factor in the spread of infection with HIV (human immunodeficiency virus), the virus that Page 1620  |  Top of Articlecauses AIDS. It is a direct cause, because many drugs are injected into a vein, and people can spread HIV by using or sharing unclean needles. It is also an indirect cause, because people whose thinking is clouded by alcohol or other drugs are more likely to have unsafe sex, which increases their risk of catching HIV from an infected partner.

How Is Substance Abuse Diagnosed and Treated?

Diagnosis Substance abuse often is difficult to diagnose and treat. Doctors can screen for substance abuse through a medical history, a physical exam, and sometimes blood or urine testing, but doctors and family members often have a hard time convincing substance abusers that they need help. In many cases, substance abusers are more afraid of losing the drug and of withdrawal symptoms than of the health and safety consequences of continued use.

Treatment Treatment for substance abuse consists of helping people stop using the substance, treating withdrawal symptoms, and preventing people from returning to substance abuse afterwards. Outpatient* psychotherapy* and self-help groups can be effective. People with severe problems may require residential treatment programs. Treatment often is provided by doctors and organizations that specialize in substance abuse programs. Steps for helping substance abusers are as follows:

  • Evaluate people for psychiatric or medical disorders
  • Teach them about the effects of the drug and their addiction
  • Offer mutual support and self-help groups
  • Provide individual and group psychotherapy
  • Offer a replacement for the substance being given up
  • Emphasize behavior changes that promote not using the substance
  • Offer rehabilitation and life skills training

Even people who are successfully treated must guard against starting to use the abused substance again. People with serious medical or psychiatric symptoms, people who overdose on drugs, and people who have toxic reactions to drugs require immediate medical treatment.

Resources

Books and Articles

Freimuth, Marilyn. Addicted? Recognizing Destructive Behavior before It's Too Late. Lanham, MD: Rowman and Littlefield, 2008.

Klosterman, Lorrie. The Facts about Drugs and the Body. New York: Marshall Cavendish Benchmark, 2008.

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Rebman, Renee C. Addictions and Risky Behaviors: Cutting, Bingeing, Snorting, and Other Dangers. Berkeley Heights, NJ: Enslow, 2006.

Schwartzenberger, Tina, ed. Substance Use and Abuse. New York: Weigl, 2007.

Organizations

Alcoholics Anonymous. Grand Central Station, P.O. Box 459, New York, NY, 10163. Telephone: 212-870-3400. Web site: http://www.aa.org .

National Institute on Alcohol Abuse and Alcoholism. 5635 Fishers Lane, MSC 9304, Bethesda, MD, 20892-9304. Telephone: 301-4433860. Web site: http://www.niaaa.nih.gov .

National Institute on Drug Abuse—National Institutes of Health. 6001 Executive Boulevard, Room 5213, Bethesda, MD, 20892-9561 Web site: http://www.nida.nih.gov .

Substance Abuse and Mental Health Services Administration. 1 Choke Cherry Road, Rockville, MD, 20857. Toll free: 877-SAMH-SA-7. Web site: http://ncadi.samhsa.gov .

* self-esteem is the value that people put on the mental image that they have of themselves.

* glaucoma is a group of disorders that cause pressure to build in the eye, which may result in vision loss.

* fetal alcohol syndrome which occurs if the fetus is exposed to alcohol, is a condition that can be associated with mental, physical, and behavioral differences. Oppositional behavioral problems, learning difficulties, mental retardation, and retarded growth can occur in the children of women who drink alcohol while they are pregnant.

* heart disease is a broad term that covers many conditions that prevent the heart from working properly to pump blood throughout the body.

* stroke is a brain-damaging event usually caused by interference with blood flow to the brain. A stroke may occur when a blood vessel supplying the brain becomes clogged or bursts, depriving brain tissue of oxygen. As a result, nerve cells in the affected area of the brain, and the specific body parts they control, do not properly function.

* miscarriage (MIS-kare-ij) is the end of a pregnancy through the death of the embryo or fetus before birth.

* stillbirth is the birth of a dead fetus.

* premature birth (pre-ma-CHUR) means born too early. In humans, it means being born after a pregnancy term lasting less than 37 weeks.

* low birth weight means born weighing less than normal. In humans, it refers to a full-term (pregnancy lasting 37 weeks or longer) baby weighing less than 5 pounds.

* euphoria (yoo-FOR-ee-uh) is an abnormally high mood with the tendency to be overactive and overly talkative, and to have racing thoughts and overinflated self-confidence.

* paranoia (pair-a-NOY-a) refers to either an unreasonable fear of harm by others (delusions of persecution) or an unrealistic sense of self-importance (delusions of grandeur).

* panic attacks are periods of intense fear or discomfort with a feeling of doom and a desire to escape. During a panic attack, a person may shake, sweat, be short of breath, and experience chest pain.

* seizures (SEE-zhurs) are sudden bursts of disorganized electrical activity that interrupt the normal functioning of the brain, often leading to uncontrolled movements in the body and sometimes a temporary change in consciousness.

* coma (KO-ma) is an unconscious state, like a very deep sleep. A person in a coma cannot be awakened, and cannot move, see, speak, or hear.

* central nervous system (SEN-trul NER-vus SIS-tem) is the part of the nervous system that includes the brain and spinal cord.

* psychosis (sy-KO-sis) refers to mental disorders in which the sense of reality is so impaired that a patient cannot function normally. People with psychotic disorders may experience delusions (exaggerated beliefs that are contrary to fact), hallucinations (something that a person perceives as real but that is not actually caused by an outside event), incoherent speech, and agitated behavior, but they usually are not aware of their altered mental state.

* HIV or human immunodeficiency virus (HYOO-mun ih-myoo-no-dih-FIH-shen-see), is the virus that causes AIDS (acquired immunodeficiency syndrome).

* bone marrow is the soft tissue inside bones where blood cells are made.

* outpatient a medical procedure that is conducted in a doctor's office or hospital for treatment but does not require an overnight stay in a hospital bed.

* psychotherapy (sy-ko-THER-a-pea) is the treatment of mental and behavioral disorders by support and insight to encourage healthy behavior patterns and personality growth.

Source Citation

Source Citation   

Gale Document Number: GALE|CX2830200413

Disclaimer:   This information is not a tool for self-diagnosis or a substitute for professional care.