Psychopathology in substance abusers: diagnosis and treatment

Phubbing and temperaments among young Lebanese adults: the mediating effect of self-esteem and emotional intelligence

Background

The rapid increasing rate of mobile and internet users in Lebanon, predisposes us to a high dependency on smartphones, leading to more phubbing. Phubbing has been found associated with many psychological factors. Thus, the main objectives of this study was (1) to evaluate the association between phubbing and temperaments, and (2) assess the mediating effect of self-esteem and emotional intelligence in the association between phubbing and temperaments among a sample of Lebanese adults.

Methods

A cross-sectional study, carried out between August and September 2020, enrolled 461 participants aged between 18 and 29 years old. Participants were recruited from all districts/governorates of Lebanon (Beirut, Mount Lebanon, North Lebanon, South Lebanon, and Bekaa) using the snowball technique. The Generic Scale of Phubbing, Rosenberg Self‐Esteem Scale, Schutte Self Report Emotional Intelligence Test and TEMPS-M were used to assess phubbing, self-esteem, emotional intelligence and temperaments respectively.

Results

Our results showed that higher depressive temperament (B = 1.21) was significantly associated with more phubbing, whereas higher self-esteem (B = − 0.32) was significantly associated with less phubbing. Regarding the mediating effect, self-esteem partially mediated the association between depressive temperament and phubbing (21.02%), whereas emotional intelligence had no mediating effect on the association between temperaments and phubbing.

Conclusion

A strong correlation between phubbing and temperaments has been found in our study with a partial mediating effect of self-esteem in this association. Our findings might be a first step for raising awareness to develop the etiquette of using smartphones by providing media education to families, and good media usage habits.

Psychiatric comorbidity in alcoholics treated at an institution with both coerced and voluntary admission

Psychiatric comorbidity in alcoholics admitted to a rehabilitation center on either a voluntary or a coerced basis were studied. A group of 104 alcoholics (37 coerced and 35 voluntarily admitted men; and 21 coerced and ten voluntarily admitted women) with a mean age (SD) of 43 ± 8 years were assessed by means of a Structural Clinical Interview in accordance with the Diagnostic and Statistical Manual (DSM)-III-R (SCID). The interview took place a mean of 7 days after admission. The frequencies of lifetime/current axis I psychiatric comorbidity (substance use disorders excluded) were 66 and 61%, respectively. Drug dependence was present in 41 and 39%, respectively, of the cases. Thirty-seven percent had a lifetime diagnosis, and 33% a current diagnosis of affective disorders, 27 and 23%, respectively, of anxiety disorders and 20 and 13%, respectively, of non-organic psychotic disorders. In a subsample of 20 subjects, depressive symptoms were found to be stable during the course of treatment. No differences in frequency of psychiatric comorbidity were found between coerced and voluntarily admitted patients (67 and 56%, respectively) or between men and women (65 and 52%, respectively). The combination of psychiatric comorbidity and drug dependence was overrepresented among the coerced patients (50 vs 16%). It was concluded that the frequencies of psychiatric comorbidity were high in the present group. The co-occurrence of alcohol dependence, drug dependence and psychiatric comorbidity was more frequent among subjects who were coercively treated.

What we have learned from the Methadone Maintenance Treatment of Dual Disorder Heroin Use Disorder patients

Mental Disorders and Heroin Use Disorder (HUD) often co-occur and constitute correlated risk factors that the authors believe are best considered from a unitary perspective. In this article we review and discuss data collected by the V.P. Dole Research Group in Dual Disorder (V.P. Dole DD-RG) patients according to the following six discussion points: (1) Treatment of personality disorders during Methadone Maintenance Treatment (MMT); (2) Treatment of Mood Disorders during MMT; (3) Treatment of Anxiety Disorders during MMT; (4) Treatment of Psychotic Disorders during MMT; (5) Treatment of violence during MMT; (6) Treatment of Alcohol Use Disorder (AUD) during MMT. In treating Mood Disorder in HUD patients, we must bear in mind the interactions (potentiation and side effects) between psychopharmacology, used substances and agonist opioid medications; the use of psychiatric medications as an anti-craving drug, and the possible use of agonist and antagonist opioid medications in treating the other mental disorders. In treating chronic psychosis in HUD patients, we must consider the potentiation and side effects of antipsychotic drugs consequent on HUD treatment, worsening addiction hypophoria and inducing a more severe reward deficiency syndrome (RDS) in hypophoric patients. Violence and AUD during MMT can benefit from adequate dosages of methadone and co-medication with Sodium gamma-hydroxybutyrate (GHB). The experience of our V.P. Dole DD-RG suggests the following: (a) DD is the new paradigm in neuroscience in deepening our understanding of mental health; (b) To successfully treat DD patients a double competence is needed; (c) In managing DD patients priority must be given to Substance Use Disorder (SUD) treatment (stabilizing patients); (d) Antidepressant use is ancillary to SUD treatment; antipsychotic use must be restricted to acute phases; mood stabilizers must be preferred; any use of Benzodiazepines (BDZs) must be avoided.

Acceptance and Commitment Therapy in the Treatment of Comorbid Substance Abuse and Post-Traumatic Stress Disorder

Although post-traumatic stress disorder (PTSD) and substance abuse are commonly co-occuring conditions, it is generally recommended that an individual must first receive successful substance abuse treatment before posttraumatic symptoms can be addressed. Given the high comorbidity of these conditions, however, it would be helpful if more broadly focused therapies were available that simultaneously targeted common functional processes underlying the multiple problems of the dually diagnosed. Both PTSD and substance abuse can be conceptualized as disorders with significant experiential avoidance components. One treatment that has been specifically developed for the treatment of experiential avoidance is Acceptance and Commitment Therapy (ACT). In this case study, application of ACT for an individual with comorbid PTSD and substance abuse is described, and its effects are examined.

The relationship of affective temperament and emotional-behavioral difficulties to internet addiction in Turkish teenagers

The purpose of this study was to investigate the association of affective temperament profiles and emotional and behavioural characteristics with Internet addiction among high school students. The study sample included 303 high school students. A sociodemographic characteristics data form, internet addiction scale (IAS), the strengths and difficulties questionnaire, and the temperament evaluation of Memphis, Pisa, Paris, and San Diego autoquestionnaire were used to collect data. Of the sample, 6.6% were found to be addicted to Internet. Having a computer in the home (P < 0.001) and using the Internet for more than two years (P < 0.001) were found to be related to higher scores on the IAS. The prevalence rate of anxious temperament for Internet addicts was more than that for nonaddicts (P < 0.001). Dysthymic (r = 0.199; P < 0.01), cyclothymic (r = 0.249; P < 0.01), hyperthymic (r = 0.156; P < 0.01), irritable (r = 0.254; P < 0.01), and anxious (r = 0.205; P < 0.01) temperaments; conduct problems (r = 0.146; P < 0.05), hyperactivity-inattention (r = 0.133; P < 0.05), emotional symptoms (r = 0.138; P < 0.05), and total difficulties (r = 0.160; P < 0.01) were found to be correlated with IAS scores. According to these findings, there is a relation between the Internet addiction and affective temperament profiles, especially with anxious temperament. Furthermore, emotional and behavioural problems are more frequent in adolescents who have problematic Internet use.

Improving quality of care in substance abuse treatment using five key process improvement principles

Process and quality improvement techniques have been successfully applied in health care arenas, but efforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for the Improvement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies to use process improvement strategies to increase client access to, and retention in, treatment. NIATx recommends five principles to promote organizational change: (1) understand and involve the customer, (2) fix key problems, (3) pick a powerful change leader, (4) get ideas from outside the organization, and (5) use rapid cycle testing. Using case studies, supplemented with cross-agency analyses of interview data, this paper profiles participating NIATx treatment agencies that illustrate successful applications of each principle. Results suggest that organizations can successfully integrate and apply the five principles as they develop and test change strategies, improving access and retention in treatment, and agencies' financial status. Upcoming changes requiring increased provision of behavioral health care will result in greater demand for services. Treatment organizations, already struggling to meet demand and client needs, will need strategies that improve the quality of care they provide without significantly increasing costs. The five NIATx principles have potential for helping agencies achieve these goals.

Mood stabilizers in the treatment of substance use disorders

Individuals suffering from drug addiction may also manifest features of bipolar spectrum disorders. Hyperthymic and cyclothymic temperaments may render individuals vulnerable to later development of substance abuse. Bipolar disorders themselves may be altered or precipitated by substance use, most notably by stimulants (amphetamines), alcohol, and cannabinoids. The clinical usefulness of mood stabilizers, particularly antiepileptics, has been established as safe and effective in substance abusers with and without comorbid mood disorders. Most studies on this issue have been of short duration and focused on the resolution of a currently manifest period of illness. Few studies have been conducted on the usefulness of these drugs on the long-term longitudinal course of these diseases, such as frequently encountered recurrent relapses into states of agitation, impulsivity, and/or dissatisfaction. As opposed to the clinical experience with traditional antidepressants and neuroleptics, antiepileptics do not induce counter-polar states (depressed patients abruptly turning manic or hypomanic; nor patients currently hypomanic or manic turning abruptly depressed). Many clinicians consider antiepileptic mood stabilizers to be the preferred category of medications for the treatment of such patients. Valproate appears to be a potentially fruitful medication to study in these dual diagnosis patients due to preliminary evidence demonstrating its anticraving efficacy.

The familial aggregation of cannabis use disorders

AIMS

The aim of this paper is to examine the familial aggregation of cannabis use disorders and other psychiatric conditions among first-degree relatives and spouses of probands with a cannabis use disorder.

DESIGN

Controlled family study methods.

SETTING

Out-patient psychiatric clinics and the local community (same geographic area).

PARTICIPANTS

Two hundred and sixty-two probands with a life-time history of cannabis use disorder, alcohol dependence, anxiety disorders or no history of any disorder, and their first-degree relatives and spouses.

MEASUREMENTS

Cannabis use disorders and other DSM-III-R disorders in the relatives and spouses using the Schedule for Affective Disorders and Schizophrenia.

FINDINGS

Results reveal an elevated risk of life-time history of cannabis use disorders among siblings [odds ratio (OR: 3.6), adult offspring (OR): 6.9], and spouses (OR: 4.4) of probands with cannabis use disorders. There is a latent familial factor underlying cannabis use disorders that was shared partially with alcohol abuse/dependence. Comorbid mood and anxiety disorders aggregated independently from cannabis use disorders in families. Equal elevation in the magnitude of the association among the first-degree adult relatives and spouses of probands with a cannabis use disorder suggests the probable contribution of both environmental and genetic factors.

CONCLUSIONS

These findings support a family-based approach to drug abuse intervention and the importance of future research concerning environmental mediators of familial transmission of drug abuse.

Factors associated with co-occurring borderline personality disorder among inner-city substance users: the roles of childhood maltreatment, negative affect intensity/reactivity, and emotion dysregulation

The co-occurrence of borderline personality disorder (BPD) among individuals with substance use disorders is a common and clinically relevant phenomenon in need of further empirical investigation. The present study adds to the extant literature on the factors associated with co-occurring BPD among substance users, examining the relationships between childhood maltreatment (in the form of sexual, physical, and emotional abuse and emotional and physical neglect), negative affect intensity/reactivity, emotion dysregulation, and BPD pathology (both diagnostic status and symptom count) among a sample of 76 inner-city treatment-seeking substance users. Emotion dysregulation was expected to mediate the relationships between childhood maltreatment and negative affect intensity/reactivity (and their interaction) and BPD pathology. Results indicate that the presence of a BPD diagnosis was associated with higher levels of both childhood maltreatment and negative affect intensity/reactivity. However, only childhood maltreatment emerged as a unique predictor of BPD diagnostic status. Conversely, both childhood maltreatment and negative affect intensity/reactivity accounted for unique variance in the number of endorsed BPD symptoms. Moreover, emotion dysregulation fully mediated the relationships between maltreatment and negative affect intensity/reactivity and BPD symptom count, as well as the relationship between emotional abuse in particular and BPD diagnostic status. Contrary to hypotheses, results provided no support for the interaction between maltreatment and negative affect intensity/reactivity in the prediction of BPD pathology (diagnosis or symptom count), above and beyond the main effects of these factors.

The mental status of 1090 heroin addicts at entry into treatment: should depression be considered a 'dual diagnosis'?

BACKGROUND

Mental symptoms are common in heroin addiction and may arise from issues of addiction and withdrawal, raising doubts about the patients truly having co-morbid psychiatric diagnoses.

METHODS

We studied the mental status of 1090 heroin addicts (831 males and 259 females aged between 16 and 51 years) at the beginning of treatment, and its relationship to relevant demographic and clinical data through the use of standardised instruments.

RESULTS

A total of 506 (46.42%) heroin addicts showed depressive-anxious symptomatology, 421 (38.62%) had psychomotor excitement and 163 (14.95%) demonstrated a psychotic state. Patients with depressive-anxious symptomatology on the whole had a less severe addictive illness compared to those demonstrating excited and psychotic symptoms. The presence of depressive-anxious features was felt to not necessarily be indicative of the presence of a dual diagnosis.

CONCLUSION

The presence of depressive-anxious symptomatology in the clinical presentation in heroin addicts appears to be unrelated to 'dual diagnosis'.

Assessing environmental prevention strategies for reducing the prevalence and associated harms of methamphetamine use

Developed primarily in clandestine laboratories, methamphetamine is a highly addictive synthetic drug whose physical effects include hyperactivity, euphoria, tremors, and a sense of increased energy. While the accuracy of recent accounts suggesting a methamphetamine epidemic in the United States is unclear, these reports have nevertheless translated into significant funding allowances by the federal government. This increased funding suggests that the opportunity is ripe for the development of a scientific, environmentally-based model for methamphetamine prevention.

Toward a unitary perspective on the bipolar spectrum and substance abuse: opiate addiction as a paradigm

Bipolar spectrum disorders and addiction often co-occur and constitute reciprocal risk factors that the authors believe are best considered under a unitary perspective. In particular, we submit that patients whose disorders fall under the bipolar spectrum - and its hyperthymic and cyclothymic temperamental substrates are at increased risk for substance use, possibly moving towards addiction through exposure to intrinsically dependence-producing substances. In our experience, the contribution of bipolar spectrum disorders to the addictive process is often clinically missed, because attenuated and subclinical expressions of such mood disorders as bipolar II and cyclothymia are not adequately appreciated by our current formal diagnostic system (e.g. DSM-IV, as well as research and clinical practice based on it). The use of agonist treatment in dual diagnosis heroin addicts has allowed us to gather valuable knowledge about the intrinsic, and historically and clinically documented mood-regulating effects of opiates. From the therapeutic point of view, the challenge of double diagnosis requires double competence from clinicians. The combination of opiate agonists and mood stabilizers often produces results difficult to obtain with the use of the two types of drugs separately. We therefore submit that the present conceptualization of the link between bipolar spectrum and addictive disorders has not only heuristic and scientific values, but also an important message for the clinician.

The association between heroin use and anxiety sensitivity among inner-city individuals in residential drug use treatment

The current study represents an initial investigation of the association between heroin use and anxiety sensitivity (AS). Within a sample of 172 inner-city treatment seeking drug users, AS was compared across past year (1) heroin users with no crack/cocaine use (n=12); (2) crack/cocaine users with no heroin use (n=66); (3) users of both heroin and crack/cocaine (n=45); and (4) individuals with no use of heroin or crack/cocaine (n=49). Consistent with expectations, primary heroin users evidenced higher levels of AS than all other groups, with these differences also evidenced for the physical and social subscales. Differences in AS total score and physical subscale score persisted after controlling for demographic variables, depressive symptoms, and primary use of drugs other than heroin and crack/cocaine including alcohol, nicotine, marijuana, and hallucinogens. Findings suggest a unique relationship between AS and heroin, and set the stage for future work explicating the direction of the observed association.

Differences in impulsivity and sexual risk behavior among inner-city crack/cocaine users and heroin users

The current study utilized a sample of 123 inner-city drug users in residential treatment, comparing sexual risk behavior (SRB) across primary users of (a) heroin and not crack/cocaine, (b) crack/cocaine and not heroin, and (c) both heroin and crack/cocaine. Additional analyses also examined impulsivity as a mediator of drug choice and SRB. Results indicated that SRB was higher in primary crack/cocaine users than in primary heroin users, with those using both drugs evidencing intermediate levels of SRB. Beyond differences in SRB, a similar pattern across drugs was found for impulsivity. Finally, impulsivity mediated the relationship between drug choice and SRB. Although further research is necessary to establish causal relationships, these results support a relationship between SBR and crack/cocaine, and suggest that disinhibition processes including impulsivity may underlie this relationship.

Diagnostic and Symptomatological Features in Chronic Psychotic Patients According to Cannabis Use Status

The prevalence and the clinical meaning of cannabis use in patients with chronic psychosis has not been systematically explored. The authors have compared the diagnostic and symptomatological characteristics of 111 male patients affected by chronic psychosis with and without past or current use of cannabis. Sixty-six patients were still using or had used cannabis; in all cases the use preceded the onset of psychotic symptoms. Forty-three patients were cannabis-positive on urinary screening at the moment of hospitalization and 23 were currently cannabis-free but reported the use of cannabis in the past. Forty-five patients were negative on urinary screening and reported no past history of cannabis use. In evaluating the psychopathological features, the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Rating Scale (AORS) were used. The three groups showed similar demographic data, except for age, which was lower in current cannabis users than in nonusers; no differences were found between current and past users. As regards diagnostic features, "mood cluster" was significantly better represented in cannabis users and "schizophrenic cluster" in nonusers; bipolar spectrum disorders were more frequently reported than unipolar ones. When past and current users were grouped together, only blunted affect score was significantly higher in nonusers than in users, while clastic violence showed higher scores in users. These data indicate that chronic, psychosis, whether associated with past or with current use of cannabis, is frequently associated with bipolar spectrum disorders and tends to display less blunted affect and more clastic behavior.

The role of medication in the treatment of pathological gambling: Bridging the gap between research and practice

After reviewing the literature on the pharmacotherapy of pathological gambling, the author discusses treatment strategies and areas for future research. The clearest indication for medicating the pathological gambler is for the treatment of comorbid disorders, primarily depression, bipolar disorder, and attention deficit hyperactivity disorder. However, there are difficulties in diagnosing the dually disordered gambler. Other current pharmacological approaches involve the use of medication to treat specific symptoms, traits, or symptom clusters; to make negative affects more tolerable; and to reduce cravings. Future approaches will be directed at subgroups of gamblers. This may include genetic profiling, paired with recognition of neurotransmitter deficits, and the identification of clinical syndromes and subtypes. The author also discusses the kindling hypothesis as it may pertain to pathological gambling. The presence of kindling would make a strong case for earlier and more aggressive use of medication and for long-term maintenance to prevent relapse.

A general causal model to guide alcohol, tobacco, and illicit drug prevention: assessing the research evidence

The problems associated with the use of alcohol, tobacco, and other drugs (ATOD) extract a significant health, social, and economic toll on American society. While the field of substance abuse prevention has made great strides during the past decade, two major challenges remain. First, the field has been disorganized and fragmented with respect to its research and prevention practices; that is, there are often separate ATOD prevention "specialists." Second, both the prevention researchers who test the efficacy of specific prevention strategies and the practitioners who implement prevention efforts often lack an overall perspective to guide strategy selection. To address these limitations, we present an ATOD causal model that seeks to identify those variables (Domains) that are theoretically salient and empirically connected across alcohol, tobacco, and illicit drugs. For the researcher, the model demonstrates important commonalities, as well as gaps, in the literature. For the practitioner, the model is a means to recognize both the complexity of the community system that produces ATOD problems and the multiple intervention points that are possible within this system. Researchers and practitioners are thus challenged to work synergistically to find effective and cost-effective approaches to change or reduce ATOD use and associated problems.

Preventive agricultural medicine: a student's perspective of farmers' mental health

As a medical student completing a required rural community medicine clerkship, I discovered my home community's concern for mental health of farmers. A local economic downturn affects everyone, but especially the farmers. One farmer had recently committed suicide. Leaning heavily on work presented at a Nebraska summit on the farm crisis and mental health and on the National Rural Health Association issue paper on rural mental health, I found farmer and rural mental health to be a widespread concern, exacerbated by a scarcity of rural mental health resources. In my recommendations for rural Alabama, I endorse recommendations of others, including strengthening the local family physician role as "front door" to the mental health system, outreach with such agents as extension personnel and ministers, and farm crisis hotlines.

Acceptability, validity and reliability of the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS): a pilot study

This paper reports on the acceptability, reliability and validity of the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS), a new instrument exploring the interactive pathway between substance abuse and psychiatric disorders. Psychiatric outpatients with (n = 21) and without (n = 32) substance abuse comorbidity according to the DSM-IV, non-psychiatric subjects with opioid dependence (OD, n = 14) and normal controls (n = 33) were assessed with the SCI-SUBS. The presence or absence of psychiatric disorders was determined with the Structured Clinical Interview for DSM IV (SCID). The SCI-SUBS was well accepted by participants. The internal consistency of the domains was satisfactory (between 0.64 and 0.93). Domain scores of OD subjects were significantly higher than those of controls and of psychiatric patients without substance abuse. The cut-off point on the SCI-SUBS total score at which there was optimal discrimination between the presence and the absence of a DSM-IV diagnosis of substance abuse was 45. The pilot version of the SCI-SUBS has satisfactory internal consistency and construct validity.

Impact of opioid use on dentistry

The oral consequences of opioid drug use are commonly attributed to personal neglect of general health and financial constraint. These factors are compounded by the increasingly recognized range of physical effects exerted by opioid drugs. The dental management of opioid drug dependents is further complicated by a variety of infections and behavioural modifications commonly associated with opioid use. Adequate strategies for the oral care of opioid users need to take cognisance of the broad medical issues for these people along with an appropriate personal approach.

Behavioral outcome of preschoolers exposed prenatally to cocaine: role of maternal behavioral health

OBJECTIVE

To examine the impact of prenatal cocaine exposure and maternal behavioral health (recent drug use and psychological functioning) on child behavior at age 5 years.

METHOD

In this longitudinal investigation, maternal report of child behavior was assessed using the Achenbach Child Behavior Checklist (CBCL) in 140 cocaine-exposed and 181 noncocaine-exposed (61 alcohol, tobacco, and/or marijuana-exposed, and 120 nondrug-exposed) low-income, African American children. Structural equation modeling was used to estimate suspected causal relationships between indicators of maternal behavioral health at 5-year follow-up, according to self-report on a modified Addiction Severity Index (ASI) and CBCL scores.

RESULTS

Prenatal cocaine exposure was not related to child behavior at age 5. Recent maternal drug use and psychological functioning had relationships with CBCL Internalizing and Externalizing scores. However, when considered within a combined model, only maternal psychological functioning remained significant.

CONCLUSIONS

Findings highlight the importance of maternal functioning in the behavioral outcome of children exposed prenatally to cocaine.

Anxiety sensitivity: relationship to negative affect smoking and smoking cessation in smokers with past major depressive disorder

The present study evaluated whether anxiety sensitivity (AS) was related to negative reinforcement smoking motives and increased risk of relapse during the early stages of a quit attempt. Specifically, the role of AS was evaluated in 60 smokers with past major depressive disorder (MDD) during smoking cessation. Consistent with expectations, AS scores, as indexed by the 16-item Anxiety Sensitivity Index (ASI) [Behaviour Research and Therapy 24 (1986) 1], were positively correlated with smoking to reduce negative affect but were not significantly correlated with smoking for other reasons. Higher ASI scores also were associated with increased risk of lapsing during the first 7 days after quit day. Results suggest that smokers with heightened levels of AS may smoke more often to manage negative moods and may be less able to tolerate early withdrawal symptoms, specifically during early stages of a quit attempt.

Antisocial personality and depression among incarcerated drug treatment participants

PURPOSE

The co-occurrence of antisocial personality (ASP) and depression among drug-dependent individuals was examined in a sample of federal inmates participating in residential or outpatient drug and alcohol treatment to increase our understanding of the co-occurrence of these disorders.

METHODS

We examined drug dependence patterns both by the number of drugs of dependence as well as by type of drug, and separately studied men and women. The Diagnostic Interview Schedule (DIS) was used to obtain DSM-III-R diagnostic information on a sample of 609 men and women participating in a multi-site drug treatment evaluation project. Logistic regression results are reported that compared lifetime rates of ASP and major depression by number of drugs of dependency for men and women. ASP and major depression diagnostic rates were also examined by type of drug dependency pattern among men.

RESULTS

We found that both the number of drugs as well as the type of drug(s) are related to prevalence patterns for both diagnoses. The high rates of ASP and major depression among specific subgroups of drug-dependent inmates highlight the need for thorough psychiatric assessment and the tailoring of treatment programs to the issues associated with these diagnoses.

IMPLICATIONS

Our results suggest that although there are similarities in co-morbidity between men and women, the differences point to the need to study men and women separately.

Bipolar disorder with comorbid substance abuse: diagnosis, prognosis, and treatment

Alcohol and drug abuse occur frequently in individuals with bipolar disorder, but clinicians may often feel ill-prepared to identify such multi-diagnosis syndromes, to contextualize drug abuse alongside affective symptoms, and to formulate appropriate treatment strategies. Plausible explanations for high comorbidity rates between bipolar illness and substance use disorders are complex and likely embrace numerous factors that extend beyond simple, older theories about drug use as sheer "self-medication." Evidence from epidemiologic, family-genetic, pharmacologic, psychosocial, and clinical psychopathology studies suggest that a majority of bipolar patients are at risk for developing lifetime drug or alcohol-related problems, which may in turn contribute to more varied and complex clinical presentations, accelerated relapses, worsening of depressive features, poorer lithium response, functional disability, and elevated suicide risk. In this article, the author reviews essential concepts about the phenomenology and treatment outcome of bipolar illness with substance use comorbidities and offers a systematic approach to the diagnosis and management of patients with such dual diagnoses.

Implications of genetic epidemiology for the prevention of substance use disorders

Despite advances in characterizing human genotypes, the complex process through which genes exert their influence limits the application of molecular genetics to human diseases. Substance use disorders are necessarily complicated by gene-environment interaction because exposure to an exogenous substance is required for their development. The methods of genetic epidemiology are specifically designed to identify sources of complexity that impede etiologic findings and prevention efforts. The goal of this paper is to illustrate the application of family study methods to identify risk factors for substance abuse and their implications for prevention. The Yale Family Study is a controlled family study of the comorbidity of substance and psychiatric disorders. The sample consists of 223 probands with substance use and/or an anxiety disorders and community controls, 1218 adult first degree relatives and spouses, and 203 offspring (ages 7-17) followed for 8 years. Results indicated familial aggregation of substance disorders in adults and children, independence of familial aggregation of alcoholism and drug dependence, and specificity of familial clustering of some drugs of abuse. Familial factors are more strongly associated with substance dependence than abuse, with an attributable risk of 55%. Premorbid psychiatric disorders--social phobia and bipolar affective disorder in adults, and depression, anxiety, conduct, and oppositional defiant disorders in children--were strongly associated with the subsequent development of substance dependence (attributable risks ranging from 44 to 86%). A family history of substance abuse and premorbid psychopathology are strongly associated with the development of substance use disorders. Implications for primary and secondary prevention are discussed. As specific genetic vulnerability markers for substance use disorders become identified, application of the tools of genetic epidemiology may be employed to identify specific environmental risk factors that may serve as targets for prevention.

Recovery challenges among dually diagnosed individuals

Although there is a high prevalence of co-occurring mental and substance abuse disorders, and empirical evidence shows the need to integrate multiple treatment services for dually diagnosed persons, service integration is relatively recent and often poorly implemented. Moreover, service providers and clients often hold divergent views of what constitute appropriate and feasible treatment goals. This paper presents interview data from an urban sample of dually diagnosed members of self-help groups (N = 310) concerning the challenges confronting them in their recovery, and discusses the interrelations of these issues. The findings indicate that most clients struggle with emotional and socioeconomic issues, which bear significantly on their ability to handle adequately other aspects of recovery.

Racial identity and its assessment in a sample of African-American men in treatment for cocaine dependence

Substance abuse treatment studies frequently include subjects from different ethnic and racial groups, but many investigations limit the examination of race and ethnicity to the use of nominal labels. This approach reveals little about the social or psychological significance of racial and ethnic group membership to the subjects of study or about the potential effects of these factors on substance-involved behaviors. In this study, a principal components analysis (PCA) with varimax rotation was conducted on the 50-item long form of the Racial Identity Attitude Scale (RIAS) (1) in a sample of 294 African-American men in treatment for cocaine dependence. The RIAS was developed to measure attitudes about race and racial status among blacks, but it has not been utilized widely in substance abuse research. Our findings provide evidence for the structural validity of this instrument in this sample of substance abusers. We discuss how recent advances in racial identity theory and its measurement may provide an important avenue for understanding the psychological consequences of racial group membership and for examining the potential effects of these factors on treatment response in studies of substance misuse.

Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA Study

OBJECTIVE

To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders.

METHOD

Diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

RESULTS

The rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults.

CONCLUSIONS

The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.

Voluntary intoxication and criminal responsibility

This paper reviews the law related to voluntary intoxication and criminal responsibility in the 50 United States, the District of Columbia, the US Virgin islands, and Puerto Rico. Statutory and case law citations are provided which govern the use of intoxication evidence in each jurisdiction to negate mens rea (i.e., to establish diminished capacity), to support an insanity defense, and to mitigate criminal sentencing. Factors that courts typically focus on when deciding whether to admit this evidence in a particular case are discussed, and these factors are related to clinically relevant criteria.

Heaviness of abuse, drug preferences, and personality organization among drug abusers in Sweden

In a case-finding sample of 1,824 substance abusers, personality organization (PO) was related to data on drug abuse. Heavy versus light abuse differentiated significantly between borderline PO (BPO) and neurotic PO (NPO), whereas psychotic PO (PPO) was characterized by inconsistent pattern of abuse in terms of heaviness. In terms of drug choice, all combinations with alcohol were associated with lower PO.

Psychiatric symptom severity in cocaine-dependent outpatients: demographics, drug use characteristics and treatment outcome

Psychiatric symptom severity and associated characteristics were assessed in 185 individuals seeking outpatient treatment for cocaine dependence. The sample was divided into groups of low, medium and high psychiatric symptom severity based on Addiction Severity Index psychiatric composite scores. Patients with high symptom severity reported poorer pre-treatment functioning and more adverse consequences of cocaine use than the lower severity groups. Relationships between psychiatric severity and treatment outcome variables were assessed in a subset of 123 patients who received one of three 24-week psychosocial treatments for cocaine abuse: (i) behavioral treatment with a voucher-based incentive program; (ii) the same behavioral treatment without vouchers; (iii) or drug abuse counseling. Psychiatric symptom severity failed to influence treatment outcome with any of these treatments. Thus, in this study the authors found no evidence to indicate that high psychiatric severity predicts poor response to psychosocial treatment for cocaine abuse.

DOUBLE TROUBLE IN RECOVERY: SELF-HELP FOR PEOPLE WITH DUAL DIAGNOSES

Self-help is gaining increased acceptance among treatment professionals as the advent of managed care warrants the use of cost-effective modalities. Traditional "one disease-one recovery" self-help groups cannot serve adequately the needs of the dually diagnosed. This article discusses Double Trouble in Recovery (DTR), a 12-step self-help group designed to meet the special needs of those diagnosed with both a psychiatric disability and a chemical addiction, DTR differs from traditional self-help groups by offering people a safe forum to discuss their psychiatric disabilities, medication, and substance abuse. Preliminary data collected at four DTR sites in NYC indicate that DTR members have a long history of psychiatric disabilities and of substance abuse, and extensive experience with treatment programs in both areas. They are actively working on their recovery, as evidenced by their fairly intensive attendance at DTR. Recent substance use is limited, suggesting that participation in DTR (in conjunction with format treatment when needed) is having a positive effect. Most members require medication to control their psychiatric disabilities, and that alone may make attendance at "conventional" 12-step groups uncomfortable. Ratings of statements comparing DTR to other 12-step meetings suggest that DTR is a setting where members can feel comfortable and safe discussing their dual recovery needs.

Effects of chronic cocaine use on physical health: a prospective study in a general population sample

Few studies have examined long-term effects of chronic cocaine use on physical health in the general population. The current study assesses the effects of chronic cocaine use by the late twenties on physical health by the mid thirties in a longitudinal cohort from the general population. Measures of physical health included self-reported health status, cardiovascular, neurological, and somatic symptoms, and number of hospital or sick days within the last year. The casual analyses were restricted to males because few females used cocaine heavily and the relationships between females' cocaine use and physical health were rarely significant. Among males, chronic cocaine use increased physical health problems, controlling for prior health status, current cocaine use, use of other drugs and sociodemographic characteristics. In turn, poor health contributed to continued cocaine use. Variance partitioning based on cocaine use patterns (frequency and chronicity) indicated that chronic users experienced the most adverse consequences on subsequent physical health. Implications for understanding how chronic cocaine use affects a broad spectrum of physical functioning are discussed.

Psychiatric problems among alcohol and other drug dependent women

This article focuses on assessment and treatment of psychiatric disorders within the alcohol and drug treatment and recovery system. Inasmuch as women are represented in all categories of psychiatric disorders, the article begins with a discussion of basic principles of assessment and treatment, examines some of the barriers to good practice, and offers recommendations for reducing them. The article then reviews in greater detail the psychiatric disorders most frequently found in women seeking help in alcohol and drug treatment settings, adding considerations relevant to those particular disorders. A brief review of key elements to facilitate planning, ongoing monitoring, and evaluation by treatment and recovery service providers is provided.

Relationship of depression with measures of social functioning in adult drug abusers

The present study describes the relationship between depression and several measures of social functioning--including employment, criminal activity, incarceration, marital functioning, and alcohol and drug use--in a population of adult drug abusers. Our investigation extends past work in this area by specifically investigating the effects of depression (as opposed to simple substance use) on social and interpersonal functioning. Predictably, elevated levels of depression were associated with increased use of hard drugs and alcohol, greater levels of institutionalization, reduced attendance at work or school, and lower overall rates of marital satisfaction. Consistent with previous reports, level of marijuana use was not related to severity of depression. It appears that depressed substance abusers experience significantly more social, vocational, and interpersonal dysfunction than their nondepressed counterparts. It is proposed that the efficacy of existing treatment programs for adult drug abusers will be enhanced through the addition of strategies to assess and ameliorate depression.

The role of cognition in complex human behavior: a contextualistic perspective

Cognitive and behavioral psychology have long debated the merits of cognitive causality in the explanation of human behavior. We argue, however, that cognitive causality must be understood in the context of the pre-analytic philosophical assumptions of the scientist, not merely as an empirical matter. Many of the issues that seemingly separate cognitive from behavioral positions cannot be answered by research. We briefly present Relational Frame Theory, which is a behavioral approach to language and cognition. RFT is not subject to the same criticisms made by Bandura of behavior analytic thinking. Finally, we describe some aspects of Acceptance and Commitment Therapy as an example of the applied implications of this contextual analysis of cognition.

The development of a partial hospitalization program for mentally ill chemically abusing (MICA) patients

The article begins with a review of the high prevalence of concurrent mental illness and chemical abuse (MICA) disorders among clinical populations, highlighting the need for development of appropriate services to treat these persons. This is followed by a description of a partial hospitalization program developed at the University of Rochester Medical Center-Strong Memorial Hospital, established to treat MICA patients. The program description includes information pertaining to the mission of the program, treatment setting, staffing, schedule, and diagnostic and sociodemographic data on 50 consecutive patients admitted to the program. It includes a review of the major goals of the program and the manner in which each of these goals is addressed. This is followed by a discussion of several arguments for the inclusion of patients with personality disorders in MICA treatment when there is concurrent substance abuse. It concludes with a case vignette of a patient treated in the MICA program.

Drug abuse and psychiatric comorbidity

Psychiatric morbidity was studied in a sample of 176 opioid-dependent men recruited from prison and treatment services. The Diagnostic Interview Schedule (DIS) was used for psychiatric assessment. Lifetime and current prevalence of any mental disorder, excluding substance use disorders, reached 90.3% and 66.1%, respectively. The most prominent lifetime DSM-III axis I disorders were anxiety (31.8% lifetime and 16.5% last month) and affective (25% lifetime and 19.9% last month) disorders. Antisocial personality disorder (ASP) had a lifetime prevalence of 69.3%. Higher rates of affective and anxiety disorders were diagnosed in the treatment sample than in the imprisoned sample, whereas the inverse was observed for ASP. Results from the psychiatric interview showing a strong association between drug--opiate--dependence and DSM-III mental disorders are further supported by findings of high levels of depressive symptoms on the Center for Epidemiological Studies-Depression (CES-D) scale (71.5%) and increased rates of self-reported suicide attempts (27.4%) and psychiatric hospitalizations (26.8%). Psychiatric disorders seem to precede drug dependence in the majority of cases. Results from this study are compared and discussed with those from similar North American Studies.

Substance misuse in individuals with spinal cord injury

The literature addressing substance misuse in spinal cord injury (SCI) is reviewed with special attention paid to differences in substance misuse in the spinal cord injury and general populations. Studies examining epidemiology indicate that while substance misuse often is present when spinal cord injuries occur, the exact prevalence of it in the SCI population has yet to be determined. The literature also suggests that risk factors unique to SCI predispose substance misuse in this population in addition to risk factors commonly present in the general population. Articles examining issues relevant to substance misuse in SCI identify some concerns specific to this population. Although treatment outcome literature for substance misuse in SCI is scarce, it is clear that treatment facilities must be adapted to suit the needs of the spinal cord injured. However, it has yet to be determined how treatment content should differ.

Assessment, diagnosis, and treatment of the dually diagnosed adolescent

The awareness of the prevalence and presentation of psychiatric diagnoses is essential in the quality treatment of adolescent substance abusers. An ongoing relationship with a psychiatrist who can be available for consultation as needed is helpful. Careful observation and history-taking and appropriate consultation results in better detection and treatment of comorbid disorders and, ultimately, in better treatment of the patient.

The drug-of-choice phenomenon psychological differences among drug users who preferred different drugs

The Eysenck Personality Questionnaire, the Sensation Seeking Scale, and the Brief Symptom Inventory were administered to 125 recovering drug users with three or more months abstinent from drugs. Subjects were divided according to drug preference: opiates, stimulants, marijuana, alcohol, and a polydrug preference. Opiate users were significantly higher in Susceptibility to Boredom. Alcohol misusers compared to a combined stimulant, opiate, and polydrug group were significantly lower in Extroversion and Susceptibility to Boredom. Subjects raised in drug/alcohol-using families scored significantly higher on Neuroticism and on the Positive Symptom Total of the BSI, and had a higher rate of suicidality.

The treatment of persons with dual diagnoses in a rural community

Persons with dual diagnoses of psychiatric illness and substance abuse represent a large subpopulation within the mental health system, but mental health service delivery systems typically do not adequately address their special needs. The literature on dual diagnoses is marked by the paucity of information on such persons in rural settings. This paper describes the characteristics of a rural community mental health system, which illustrate the difficulties in treating persons with dual diagnoses in rural communities. These problems include a fragmented system of services, centralized services in a large geographic area, overly restrictive regulations, conceptual differences in treatment approaches, confidentiality and stigma in a rural culture, and the academic and professional isolation of mental health workers, leading to high turnover and a shortage of staff having sufficient training and experience to work with persons with dual diagnoses. Some recommendations to address these problems and to improve the delivery of services to persons with dual diagnoses are suggested.