ch. 3 - Diagnostic Issues Flashcards
Diagnosis of SUD is considered across what 10 drug classes
- Alcohol
2. Cannabis
3. Phencyclidine
4. other hallucinogens
5. Inhalants
6. Opioids
7. Sedatives
8. Stimulants
9. Tobacco
10. Other/unknown
* The DSM Diagnostic criteria for SUD specify maladaptive behaviors that fall into 11 criteria with overall groupings of impaired control, social impairment, risky use, and tolerance/withdrawal criteria.
Impaired control
consists of the first four diagnostic items:
- The individual may take the substance in larger amounts or over a longer period than was originally intended
- The individual may express a persistent desire and/or unsuccessful history to cut down, cease, or regulate substance use
- The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects;
- Craving is manifested by an intense desire or urge for the drug that may occur at any time
Social impairment
consists of diagnostic items 5 to 7:
- Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home;
- The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance; and
- Important social, occupational, or recreational activities may be given up or reduced because of substance use.
Risky Use
consists of diagnostic items 8 and 9:
- The recurrent substance use in situations in which it is physically hazardous (such as driving while intoxicated); and
- The individual continues substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance and Withdrawal
consists of Diagnostic Criteria 10 and 11:
- Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.
- Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms.
* Withdrawal syndromes must cause impairment and distress as well as not be better explained by a co-occurring psychological and/or medical disorder
Alcohol withdrawal
2 or more: pulse greater than 100 beats/min, increased hand tremors, insomnia, nausea, temporary hallucinations, psychomotor agitation, tonic-clonic seizures, anxiety
Cannabis withdrawal
3 or more: irritability/anger, anxiety, sleep difficulties, decreased appetite, restlessness, depression, somatic complaints
Opioid withdrawal
3 or more: depressed mood, nausea, body aches, lacrimation, rhinorrhea, pupil dilation, sweating, diarrhea, yawning, fever, insomnia
Sedative, Hypnotic, or Anxiolytic withdrawal
2 or more: pulse greater than 100 beats/min, increased hand tremors, insomnia, nausea, auditory hallucinations, psychomotor agitation, tonic-clonic seizures, anxiety…these are similar to alcohol withdrawal
Stimulant withdrawal
2 or more: fatigue, nightmares,insomnia/hypersomnia, increased appetite, psychomotor agitation or retardation
Severity Ratings
based on the number of diagnostic criteria (out of 11) endorsed via client self-report , clinician observation, collateral report, and/or biological testing.
· The ratings run from mild(two to three criteria endorsed), moderate(four to five criteria endorsed), and severe(six or more criteria endorsed).
Course Specifiers
Early remission occurs if the individual had met the full substance use disorder (SUD) criteria but now has gone between 3 and 12 months without experiencing any of the diagnostic criteria with the exception of craving.
· Sustained remission occurs if the individual had met the full SUD criteria but now has gone greater than 12 months without experiencing any of the diagnostic criteria with the exception of craving.
· “In a controlled environment” pertains to those who ceased substance use but did so in a context that (in theory) restricted their access to the substance(s), such as inpatient treatment or prison;
· “On maintenance therapy” is reserved for opioid use disorder and stipulates whether no SUD criteria are met due to the client being prescribed and using agonist and/or antagonist medication, such as methadone or oral naltrexone.
ICD-10 Classification - medical classification with 2 categories:
- harmful use requiring medical or physical harm
2. Dependence- There are questions about how the DSM V severity scale matches with ICD-10 categories
what are the requirements for a substance-induced psychiatric disorder as per the DSM-5:
- The psychiatric symptom in question (anxiety for induced-anxiety, for example) needs to be a prominent factor in the overall clinical picture.
- The psychiatric symptoms developed soon after intoxication and/or withdrawal from the substance.
- The substance is capable of inducing the psychiatric symptom(s) in question.
- Psychiatric symptoms that are not better explained by a non substance-related version of this disorder.
- The psychiatric symptoms appear to not be better explained by delirium.
Common factor model
maintains that the co-occurring SUD and psychiatric disorder originate from a single risk factor that increases the risk for both substance use and psychiatric disorder. Some common risk factors are genetic vulnerability, disordered mesolimbic activity in the brain, or psychosocial factors such as poverty or homelessness.
Random multiformity and extreme multiformity models
state that one disorder can take heterogeneous or atypical forms. Symptoms will appear that seem associated with other disorders. This complicates the diagnostic accuracy and also seems to underscore the need for consistent and frequent reevaluation to determine the true origin of the symptom
correlated liabilities model
proposes that the onset of co-occurring conditions arise due to shared common sets of risk factors. For example, co-occurring SUD and depression in adolescence may arise from a variety of forms of neglect and abuse during childhood.
secondary substance abuse model
proposes that psychopathology precedes and causes substance use disorder.
secondary psychiatric disorder model
states that substance use disorder precedes and causes psychiatric disorders.
reciprocal causation model
proposes that one disorder will exacerbate the other. This model is less concerned with the order of onset and more focused on the integration of SUD and psychiatric disorders for the sake of best-fitting treatment options
Anxiety & Depression
· 20% of the anxiety disorder population self-medicates with alcohol due to the anxiolytic effect of alcohol.
· Anxiety disorder onset seems to come prior to opioid use disorder onset
· 25% of individuals with depressive disorders use substances to relieve symptoms
· Mood disorders (particularly major depression) and SUDs were the most common disorders for those who died by suicide.
· 38% of these suicidal individuals had one or more substance use disorder plus one or more other psychiatric disorder
· The SUD/mood disorder co-occurring condition also produces a heightened risk for attempted suicide
· the suicide risk is present regardless if the depressed mood is due to an independent co-occurring mood disorder or a substance-induced mood disorder.
Bipolar Disorders
· Bipolar disorder and SUDs are a common and complex combination.
· The co-occurring relationship between these disorders complicates the course and duration of the bipolar depressive and manic episodes
· These clients are also dangerous to self as they demonstrate medication nonadherence as well as a higher risk for suicide
Psychotic Disorders
· Psychotic symptoms are also common in SUDs, whether due to withdrawal, substance-induced, or non substance-related co-occurring disorder
· High proportion of methamphetamine users having co-occurring psychotic disorders.
· Severe psychotic disorders increased the risk for heavy alcohol use, heavy cannabis use, and recreational substance use
· Cannabis use could induce psychosis, whereas Rubio et al. (2012) underscored the commonalities of symptoms between cannabis-induced psychotic disorder and a recent onset non-substance-related psychotic disorder.
· Little is actually known regarding alcohol-induced psychotic disorder, specifically in regard to how to distinguish the symptoms from alcohol withdrawal delirium or schizophrenia.
Personality Disorders
· Anti-social personality disorder (ASPD) and borderline personality disorder (BPD) are the two personality disorders most commonly associated with co-occurring SUD.
· High levels of comorbidity between SUDs and ASPD have been reported within samples of individuals with SUDs in treatment. ASPD clients present as complex cases and are associated with a more severe course of SUD
· BPD is also prevalent within the SUD treatment population. One study (Sansone, Whitecar, & Wiederman, 2008) found a prevalence rate of BPD in those seeking buprenorphine treatment for opioid addiction exceeding 40%; nearly 50% of individuals with BPD reported a history of prescription drug misuse.
PTSD
· PTSD is common in the SUD population, with one-quarter to one-third of SUD clients in treatment meeting PTSD diagnostic criteria
· Those with a PTSD diagnosis have nearly a twofold risk of a lifetime SUD diagnosis
· heightened risk of developing PTSD and/or other co-occurring psychiatric disorders
Pathological Gambling
the only process addiction included in the DSM-5
pathological gambling criteria
- an increasing need to gamble with greater amounts of money to achieve an exhilaration from the gambling;
- restlessness and irritability when the individual tries to reduce or stop gambling;
- repeated and unsuccessful efforts to reduce or cut down gambling;
- a preoccupation with gambling;
- gambles when experiencing negative affect and/or mood;
- tries to “get even” immediately after losing large amounts of money:
- lying to conceal gambling behaviors;
- important family, relationship, work, or school obligations jeopardized or lost due to gambling;
- requires money from others to support gambling behaviors.
· Severity ratings are four or five criteria endorsed (mild), six or seven criteria (moderate), and eight or more criteria (severe).
Sex Addiction
· no clear diagnostic paradigm for sex addiction.
· still much known about sex addiction.
Hypersexual disorder criteria:
For at least the past 6 months there needs to be recurrent and intense sexual urges and/or behaviors demonstrated in four or more of the following ways:
1. a great deal of time is spent on sexual fantasies or sexual behaviors;
2. the individual repeatedly engages in sexual fantasies and/or behaviors as a response to dysphoric mood;
3. the individual repeatedly engages in sexual fantasies and/or behaviors as a response to stressful life events;
4. there have been repeated unsuccessful efforts to cut down or cease the hypersexual fantasies, urges, and/or behaviors; and
5. the sexual fantasies, urges, and/or behaviors are continued despite the risk of harm to self and/or others.
· includes specifiers regarding whether the sexual activity is focused on masturbation, pornography, sex with consenting adult(s), cybersex, phone sex, or strip clubs.
Food Addiction
not a recognized disorder in the DSM-5.
food addiction criteria
Yale Food Addiction Scale for the diagnostic assessment of a potential food addiction - 3 or more criteria:
- substance taken in larger amount and for longer period than intended;
- persistent desire or repeated unsuccessful attempts to quit;
- much time/activity to obtain, use, recover;
- important social, occupational, or recreational activities given up or reduced;
- use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligations, use in physically hazardous situations);
- tolerance (marked increase in amount; marked decrease in effect);
- characteristic withdrawal symptoms; substance taken to relieve withdrawal; and
- use causes clinically significant impairment or distress.
Non-Suicidal Self-Injury
criteria stipulates that in the past year on at least five occasions the individual has engaged in “intentional, self-inflicted damage” such as cutting, burning, stabbing, punching, or excessive rubbing that is not culturally sanctioned (i.e., as part of a religious or cultural ceremony/ritual); not inflicted as part of a suicidal act.
Non-Suicidal Self-Injury criteria
· There are high rates of various co-occurring disorders within the NSSI population such as anxiety, mood, substance use, and eating disorders as well as symptoms of emotional dysregulation and heightened general psychiatric distress.
· Whether ingesting cocaine, gambling, being involved in excessive hypersexual behaviors, or engaging in an NSSI act such as cutting, the client is primarily engaged in negative reinforcement.
Signs to look for SUD in adolescents:
o Change in attitude, friends, hobbies, school performance, grooming habits
o Difficulty with attention, black outs, forgetfulness
o Lack of motivation “I don’t care”
o Sudden mood swings, paranoia, aggression, confusion
o Excessive need for privacy, secretive behavior
o Chronic dishonesty, stealing
o Risky behavior, accidents
o Drug paraphernalia, use of room deodorizers
Substance use criteria of DSM V in Adolescents
Substance use criteria of DSM V do not fit adolescents well - adolescents may have substance use issues without signs of withdrawal or dependence
· Changes from the DSM IV to the DSM V make it more difficult to diagnose teens, and therefore more difficult to receive 3rd party reimbursement for SUD treatment
Older Adults and substance use
· Substance use within this population continues to rise
· More likely to: be sensitive to substances ingested at low levels, have drug interactions, have increased tolerance levels, and struggle with dementia or other cognitive impairments
· More likely than younger adults to have a SUD while not meeting criteria bc the amount of alcohol considered problematic is unclear and bc some symptoms of SUD are dismissed as being what older people do
· Prescription medication and opioid abuse more common
Please explain how and why the DSM-5 does not consider the craving criterion in calculating the presence of SUD symptoms to designate a relapse. (5 points)
Sustained remission occurs if full SUD criteria were met, but now have gone greater than 12 months without experiencing any of the diagnostic criteria EXCEPT for the presence of cravings. Craving is a new criteria of SUD in the DSM V and demonstrates that the DSM considers active craving to be a common symptom for more than a year into full recovery. This decision supports research that has found cravings to be normal and a main focus of clinical intervention. Craving should not be considered a criterion for relapse, but rather a general gauge for stability and coping skills when negative affect arises without returning to substance use.
According to Morgen in Chapter 3, why should NSSI be considered a process addiction?
NSSI is proposed as a condition in need of further study in the DSM V, however Morgen feels it should be classified as a process addiction. Per the DSM V, NSSI occurs for one of the following reasons: 1) to seek relief from negative emotion, 2) to produce a positive emotion, and/or 3) to resolve interpersonal difficulties. In addition, NSSI occurs in one of the following situations: 1) negative mood/affect leading up to the act, 2) preoccupation with the NSSI behavior that is difficult to control, and/or 3) frequent rumination regarding NSSI acts. These proposed diagnostic criteria mirror the experiences of those who struggle with SUD. It appears that individuals with NSSI also struggle with issues that overlap with those of SUD. NSSI entails issues of compulsion, loss of control, continued use despite negative consequences, and the development of tolerance, which are all indicators of an addiction.
