Alcoholism

Substance Use Disorders in the DSM

• Substance* Dependence

• Substance* Abuse

• Substance* Induced Disorder

* The specific substance which is abused, depended on, or induces a disorder must be named in the diagnosis

Substance* Dependence

• Maladaptive pattern of substance use, leading to impariement or distress which manifests in 3+ symptoms in a 12 month period:
• Tolerance: -Increased use to mainatain effect or decreased effect if same level use is maintained (How much are you using now? How much did you use when you first started?)
• Withdrawal - Characteristic withdrawal sybdrome to the substance

                        -Same or similar substance used to relieve withdrawal

                        -Use of opiates for pain have high tolerance/dependence, but low potential for addiction

• Loss of Control-Substance taken in larger amounts or for a longer time than was intended
• Time Spent - Considerable effort & time in use & procurement
• Lower LOF in social, occupational, & recreational activities
• Use despite consequences

Substance Dependece Specifiers

• With or without physiological dependence
• Course @ 1 month:

       -Early full remission

       -Early partial remission

       -Sustained full remission

       -Sustained partial remission

       -On agonist therapy (methadone or buprenorphine)

       -In a controlled environment

Substance Abuse

(often diagnosed if we do not have the criteria to diagnose w/dependence)

• Maladaptive pattern (2 or more times) of substance use, leading to impairment or distress, manifesting in 1 of the following in a 12 month period:

      -Lower functioning due to use

      -Use in hazardous situaitons (driving)

      -Recurrent legal probems connected to use

      -Use despite consequences (medical, legal, relational)

• 1 time of driving a car high- substance abuse
• Use drugs at least twice- substance abuse

Substance Induced Disorders

• Substance Intoxication
• Substance Withdrawal (specific to drug)
• Substance-induced Delerium (sensory impairments, usually short term visual hallucinations)
• Substance-induced persisting Dementia (long term lowered cognitive functioning)
• Substance-induced Amnestic disorder (Korsikov syndrom or loss of memory)
• Substance-induced Psychotic disorder 
• Substance-induced Mood disorder
• Substance-induced Anxiety disorder
• Substance-induced Sexual dysfunction
• Substance-induced Sleep disorder

VAILLANT Study

• There are no specific symptoms which identify alcoholism-it is the number & frequency of alcohol-related problems which identify the disorder
• The only way to diagnose substance abuse is by the effect of the drugs on ones life, not by the quantity or the frequency alcohol or drugs are used
• Alcoholics who achieve stable abstinence are not pre-morbidly healthier than alcohoics who continue drinking.

        -No such thing as an alcoholic personality. Alcoholism is usually not a symptom of an underlying personality disorder.

• Outcome depends little on the type of treatment. (Special inpatient alcoholism units are no more successful in outcome than community programs or AA or provision of common sense advice)
• No matter what treatment is given, 10-20% will never relapse, and 2-3% will achieve stable recovery each year.

Best Predictors of Recovery

(Vaillant)

• A substitute dependency (AA, religion, people, work, exercise, hobbies)
• An external reminder that drinking is adversive (drunkalogs, antabuse, jail)
• A source of inspiration, hope, self-esteem (recovery stories, religion, therapy)
• Unambivalently offered social support (friends, community)

Principles of Drug Addiction Treatment: A research based Guide (national institute of health)

1. No single treatment is appropriate for all individuals
2. Treatment needs to be readily available
3. Effective treatment attends to multiple needs of the individual, not just their drug use (connect to community, etc)
4. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness (3 months on average-difficukt with budget cuts)
6. Counseling (individual and or group) and other behavioral therapies are critical components  of effective treatment for addiction
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies
8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an intergrated way
9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use
10. Treatment does not need to be voluntary to be effective
11. Possible drug use during treatment must be monitored continuously
12. Treatment programs should provide assessment for HIV, hepatitis, TB, & other infectious diseases and counseling to help patients modify or change behaviors that place themselves or others at risk of infection
13. Recovery from drug addiction can be a long-term process  and frequently require multiple episodes of treatment (average of 7 relapses before achieving stable sobriety, don't be discouraged when clients drink again)

Hypertension, Diabetes, Asthma, & Substance Use Disorders

• Hypertension, Diabetes, & Asthma- no doubt they are all illnesses, all chronic conditions, influenced by genetic, metabolic, & behavioral factors. Allhave no cures, but effective treatments are available.

1. With the high treatment noncompliance rates and high relapse rates for these illnesses, would you say that treatment for these disorders is ineffective? Why not?
2. If treatment of substance use disorders has virtually the same non-compliance and relapse rates, would you say that the treatment for substance use disorders is ineffective? Why?

Basic Medical Treatment for Substance Abuse/Dependence

• Medical Detoxification
• Agonist Maintenance (methadone/LAAM)
• Antagonist Treatment (naltroxene/buprenorphine)-makes you throw up when you drink

Basic Behavioral Treatment for Substance Abuse/Dependence

• Outpatient drug free treatment
• Long term residential treatment
• Short term residential treatment
• Specialized treatment for criminal justice populations

Methadone

• Methadone saves society money
• Super effective
• Has the biggest effect on treatment
• Has a gradual onset (no euphoria) and longer half life (no crash) so it disrupts the craving cycle

Scinetifically Supported Substance Abuse Treatments

(National Institute of Health)

• Relapse Prevention
• Supportive-Expressive Psychotherapy
• Individualized drug counseling
• Motivational enhancement therapy
• Combined behavioral and nicotine replacement therapy for nicotine dependence addiction
• Community reinforcement approach plus vouchers
• Behavioral couple therapy for alcohol abuse
• Voucher-based reinforcement therapy in methadone maintenance treatmen
• Day treatment with absitinence contigencies and vouchers
• The matrix model for cocaine addiction

Personality Disorders

DSM General Criteria

• Lifelong patterns of thinking, feeling, interpersonal relations, and impulse management which deviates markedly from the expectations of one's culture
• Integrated, rather than discrete behavior -Relatively inflexible across contexts (horizontal     integration)-Longstanding, can be traced to adolescence (vertical integration)

• Leads to distressor impairment in functioning (patient has to be troubled to themselves-except for schizoid)
• Can't be accounted for by an Axis I symptom of disorder

Paranoid Personality

• Suspicion
• Preoccupation with loyalty, trustworthiness
• Reluctant to confide in others
• Sees hidden meanings & motives
• Bears grudges
• Perceives attack on character
• Heightened attention to partner fidelity

Schizoid Personality

• Neither desires nor enjoys cose relationships
• Prefers solitary activities
• Little interest in sex
• Takes pleasure in few, if any activities
• Lacks close friends/confidants
• Indifferent to praise/criticism
• Emotional coldness. detachment, flattened affect
• Withdrwan and okay with being withdrwan

Schizotypal Personality

• Unusual, eccentric
• Ideas of reference
• Unusual perceptions
• Odd thinking and speech
• Suspicioness and paranoid ideas
• Inappropriate or constricted affect
• Odd, eccentric behavior or appearance
• Lack of close friends, confidants
• Social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears  rather than negative judgments about self

Borderline Personality

• Fear of abandonment
• Unstable and intense relationships- alternating between idealization/devaluation
• Identity disturbance, unstable self-image
• Suicidal threats, actions, or self-mutilation
• Affective instability
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Transient, stress-related paranoia or dissociation

Narcissitic Personality 

• Grandiose sense of self-importnace
• Preoccupied: success, power, brilliance, beauty, love
• Belief in own uniqueness and best understood by other 'special' people
• Needs excessive admiration of others
• Strong sense of entitlement
• Exploits others to achive their own needs
• Lacks empathy
• Envious or beieves others are envious of them
• Arracogant affect

Histrionic Personality

• Drama queen, talks and dresses dramatically
• Uncomfrtable in situations in which they are not the center of attention
• Inappropriate sexually seductive or provocative behavior
• Rapidly shifting and shallow expression of emotions
• Uses physical appearance to draw attention to self
• Speech is excessively impressionistic and lacking in detail
• Self-dramatization, theatricality, and exaggerated expression of emotion
• Easily influenced by others or circumstances
• Considers relationships to be more intimate than they are

Antisocial Personality

• Have to meet conduct disorder criteria before they were 18yo. (Conduct and ADHD all grown up)
• Failure to conform to social norms (unlawful behavior)
• Deceitfulness, lying, use of aliases, conning for personal gain
• Impulsivity, failure to plan ahead
• Irritability and aggressiveness, frequent physical fights
• Reckless disregard for safety of self and others
• Irresponsible, doesn't work or pay off debts
• Lack of remorse, indifferent to hurting others

Avoidant Personality

• Wants to connect, but is afraid of rejection
• Avoids jobs with interpersonal contact
• Unwilling to get involved  with people unless certain of being liked
• Restrained relationships, fear of being shamed
• Preoccupied with being criticized
• Inhibited in interpersonal situations because of inadequacy
• Views self as socially inept, unappealing, or inferior
• Reluctant to take personal risks or to engage in any new activities because they may rove embarassing

Dependent Personality

• Needs structure from other people
• Difficulty making everyday decisions without advice
• Needs others to be responsible for areas of life
• Hard to disagree with others because of fear of loss
• Difficulty initiating projects or doing things on their own
• Goes to great lengths to obtain nurturance and support
• Feels uncomfortable or helpless when alone
• Seeks another relationship quickly when a close relationship ends
• Preoccupied with fears of being left to take care of self

AXIS I

Clinical Disorder (Reason for visit)

AXIS II

Personality disorder or mental retardation (if unknown, write defer)

AXIS III

General medical conditions (indicate whether the information is from client self-report, existing record, or physician report)

AXIS IV

Psychosocial/Environmental problems (support group, social environment, education, occupation, housing, economic, access to health care, legal system, other)

AXIS V

Global Assessment of Functioning (GAF)

91-100 Superior

81-90 Minimal sx

71-80 transient/expected sx

61-70 Mild sx

50-60 Moderate sx 41-50 Serious sx

31-40 Impaired reality testing major sx

21-30 Delusion, hallucination, impaired judgment

11-20 Danger to self/others; gross impairment

1-10 Persistent danger; serious suicide risk 0 No information