Drug Abuse and Mental Health
The Relationships Between Alcohol and Other Drug Use and Psychiatric Symptoms and Disorders
An accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and drug abuse. To do so, clinicians must obtain a thorough history of alcohol and drug use and psychiatric symptoms and disorders.
There are several possible relationships between alcohol and drug use and psychiatric symptoms and disorders. alcohol and drug use may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process.
The primary relationships between alcohol and drug use and psychiatric symptoms or disorders are described in the following classification model (Landry et al., 1991a; Lehman et al., 1989; Meyer, 1986). All of these possible relationships must be considered during the screening and assessment process.
- Alcohol and drug use can cause psychiatric symptoms and mimic psychiatric disorders. Acute and chronic alcohol and drug use can cause symptoms associated with almost any psychiatric disorder. The type, duration, and severity of these symptoms are usually related to the type, dose, and chronicity of the alcohol and drug use.
- Acute and chronic alcohol and drug use can prompt the development, provoke the reemergence, or worsen the severity of psychiatric disorders.
- Alcohol and drug use can mask psychiatric symptoms and disorders. Individuals may use alcohol and drug to purposely dampen unwanted psychiatric symptoms and to ameliorate the unwanted side effects of medications. Alcohol and drug use may inadvertently hide or change the character of psychiatric symptoms and disorders.
- Alcohol and drug use withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Cessation of alcohol and drug use following the development of tolerance and physical dependence causes an abstinence phenomenon with clusters of psychiatric symptoms that can also resemble psychiatric disorders.
- Psychiatric and alcohol and drug use disorders can coexist. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Determining whether the disorders are related may be difficult, and may not be of great significance, when a patient has long-standing, combined disorders. Consider a 32-year-old patient with bipolar disorder whose first symptoms of alcohol abuse and mania started at age 18, who continues to experience alcoholism in addition to manic and depressive episodes. At this point, the patient has two well-developed independent disorders that both require treatment.
- Psychiatric behaviors can mimic behaviors associated with alcohol and drug use problems. Dysfunctional and maladaptive behaviors that are consistent with alcohol and drug abuse and addiction may have other causes, such as psychiatric, emotional, or social problems. Multidisciplinary assessment tools, drug testing, and information from family members are critical to confirm alcohol and drug use disorders.
The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete "recovery" from alcohol and drug addiction. Psychiatric disorders may interfere with patients' ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines.
For example, patients with anxiety and phobias may fear and resist attending Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated and lethargic to participate in treatment. Patients with psychotic or manic symptoms may exhibit bizarre behavior and poor interpersonal relations during treatment, especially during group-oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse.
- Alcohol and Drug Use and Psychiatric Symptoms
- Alcohol and Drug use can cause psychiatric symptoms and mimic psychiatric syndromes.
- Alcohol and Drug use can initiate or exacerbate a psychiatric disorder.
- Alcohol and Drug use can mask psychiatric symptoms and syndromes.
- Alcohol and Drug withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes.
- Psychiatric and Alcohol and Drug use disorders can independently coexist.
- Psychiatric behaviors can mimic alcohol and drug use problems.
The Terminology of Dual Disorders
The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and alcohol and drug problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP).
The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an alcohol and drug disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).
Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders.
The combinations of alcohol and drug problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.
Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients.
Patients with mental disorders have an increased risk for alcohol and drug disorders, and patients with alcohol and drug disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience alcohol and drug abuse at some point (Regier et al., 1990), which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse alcohol and drug use have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder (Regier et al., 1990; Ross et al., 1988), although many of these symptoms may be alcohol and drug related and might not represent an independent condition.
Compared with patients who have a mental health disorder or an alcohol and drug use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both alcohol and drug relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.
Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders. Each of these clusters of disorders and symptoms is dealt with in more detail in separate chapters.
Alcohol and Drug Abuse, Addiction, Dependence, Misuse
The characteristic feature of alcohol and drug abuse is the presence of dysfunction related to the person's alcohol and drug use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), produced by the American Psychiatric Association and updated periodically, is used throughout the medical and mental health fields for diagnosing psychiatric and alcohol and drug use disorders. It provides clinicians with a common language for communicating about these disorders and for making clinical decisions based on current knowledge. For each diagnosis, the manual lists symptom criteria, a minimum number of which must be met before a definitive diagnosis can be given to a patient.
Criteria for alcohol and drug abuse hinge on the individual's continued use of a drug despite his or her knowledge of "persistent or recurrent social, occupational, psychologic, or physical problems caused or exacerbated by the use of the [drug]" (American Psychiatric Association, 1987). Alternately, there can be "recurrent use in situations in which use is physically hazardous." The DSM-IV draft continues this emphasis (American Psychiatric Association, 1993).
Thus, alcohol and drug abuse is defined as the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning. Alcohol and drug abuse may or may not involve physiologic dependence or tolerance. Importantly, evidence of physiologic dependence and tolerance is not sufficient for diagnosis of alcohol and drug abuse. For example, use of alcohol and drugs in weekend binge patterns may not involve physiologic dependence, although it has adverse effects on a person's life.
Alcohol and Drug Abuse
- Significant impairment or distress resulting from use
- Failure to fulfill roles at work, home, or school
- Persistent use in physically hazardous situations
- Recurrent legal problems related to use
- Continued use despite interpersonal problems
Therefore, screening questions should relate to life problems that result from alcohol and drug use, taking into consideration that patients may not have the insight to perceive that their life problems are caused by alcohol and drug abuse.
The phrase alcohol and drug addiction (called "psychoactive substance dependence" in the DSM-III-R and "substance dependence" in the DSM-IV draft) is an often progressive process that typically includes the following aspects: 1) compulsion to acquire and use alcohol and drugs and preoccupation with their acquisition and use, 2) loss of control over alcohol and drug use or alcohol and drug-induced behavior, 3) continued alcohol and drug use despite adverse consequences, 4) a tendency toward relapse following periods of abstinence, and 5) tolerance and/or withdrawal symptoms.
Alcohol and Drug Addiction or Dependence
- Pathologic, often progressive and chronic process
- Compulsion and preoccupation with obtaining a drug or drugs
- Loss of control over use or alcohol and drug-induced behavior
- Continued use despite adverse consequences
- Tendency for relapse after period of abstinence
- Increased tolerance and characteristic withdrawal (but not necessary or sufficient for diagnosis)
The DSM-III-R describes nine diagnostic criteria, of which three or more must be present for a month or more to establish a diagnosis of dependence. Screening questions can be based on these criteria. The DSM-IV draft committee deleted DSM-III-R criterion 4 and the requirement of symptoms being present for at least 1 month. The DSM-IV draft emphasizes the symptoms of tolerance and withdrawal, which the draft committee placed at the top of the list of criteria.
In the DSM-III-R, criteria 1 and 2 deal with loss of control; criterion 3 addresses time involvement; criteria 4 and 5 relate to social dysfunction; criterion 6 relates to continued use despite adverse consequences;and criteria 7, 8, and 9 relate to the development of tolerance and withdrawal. It is important to note that tolerance, physiologic dependence, and withdrawal are neither necessary nor sufficient for the establishment of a diagnosis of alcohol and drug addiction.
The term alcohol and drug dependence can be confusing because it has multiple meanings. The DSM-III-R uses the phrase "psychoactive substance dependence" to describe the process of addiction, while many pharmacologists use the term "dependence" exclusively for describing the biologic aspects of physical tolerance and/or withdrawal. The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychologic dependence and 2) physical dependence.
Psychologic dependence centers on the user's need of a drug to reach a level of functioning or feeling of well-being. Because this term is particularly subjective and almost impossible to quantify, it is of limited usefulness in making a diagnosis.
Physical dependence refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of alcohol and drug use. In this case, alcohol and drug type, volume, and chronicity are the important variables: Given a certain substance, the higher the dose and longer the period of consumption, the more likely is the development of tolerance, dependence, and subsequent withdrawal symptoms. Physical dependence and tolerance are best understood as two of many possible consequences (which may or may not include addiction and abuse) of chronic exposure to psychoactive substances.
Among patients with a psychiatric problem, any alcohol and drug use -- whether abuse or not -- can have adverse consequences. This is especially true for patients with severe psychiatric disorders and patients who are taking prescribed medications for psychiatric disorders. For patients with psychiatric disorders, the infrequent consumption of alcohol can lead to serious problems such as adverse medication interactions, decreased medication compliance, and alcohol and drug abuse. Screening questions can relate to evidence of any use of alcohol and drugs, as well as frequency, dose, and duration.
Medication misuse describes the use of prescription medications outside of medical supervision or in a manner inconsistent with medical advice. While medication misuse is not an abuse problem per se, it is a high-risk behavior that: 1) may or may not involve alcohol and drug abuse, 2) may or may not lead to alcohol and drug abuse, 3) may represent medication noncompliance and promote the reemergence of psychiatric symptoms, and 4) may cause toxic effects and psychiatric symptoms if it involves overdose.
Thus, some patients may consume medications at higher or lower doses than recommended or in combination with alcohol and drugs. Also, certain patients may respond to prescribed psychoactive medications by developing compulsive use and loss of control over their use.
Source: The U.S. Department of Health and Human Services
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