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THE SEVERITY OF SUBSTANCE USE DISORDERS
The DSM 5 changed the definition and criteria for diagnosing what are now called Substance Use Disorders. The old terms were Substance Abuse and Substance Dependence. These new criteria allow clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder, four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” for certain substances and “in a controlled environment”. It should be noted that a person can have more than one Substance Use Disorder.
Criteria for Substance Use Disorders
Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria for making the diagnosis.
- Taking the substance in larger amounts or for longer than you’re meant to.
- Wanting to cut down or stop using the substance but not managing to.
- Spending a lot of time getting, using, or recovering from use of the substance.
- Cravings and urges to use the substance.
- Not managing to do what you should at work, home, or school because of substance use.
- Continuing to use, even when it causes problems in relationships.
- Giving up important social, occupational, or recreational activities because of substance use.
- Using substances again and again, even when it puts you in danger.
- Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
- Needing more of the substance to get the effect you want (tolerance).
- Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Substance intoxication, a group of substance-induced disorders, details the symptoms that people experience when they are “high” from drugs. Disorders of substance intoxication include:
- Marijuana intoxication
- Cocaine intoxication
- Methamphetamine intoxication (stimulants)
- Heroin intoxication (opioids)
- Acid intoxication (other hallucinogen intoxication or “acid trip”)
- Substance intoxication delirium
- Substance/Medication-Induced Mental Disorders
Substance/medication-induced mental disorders are mental problems that develop in people who did not have mental health problems before using substances, and include:
- Substance-induced psychotic disorder
- Substance-induced bipolar and related disorders
- Substance-induced depressive disorders
- Substance-induced anxiety disorders
- Substance-induced obsessive-compulsive and related disorders
- Substance-induced sleep disorders
- Substance-induced sexual dysfunctions
- Substance-induced delirium
- Substance-induced neurocognitive disorder
WHAT IS ADDICTION
In 2019 the American Society of Addiction Medicine formulated this definition of “addiction” based upon the current science and knowledge about the subject:
“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.” Adopted by the ASAM Board of Directors September 15, 2019
What causes addiction? Why do some people become addicted while others do not? There have been many theories about the cause of addiction but at this point it seems to boil down to these primary causes:
Scientific research has shown that 50–75% of the likelihood that a person will develop addiction comes from genetics, or a family history of the illness. Exactly how genetics factor into addiction, and what we could do to protect against their influence, is something scientists are actively researching right now.
Research shows that growing up in an environment with older adults who use drugs or engage in criminal behavior is a risk factor for addiction. Protective factors like a stable home environment and supportive school are all proven to reduce the risk. Exposure to adverse childhood experiences (trauma) can affect the developing brain in ways that may predispose one to addiction.
Addiction can develop at any age. But research shows that the earlier in life a person tries drugs, the more likely that person is to develop addiction. Our brains aren’t finished developing until we’re in our mid-20s. Introducing drugs to the brain during this time of growth and change can cause serious, long-lasting damage.
Co-Occurring Disorders (COD’s) or “Dual Diagnosis” refers to people who have both a Substance Use Disorder (SUD) and a Mental Disorder. COD’s are very common in people with SUD’s. It is estimated that between 50-80% of the people with an SUD have a COD, especially when you include past trauma in the equation. Trauma may be at the root of most SUD’s, Depression, Anxiety, and other emotional problems. They may even exacerbate the symptoms and onset of more severe mental disorders like Bipolar Disorder and Schizophrenia.
More and more participants entering SUD treatment have severe, undiagnosed, or untreated mental health problems, which may be related to their substance use. People often use psychoactive substances to “self-medicate” their symptoms or exacerbate (enhance or worsen) their symptoms. Many symptoms of mental disorders are caused by substance intoxication or withdrawal which can confuse practitioners during assessment. Sometimes it is difficult to initially assess whether a client’s symptoms and behavior are due to their substance use or to a mental disorder or both. Usually the only way to know for sure is to treat the prominent conditions, stabilize the symptoms and behaviors, and wait until sufficient time has occurred (sometime with the need for detoxification, medication, and even hospitalization) for the effects of the substance use diminish.
The incidence of Co-Occurring Disorders varies but there have been studies that suggest that 50-80% of people with a Substance Use Disorder will also have at least one co-occurring mental disorder. About 47% of Schizophrenics, 62% of Bipolar Disorders, 30-40% of Mood Disorders, and 40-50% of Anxiety Disorders have a co-occurring Substance Use Disorder. Dr. Kenneth Minkoff, a pioneer in the study of COD’s says that COD’s “are the expectation not the exception.”
There are three primary models of treatment for COD’s that are still prevalent. The first one is “Serial” treatment. This means one and then the other. Unfortunately the “serial” model is the least effective but it is possibly still the most prevalent way services are delivered. In this model you would get either your Mental Health or Substance Use problem treated first before you got treated for the other. In most cases it would depend on which “door” you entered to get treatment. Often the severity of one would cause the person to be referred to the “other” treatment first “before” the other problems were treated. For example, if one walked into the Mental Health clinic with anxiety, but were also found to have a Substance Use problem, they would be referred to SUD treatment “before” the anxiety could be treated. The system is set up to treat problems not people. This model causes delays, confusion, and requires the client to navigate several complex treatment systems and overcome access barriers to treatment. It is the least effective model of treatment.
The second model is somewhat better but still requires effective coordination of care and communication between providers. It is called the “parallel” model of treatment. This means “both at the same time, but in different settings”. An example would be a person getting residential substance use disorder treatment and being referred out for individual therapy and/or Psychiatry.
The third, and most effective model of treatment, is “integrated”. Integrated means all at the same time under one program of treatment. It is handled by a multi-disciplinary team made up of a Psychiatrist, therapist, SUD Counselor, and other professionals. They work as a coordinated treatment team and hopefully can stay with the person throughout their course of treatment.
Unfortunately, integrated treatment is slow to catch on. While it has been consistently shown to be the most effective way to treat COD’s, it hasn’t been implemented for many reasons. For some it appears more costly, however there is no data to support this. Perhaps in the short run it is more costly to assemble a team of professionals and to implement integrated programming, but in the long run it would be a cost savings with better and more effective results. Also, integrated treatment is seen by some as a “medical” model of treatment and not consistent with the more traditional “social” model or 12-Step focused program. There is a great deal of resistance in the SUD treatment field to this kind of treatment.
The good news is that Social Model Recovery Systems has been offering integrated treatment for Co-Occurring Disorders since 1986 at our River Community Residential Program and River Community Day Treatment and Outpatient programs. These programs offer a unique combination of both the “social model” of recovery along with the “medical model” used for treating mental health conditions.
Personality Disorders are defined as “a deeply ingrained and maladaptive pattern of behavior of a specified kind, typically manifest by the time one reaches adolescence and causing long-term difficulties in personal relationships or in functioning in society.
The DSM-5 identifies ten different personality disorders, but the ones that co-occur most frequently with SUD’s are what are called the “Cluster B” Personality Disorders. The most common with COD’s are the Antisocial, Borderline, and Narcissistic Personality Disorders. Here are the characteristics of each disorder.
Antisocial Personality Disorder
- Thought to be a “common” factor in co-occurring disorders
- Failure to conform to social and legal norms
- Deceitfulness (lying, conning, etc.)
- Irritability or aggressiveness (violence, fighting)
- Reckless disregard for safety (self/others)
- Lack of remorse/empathy/ conscience
Borderline Personality Disorder
- More prevalent in women than men
- Often a history of sexual or physical abuse especially during childhood
- Frantic efforts to avoid real or perceived abandonment
- The pattern of unstable and intense interpersonal relationships
- Impulsivity (spending, sex, substance misuse, eating)
- Recurrent suicidal behavior, threats, or self-harm behavior
- Inappropriate, intense displays of anger
- Identity disturbance
Narcissistic Personality Disorder
NPD is a mental condition in which people have an inflated sense of their own importance, a deep need for excessive attention and admiration, troubled relationships, and a lack of empathy for others. But behind this mask of extreme confidence lies a fragile self-esteem that’s vulnerable to the slightest criticism.
A narcissistic personality disorder causes problems in many areas of life, such as relationships, work, school or financial affairs. People with narcissistic personality disorder may be generally unhappy and disappointed when they’re not given the special favors or admiration they believe they deserve. They may find their relationships unfulfilling, and others may not enjoy being around them.
Signs and symptoms of narcissistic personality disorder and the severity of symptoms vary. People with the disorder can:
- Have an exaggerated sense of self-importance
- Have a sense of entitlement and require constant, excessive admiration
- Expect to be recognized as superior even without achievements that warrant it
- Exaggerate achievements and talents
- Be preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate
- Believe they are superior and can only associate with equally special people
- Monopolize conversations and belittle or look down on people they perceive as inferior
- Expect special favors and unquestioning compliance with their expectations
- Take advantage of others to get what they want
- Have an inability or unwillingness to recognize the needs and feelings of others
- Be envious of others and believe others envy them
- Behave in an arrogant or haughty manner, coming across as conceited, boastful and pretentious
- Insist on having the best of everything — for instance, the best car or office
At the same time, people with narcissistic personality disorder have trouble handling anything they perceive as criticism, and they can:
- Become impatient or angry when they don’t receive special treatment
- Have significant interpersonal problems and easily feel slighted
- React with rage or contempt and try to belittle the other person to make themselves appear superior
- Have difficulty regulating emotions and behavior
- Experience major problems dealing with stress and adapting to change
- Feel depressed and moody because they fall short of perfection
- Secret feelings of insecurity, shame, vulnerability, and humiliation
SCHIZOPHRENIA AND PSYCHOTIC DISORDERS
“Psychosis” refers to the presence of hallucinations and/or delusions as well as being “out of touch with reality”. Hallucinations (auditory, visual, tactile, olfactory) are hearing, seeing, feeling, or smelling things that are not there (real). Command Hallucinations (telling the person to do or not do something) is considered a high-risk situation if they are telling a person to harm themselves or someone else. Another interesting symptom is called “Ideas of reference” where the person believes that the TV/radio is talking directly to/about them.
Psychosis is often confused with Schizophrenia and rightfully so because “Psychosis” is a symptom of Schizophrenia, but psychosis is a condition that can be caused by many things. For example, psychosis may be secondary to drug intoxication/withdrawal (common in methamphetamine abuse, cocaine abuse, and alcohol withdrawal). Psychosis from alcohol withdrawal could signify onset of DT’s, a potentially life-threatening medical emergency. Psychosis can be caused from other medical conditions and can be a side effect from some prescription medications. Psychosis from marijuana use is increasingly common due to the high levels of THC in today’s marijuana supply. So “psychosis” and “schizophrenia” are not synonymous but related.
Schizophrenia is probably the most well-known of the Psychotic Disorders. It is increasingly thought that this disorder actually falls on a “spectrum” as there are many types and degrees of schizophrenia. Besides Schizophrenia there is Schizoaffective Disorder which is a combination of Schizophrenia and Bipolar Disorder. Schizophrenia is a brain disorder and as of now is chronic and incurable. It is treatable with medications and psychosocial therapies. People develop this disorder usually in their late teens to late twenties, mostly early to mid-twenties. It is rare for a person to develop Schizophrenia later in life. Psychosis can be caused at any time and any age due to numerous reasons. Persons with Schizophrenia have serious problems with social, occupational, and educational functioning. They often develop SUD’s as a part of their condition.
Schizophrenia is characterized by “positive” and “negative symptoms”. There isn’t anything “positive” about these symptoms which include psychosis and disorganized or bizarre thinking/speech/ or behavior. “Negative symptoms” refer to what is called flat affect (no emotional expression), a lack of goal directed behavior, and poor motivation. They may be difficult to engage in treatment and they may appear unmotivated or resistant. They may also require a slower pace of treatment and repetition due to cognitive deficits that tend to occur with this disorder. They also may not respond well to direct confrontation or heightened emotional content.
Skills training, psychoeducation, and motivational enhancement have been shown to produce favorable outcomes along with proper medication and of course sobriety.
What is anxiety?
Anxiety Disorders are disorders that have anxiety as their primary symptom.
Generalized Anxiety Disorder is just like it sounds. A person experiences a general state of anxiety manifested by heart palpitations, increased respiration, tenseness in the muscles and body, sweating, shakiness, hyperarousal, and other symptoms associated with anxiety. There may or may not be a precipitating cause or event.
Panic Disorder is when a person has had one or more “panic” attacks. A panic attack would be a “10” on the anxiety meter. Often a person thinks that they are going to die or that something is terribly wrong and they wind up in an Emergency Room only to be told that “it’s just anxiety”. Panic attacks can occur frequently and can become debilitating. A person may begin to avoid places or situations that they believe precipitated the attack (as you will see later, this isn’t actually the case). In some cases, they get to the point where they cannot leave the house or participate in normal activities. This is a condition known as Agoraphobia.
Obsessive-Compulsive Disorder is driven by an urge or need to engage in compulsive ritualistic behavior (such as hand-washing, counting, cleaning, organizing, etc.) in order to relieve the anxiety. Sometimes the person is affected by strange and intrusive thoughts (they know they are strange but cannot stop them) that preoccupy them (obsessions). Interestingly severe SUD’s involve both ritualistic and compulsive behaviors, however, there has currently been no link between SUD and OCD. The main thing about OCD is that the behavior/thinking has to interfere with the person’s ability to perform daily functions.
Social Anxiety Disorder is common among people with SUD’s. It involves experiencing extreme anxiety in novel social situations (meeting new people, parties, public events, etc.) A person with this disorder will go to great lengths to avoid these situations or have to “take a shot of courage” to participate.
Phobias are considered excessive and irrational fears about something. Common phobias are fear of heights, fear of closed in spaces, fear of flying, fear of snakes/spiders, fear of public speaking, to name a few.
Post Traumatic Stress Disorder is considered an anxiety-based disorder. It develops in response to a traumatic event(s). The person develops hyperarousal (always anxious/on guard, exaggerated startle response, always “on”), hypervigilance (always looking over the shoulder), and may have nightmares, flashbacks, and a host of other symptoms. They are also more prone to SUD’s, depression, and other anxiety disorders.
One of the problems for anxiety sufferers is that they feel helpless and powerless to control their symptoms. This is especially true for those who suffer panic attacks. The mind will associate what the person was doing, where they were, sights, sounds, smells, and other stimuli with the cause of the panic attack. Now the person becomes anxious just thinking about driving or going to the grocery, going to the mall, or doing whatever they believe caused the attack. Now they avoid the activity, place, or environment that they believe is the source. Fear of a panic attack will cause another panic attack. It actually had nothing to do with driving, or the mall, or whatever. It happened because of a random thought that the person probably didn’t even realize they were having at the time of the attack. Now they won’t drive on the freeway because they are afraid of having a panic attack when they do and then they will be helpless, and alone, and THEY WILL DIE!!!! What if it happens again? While I am alone? On the freeway and surrounded by semis? What if I am trapped? So they won’t get behind the wheel or drive on the freeway. In many cases, the person eventually stops going anywhere and won’t leave the house. This is a condition known as “Agoraphobia”. You can see how alcohol and drugs sound appealing to someone with anxiety, and they actually work well to ease the symptoms, however, what starts as a solution often becomes a problem.
There are many methods for treating anxiety from Cognitive Behavioral Therapy, Relaxation techniques, Mindfulness exercises, and of course medications. They are effective for some and not so effective for others. I have encountered hundreds of clients who have sought or tried all of these treatments and more without success. Many were feeling hopeless and helpless to find a treatment that could ease their symptoms or eliminate their anxiety. As counselors, we will be working with clients who suffer from anxiety. How can we help them? Well, the good news is that there are some simple yet effective techniques for eliminating and controlling anxiety symptoms, some that I have learned and some that I have developed and used successfully on hundreds of clients, some who had tried several doctors, therapists, medications, and techniques.
Mood Disorders are just disorders of mood. This includes Depressive disorders and Bipolar Disorders (formerly Manic-Depression). Depression is common in persons with a substance use disorder. Depressive symptoms may surface and persist when substance use is halted. Some common symptoms of what is called “Major Depression” are:
- Ongoing depressed (sad, empty) mood
- Loss of interest in pleasurable activities
- Significant weight loss or gain (+/- 5%)
- Insomnia or hypersomnia
- Psychomotor agitation/retardation; fatigue
- Worthlessness or excessive guilt
- Difficulty thinking or concentrating
- Recurrent thoughts of death or suicide
Depression is best treated with a combination of medication and cognitive-behavioral therapy.
Bipolar Disorder is characterized by frequent and severe mood swings and symptoms ranging from depression to mania.
Symptoms of Mania:
- Increased energy, activity, restlessness, racing
- Thoughts and rapid speech
- Excessive euphoria
- Extreme irritability and distractibility
- Decreased sleep requirement
- Uncharacteristically poor judgment
- Increased sexual drive
- Denial that anything is wrong
Bipolar disorder is one of the most common disorders to co-occur with SUD’s.