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.