PSY600:Diagnosis and treatment of mental health disorders

1. PSY600:Diagnosis and treatment of mental health disorders Class 8: Substance Disorders

2. Substance Disorders • Substance includes those traditionally understood to be drugs/substances of abuse as well as medications and toxins • Substance Use Disorders – • Diagnosed based on a pathological pattern of Bx related to use of a substance • Substance-Induced Disorders – • Intoxication and Withdrawal – found in Substance section • Delirium and Dementia – found in Neurocognitive section • Psychotic, depressive, bipolar, anxiety, obsessive compulsive, sexual dysfunction, sleep – found in relevant section of DSM

3. Substance Disorders • Any use of a substance ≠ disordered use • There is nonpathological substance use • Patient does not have to acknowledge his/her substance use is disordered for you to Dx a substance use disorder • Criteria for substance use, intoxication, and withdrawal vary by substance class • Substance use criteria are very similar between classes • Intoxication and withdrawal criteria vary substantially between classes

4. Substance Classes in DSM Alcohol Caffeine Cannabis – marijuana; hashish Hallucinogens – LSD; Ecstasy; PCP Inhalants – volatile hydrocarbons, e.g., glue; gasoline; spray paint Opioids – Heroin; morphine; Rx painkillers Sedatives, hypnotics, anxiolytics – Benzodiazepines (e.g., Valium, Xanax); barbiturates (Seconal) Stimulants – amphetamines, cocaine Tobacco Other/Unknown Substance – e.g., steroids, nitrous oxide, NSAIDs, antihistamines

5. Substance Use Disorder • Basic criteria: 2 or more within a 12-month period • Taking substance more or longer than intended • Unsuccessful attempts to stop or cut down • Large amount of time spent getting, using, or recovering from substance • Craving for the substance • Recurrent use resulting in failure to fulfill major role obligations at work, school, or home • Continued use despite persistent social/interpersonal problems caused by substance use

6. Substance Use Disorder Basic criteria (cont.) • Giving up/reducing important social, occupational or recreational activities • Recurrent use in situations in which it is physically hazardous • Continued use despite knowledge that use is causing physical or psychological problems • Tolerance (taking more to get same effect or lowered effect with same amount) • does not apply to tobacco • Withdrawal (experiencing a withdrawal syndrome or taking a substance to avoid withdrawal Sx) • This criterion does not apply to all substance classes

7. Substance Use Disorder • Specify if: • In early remission • No criteria met for 3-12 mos. (except “craving”) • In sustained remission • No criteria met for at least 12 mos. (except “craving”) • In a controlled environment • Patient is in environment where access to substance is restricted • On maintenance therapy (opioids and tobacco only) • Patient is using replacement medication and no criteria are met for substance use other than tolerance/withdrawal from replacement medication • Specify current severity (severity also determines code) • Mild – 2-3 criteria • Moderate – 4-5 criteria • Severe – 6 or more criteria

8. Substance Intoxication and Withdrawal • Substance Intoxication • Reversible manifestation of recent substance ingestion or exposure • Ingestion or exposure results in significant maladaptive behavioral or psychological changes • Substance Withdrawal • Development of substance-specific syndrome due to cessation of heavy and prolonged substance use • Syndrome causes distress or impairment in functioning

9. Coding for Substance Disorders Substance Use disorders: code according to substance and severity When recording Dx, use the name of specific substance involved, not name of substance class For substances that do not fall into the designated classes or are unknown, use code for “Other (or Unknown) Substance” Dx, and use name of specific substance or “Unknown Substance” when recording Dx If criteria are met for more than one substance disorder, all should be diagnosed

10. Substance-Induced Disorders • Some categories of mental disorders have a substance-induced option for relevant Sx that did not exist before substance exposure • To help determine if Sx are substance-induced or indicative of the mental disorder itself, consider: • Is there a Hx of previous episodes of the disorder? • Do Sx match substance? • Does dosage match Sx? • If Sx persist for more than 1 month after acute intoxication or withdrawal, non-substance-induced mental disorder may be present • If Sx are induced by Rx, be sure underlying GMC isn’t causing Sx

11. Differential Dx for Substance Disorders • Many mental disorders are frequently co-morbid with substance disorders. Dx both if applicable. • Many substances produce Sx that look like other mental disorders. Rule out substances ASAP. • Many other medical conditions can produce Sx that look like intoxication, and many substances can produce Sx that look like other medical conditions. Rule out other medical conditions ASAP. • Intoxication and Withdrawal can be difficult to distinguish. Get good use history. • It is possible to be experiencing both at the same time with different substances

12. Treatment for Substance Use Disorders • Tx approaches are highly individualized and greatly varying. • Tx plan will require clinical judgment and likely a combination of interventions. Tx will in part depend on: • Severity • Presence or absence of “addiction” • Presence of other mental disorders • Patient’s resources • With lesser severity and minimal or no indication of “addiction” • Brief, targeted behavioral and cognitive interventions

13. Treatment for Substance Use Disorders • With greater severity and/or presence of “addiction”: • Detoxification • Setting goals for abstinence or controlled use (if feasible) • Tx options include: • Motivational enhancement therapy • Education • Individual and group Bx Tx • Psychotherapy for coping skills and other psychological concerns • CBT • Supportive therapy • Family Tx • Residential Tx program • Self-help/12-step groups • Pharmacotherapy • Tx plan will be formulated as a combination of the above or other intervention options based on needs of individual cases

14. Treatment for Substance Use Disorders • Relapse prevention vital to long-term sobriety • 12-step or some other kind of regular self-help program is associated with greater success when part of a larger Tx program • Identifying triggers and high-risk situations • Tx for family other than patient may be needed, particularly if children are involved. • Prognosis variable depending on individual’s motivation, goals for drinking, coping skills, social support and stress levels and relationship with therapist. • These factors are more important than type of Tx • Greater than 50% relapse within one year