CHAPTER 5: Assessment and Diagnosis

1. CHAPTER 5:Assessment and Diagnosis Substance Abuse Counseling: Theory and Practice Fifth Edition Patricia Stevens Robert L. Smith Prepared by: Dr. Susan Rose, University of the Cumberlands

2. Overview of Chapter • Issues in Assessment • The Diagnostic Interview • DSM-IV-TR Diagnosis • Behavioral Characteristics • Assessing the Behavioral Symptoms • Assessing the Social and Family-Related Symptoms • Screening and Assessment Instruments • Diagnosis

3. Issues in Assessment • No single medical or psychological test can determine with absolute certainty that a person is drug or alcohol dependent • Inconsistencies in social attitudes complicate what actually defines substance abuse • Stigma associated with addiction leads to denial • Several problems interfere with diagnostic process: • Therapist biases about substance abuse clients • Client’s attitude about alcohol or drugs and sense of shame in seeking help may create a barrier to accurate assessment

4. The Diagnostic Interview • Collateral interviews often help to give a more complete picture of both the user and the impact they are having on others in their environment. • Readiness for Change • Transtheoretical model • Structured Interview format • Substance Use History Questionnaire

5. DSM-IV Diagnosis • Substance: a drug of abuse, a medication, or a toxin that is used in a manner incongruent with medical treatment. • Substances are grouped in 11 classes: • Alcohol • Amphetamines • Caffeine • Cannabis • Cocaine • Hallucinogens • Inhalants • Nicotine • Opioids • Phencyclidine (PCP • Sedatives/Hypnotics/Anxiolytics (Anti-anxiety drugs)

6. DSM-IV Diagnosis: Criteria for Substance Dependence • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period: • Tolerance • Withdrawal • Substance is taken in larger amounts or over a longer period than was intended • A persistent desire or unsuccessful effort to cut down or control substance use • A great deal of time is spent in activities to obtain the substance, use the substance or recover from its effects • Important social, occupational, or recreational activities are given up or reduced because of substance use • Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by a substance

7. DSM-IV Diagnosis: Criteria for Substance Abuse • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring at any time in the same 12-month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused by exacerbated by the effects of the substance

8. Behavioral Characteristics • Common presenting problems related to substance abuse: • Marital and family conflict • Child abuse or neglect • Unemployment • Financial problems • Multiple medical problems • Anxiety • Depression • Suicide • Problems with aggression and violence

9. Behavioral Characteristics • A drug or alcohol problem exists and requires treatment if the use of substance continues despite interference in any on of the six major areas of a person’s life: • Job or school • Relationships with family • Social relationships • Legal problems • Financial problems • Medical problems

10. Behavioral Characteristics • Phase 1: The Prodomal Phase • In this early phase, the following behavioral changes generally occur: • Increase of tolerance • First blackout or loss of significant time to drug use • Sneaking drinks or drugs • Preoccupation with drinking or drug use • Gulping drinks or hurried ingestion of chemicals • Avoiding reference to drinking or drug use

11. Behavioral Characteristics • Phase 2: The Crucial Phase • In this second phase, the following behavioral symptoms generally occur: • Loss of control of substance use • Denial and minimization of use • Confrontation by others • Behavioral loss of control • Guilt and remorse • Periodic abstinence or change in patterns of use • Losses • Medical and psychological interventions • Growing alienation and resentment • More frequent substance use

12. Behavioral Characteristics • Phase 3: The Chronic Phase • In this last phase, the following symptoms appear and often continue in a vicious cycle until the user either dies or finds help: • Continuous use of the substance for longer periods • Indefinable fears and vague spiritual desires • Impaired judgment and irrational thinking • Tremors, malnutrition, overdoses, decreased tolerance, and/other psychological problems with the drug • Obsessive use of the substance until recovery or death

13. Assessing the Behavioral Symptoms • Questionnaire (Figure 5.1, Pages 133-134) • Social Characteristics • As user becomes more involved in abuse or dependence, the primary relationship in life becomes the relationship with the substance • Family Characteristics • Family members, like the user, progress through different phases in their journey with the addict. • Addiction is often classified as a “family illness” • Four Stages in the Family System of the Addict • Denial • Home Treatment • Chaos • Control

14. Assessing the Social and Family-Related Symptoms • Important to have family members, friends and/or important others in the addict’s life • Family Questionnaire (Figure 5.2, Page 136) • Information gathered from others can be compared with the responses given by the client in order to assess the degree of minimization or denial • Common Social Consequences: • Frequent job loss • A driving under the influence (DUI) arrest or other legal problems • Break-up of important relationships • A series of moves (“The geographic cure” • History of psychological or medical problems • Lack of interest in activities that were once important

15. Screening and Assessment Instruments • The Michigan Alchoholism Screening Test (MAST) • The Short Michigan Alcoholism Screening Test (SMAST) • The Drug Abuse Screening Test (DAST-20) • The Cage Questionnaire • The Substance Abuse Subtle Screening Inventory (SASSI-3 & SASSI-A2) • The Alcohol Use Inventory (AUI) • The Addiction Severity Index (ASI) • Adolescent Diagnostic Interview (ADI) • The Millon Clinical Multiaxial Inventory (MCMI-II) • Minnesota Multiphasic Personality Inventory (MMPI-2) • ASAM Criteria for Patient Placement

16. Diagnosis • Inconsistent attitudes and precise standards for what constitutes an “addiction” have always complicated the diagnosis of substance abuse. • Differential Diagnosis • It is frequently the case that one of the most challenging aspects of diagnosing substance abuse is the interplay of addiction and other mental disorders • Longitudinal approach is useful in differentiating between psychiatric and substance-abuse symptoms • Many symptoms of substance intoxication and withdrawal improve or are alleviated within days or weeks.

17. Diagnosis • DualDiagnosis • Many individuals with substance abuse problems also meet the criteria for other psychological disorders. • Other social and familial factors appear more frequently in substance-abusing groups. • Genetic factors • Lack of Family Cohesiveness (Early death or divorce or separation of parents) • Adolescent behaviors – Adolescents who later became substance abusers are more likely to: • Identify with groups who shared alcohol and drugs during adolescence • Be more impulsive • Display greater evidence of rebelliousness and/or nonconformity

18. Diagnosis • Dual Diagnosis cont. • Relationship between suicide and substance abuse • Approximately 25% of substance abusers entering treatment have made a suicide attempt at some point in the past (Francis & Miller, 1991)