Substance-abuse disorders diagnosis

The psychiatrist may have anywhere from 30-50 minutes for an initial evaluation, whereas the primary care physician will probably have 15-30 minutes for the first visit. Both of them will probably have about 15 minutes for follow-up visits, sometimes less. Visits are often rushed, and any patient can look like anything for an hour. Patients can look healthy when they are psychotic, they can look happy when they are depressed and suicidal, they can successfully sublimate personality-disordered behavior, and they can (and usually do) hide substance abuse disorders. Whomever is chosen, it is critical to communicate the reasons for referral never assume that the presenting problem or diagnosis will be obvious in the visit with the physician. 

Untreated ADHD is a significant risk factor for substance abuse disorders in adolescents (36). In contrast, pharmacotherapy, that is stimulants, was associated with an 85% reduction in the risk of substance abuse disorders in youths with ADHD. Most authorities recommend complete assessment and diagnosis of both ADHD and any dual diagnoses before starting stimulant medication. 

Differentiating SAD from other anxiety disorders can be difficult. Panic attacks occur in both SAD and panic disorder, but the distinction between the two is the rationale behind fear fear of anxiety symptoms is characteristic of panic disorder, while fear of embarrassment from social interaction typifies SAD. GAD is hkely the diagnosis if anxiety regarding social situations are part of a pattern of worries about multiple fife areas or numerous potential negative outcomes. A majority of SAD patients have a comorbid mood, anxiety, or substance abuse disorder. The SAD typically precedes the development of comorbid disorders, which is associated with increased suicidal ideation. ... 

Kranzler HR, Rosenthal RN Dual diagnosis alcoholism and co-morbid psychiatric disorders. Am J Addict 12 (suppl 1) S26—S40, 2003 Kranzler HR, Tinsley JA (eds) Dual Diagnosis Substance Abuse andComorbid Medical and Psychiatric Disorders, 2nd Edition. New York, Marcel Dekker, 2004... 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

Much less attention has been paid to chronic PCP use per se, i.e., the substance use disorder itself. Such issues as the effects of chronic PCP use, and the diagnosis, clinical characterization, and treatment of chronic PCP abusers are rarely discussed in the published literature, even in detailed review articles (Davis 1982 Pearlson 1981 Pradhan 1984). This paper reviews the literature on inpatient and outpatient treatment of PCP abuse, outlines our own experience with PCP users and abusers in one large, public, urban hospital, and makes suggestions for future research based on this information and animal research findings (Balster, this volume). 

Bipolar I disorder affects men and women equally bipolar II seems to be more common in women. Rapid cycling and mixed mania occur more often in women. Individuals with bipolar disorder commonly have another psychiatric disease with 78% to 85% reporting another Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis during their lifetime. The most common comorbid conditions include anxiety, substance abuse, and eating disorders.2... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

Lifetime prevalence rates of psychiatric comorbidity co-existing with bipolar disorder are 42% to 50%.16 Comorbidities, especially substance abuse, make it difficult to establish a definitive diagnosis and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidal-ity, and onset of depression.2 Psychiatric comorbidities include ... 

Although ADHD is considered a childhood disorder, signs and symptoms persist into adolescence and adulthood in approximately 40% to 80% and 60% of cases, repectively.1,9 Adult ADHD is difficult to assess, and diagnosis is always suspect in patients failing to display clear symptoms prior to 7 years of age.4 Adults with ADHD have higher rates of psychopathology, substance abuse, social dysfunction, and occupational underachievement. 

Substance Use Disorder. Patients abusing alcohol or other substances may be prone to erratic behavior reminiscent of the Cluster B personality disorders. If these behaviors occur exclusively in a context of intoxication or during periods of heavy substance use, then the diagnosis of a Cluster B personality disorder is not warranted. Instead, treatment should be focused on the substance use disorder. This is not to say, however, that substance use disorders and Cluster B personality disorders cannot occur together. In fact, the difficulty that these patients have in self-soothing leaves them especially vulnerable to substance abuse. 

In a 1994 study Teplin evaluated 728 male jail detainees, and found that nearly two-thirds of this population had a psychiatric disorder with antisocial personality disorder (ASP), the most common diagnosis at 50%. However, 35% of the population had a current diagnosis other than ASP, and two-thirds had previously been given a lifetime diagnosis other than ASP. Substance abuse was common, with a 62% lifetime prevalence. More than one out of three detainees had a severe mental disorder (schizophrenia, bipolar affective disorder, or major depression). In another study, 693 homicide offenders were evaluated and elevated rates of schizophrenia and ASP were found (Eronen et al., 1996). Earlier studies found schizophrenia in 29%-75% and affective disorders in 4%-35% of prisoners. 

An important related problem is the trend toward demedicalization of state mental health facilities. Given a host of clinical and economic realities, many HIV-infected patients can only be served by such institutions ( 472). Their complicated psychiatric and medical presentations, however, require a high level of clinical sophistication, particularly in recognizing and managing their physical co-morbidities ( 473, 474). Indeed, an increasing number of patients suffer from a triple diagnosis (i.e., a psychiatric disorder with co-morbid substance abuse and HIV-positive status) ( 475). 

Consider evaluation for another diagnosis or tor a comorbid condition (e.g., bipolar disorder, substance abuse, medical illness, etc.)... 

A thorough patient evaluation (e.g., history, mental status exam, physical exam, and laboratory analysis) should occur to establish a diagnosis of schizophrenia and to identify potential co-occurringdisorders, including substance abuse and general medical disorders. 

Dual-diagnosis treatment program substance abuse plus standard pharmacologic/ nonpharmacologic treatments for bipolar disorder hepatic dysfunction from chronic alcohol abuse or from hepatitis may alter the metabolism of some agents Lithium long-term treatment associated with reduction of suicide risk and mortality... 

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