Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse
Treatment Improvement Protocol (TIP) Series 9

The Relationships Between AOD Use and Psychiatric Symptoms and Disorders

Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders.

There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process.

The primary relationships between AOD use and psychiatric symptoms or disorders are described in the following classification model (Landry et al., 1991a; Lehman et al., 1989; Meyer, 1986). All of these possible relationships must be considered during the screening and assessment process.

• AOD use can cause psychiatric symptoms and mimic psychiatric disorders. Acute and chronic AOD use can cause symptoms associated with almost any psychiatric disorder. The type, duration, and severity of these symptoms are usually related to the type, dose, and chronicity of the AOD use.

• Acute and chronic AOD use can prompt the development, provoke the reemergence, or worsen the severity of psychiatric disorders.

• AOD use can mask psychiatric symptoms and disorders. Individuals may use AODs to purposely dampen unwanted psychiatric symptoms and to ameliorate the unwanted side effects of medications. AOD use may inadvertently hide or change the character of psychiatric symptoms and disorders.

• AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Cessation of AOD use following the development of tolerance and physical dependence causes an abstinence phenomenon with clusters of psychiatric symptoms that can also resemble psychiatric disorders.

• Psychiatric and AOD disorders can coexist. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Determining whether the disorders are related may be difficult, and may not be of great significance, when a patient has long-standing, combined disorders. Consider a 32-year-old patient with bipolar disorder whose first symptoms of alcohol abuse and mania started at age 18, who continues to experience alcoholism in addition to manic and depressive episodes. At this point, the patient has two well-developed independent disorders that both require treatment.

• Psychiatric behaviors can mimic behaviors associated with AOD problems. Dysfunctional and maladaptive behaviors that are consistent with AOD abuse and addiction may have other causes, such as psychiatric, emotional, or social problems. Multidisciplinary assessment tools, drug testing, and information from family members are critical to confirm AOD disorders.

The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete "recovery" from AOD addiction. Psychiatric disorders may interfere with patients' ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines.

For example, patients with anxiety and phobias may fear and resist attending Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated and lethargic to participate in treatment. Patients with psychotic or manic symptoms may exhibit bizarre behavior and poor interpersonal relations during treatment, especially during group-oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse.

The Terminology of Dual Disorders

The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and AOD problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP).

The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).

Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders.

The combinations of AOD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. For instance, some methadone treatment programs treat a high percentage of opiate-addicted patients with personality disorders. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients.

Patients with mental disorders have an increased risk for AOD disorders, and patients with AOD disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience AOD abuse at some point (Regier et al., 1990), which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse AODs have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder (Regier et al., 1990; Ross et al., 1988), although many of these symptoms may be AOD related and might not represent an independent condition.

Compared with patients who have a mental health disorder or an AOD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both AOD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.

Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders. Each of these clusters of disorders and symptoms is dealt with in more detail in separate chapters.

AOD Abuse, Addiction, Dependence, Misuse

The characteristic feature of AOD abuse is the presence of dysfunction related to the person's AOD use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), produced by the American Psychiatric Association and updated periodically, is used throughout the medical and mental health fields for diagnosing psychiatric and AOD use disorders. It provides clinicians with a common language for communicating about these disorders and for making clinical decisions based on current knowledge. For each diagnosis, the manual lists symptom criteria, a minimum number of which must be met before a definitive diagnosis can be given to a patient.

Criteria for AOD abuse hinge on the individual's continued use of a drug despite his or her knowledge of "persistent or recurrent social, occupational, psychologic, or physical problems caused or exacerbated by the use of the [drug]" (American Psychiatric Association, 1987). Alternately, there can be "recurrent use in situations in which use is physically hazardous." The DSM-IV draft continues this emphasis (American Psychiatric Association, 1993).

Thus, AOD abuse is defined as the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning. AOD abuse may or may not involve physiologic dependence or tolerance. Importantly, evidence of physiologic dependence and tolerance is not sufficient for diagnosis of AOD abuse. For example, use of AODs in weekend binge patterns may not involve physiologic dependence, although it has adverse effects on a person's life.

Therefore, screening questions should relate to life problems that result from AOD use, taking into consideration that patients may not have the insight to perceive that their life problems are caused by AOD abuse.

The phrase AOD addiction (called "psychoactive substance dependence" in the DSM-III-R and "substance dependence" in the DSM-IV draft) is an often progressive process that typically includes the following aspects: 1) compulsion to acquire and use AODs and preoccupation with their acquisition and use, 2) loss of control over AOD use or AOD-induced behavior, 3) continued AOD use despite adverse consequences, 4) a tendency toward relapse following periods of abstinence, and 5) tolerance and/or withdrawal symptoms.

The DSM-III-R describes nine diagnostic criteria (shown in Exhibit 2-1), of which three or more must be present for a month or more to establish a diagnosis of dependence. Screening questions can be based on these criteria. The DSM-IV draft committee deleted DSM-III-R criterion 4 and the requirement of symptoms being present for at least 1 month. The DSM-IV draft emphasizes the symptoms of tolerance and withdrawal, which the draft committee placed at the top of the list of criteria.

In the DSM-III-R, criteria 1 and 2 deal with loss of control; criterion 3 addresses time involvement; criteria 4 and 5 relate to social dysfunction; criterion 6 relates to continued use despite adverse consequences;and criteria 7, 8, and 9 relate to the development of tolerance and withdrawal. It is important to note that tolerance, physiologic dependence, and withdrawal are neither necessary nor sufficient for the establishment of a diagnosis of AOD addiction.

The term AOD dependence can be confusing because it has multiple meanings. The DSM-III-R uses the phrase "psychoactive substance dependence" to describe the process of addiction, while many pharmacologists use the term "dependence" exclusively for describing the biologic aspects of physical tolerance and/or withdrawal. The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychologic dependence and 2) physical dependence.

Psychologic dependence centers on the user's need of a drug to reach a level of functioning or feeling of well-being. Because this term is particularly subjective and almost impossible to quantify, it is of limited usefulness in making a diagnosis.

Physical dependence refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of AOD use. In this case, AOD type, volume, and chronicity are the important variables: Given a certain substance, the higher the dose and longer the period of consumption, the more likely is the development of tolerance, dependence, and subsequent withdrawal symptoms. Physical dependence and tolerance are best understood as two of many possible consequences (which may or may not include addiction and abuse) of chronic exposure to psychoactive substances.

Among patients with a psychiatric problem, any AOD use -- whether abuse or not -- can have adverse consequences. This is especially true for patients with severe psychiatric disorders and patients who are taking prescribed medications for psychiatric disorders. For patients with psychiatric disorders, the infrequent consumption of alcohol can lead to serious problems such as adverse medication interactions, decreased medication compliance, and AOD abuse. Screening questions can relate to evidence of any use of alcohol and other drugs, as well as frequency, dose, and duration.

Medication misuse describes the use of prescription medications outside of medical supervision or in a manner inconsistent with medical advice. While medication misuse is not an abuse problem per se, it is a high-risk behavior that: 1) may or may not involve AOD abuse, 2) may or may not lead to AOD abuse, 3) may represent medication noncompliance and promote the reemergence of psychiatric symptoms, and 4) may cause toxic effects and psychiatric symptoms if it involves overdose.

Thus, some patients may consume medications at higher or lower doses than recommended or in combination with AODs. Also, certain patients may respond to prescribed psychoactive medications by developing compulsive use and loss of control over their use.