Substance Abuse: Diagnosis, Comorbidity, and Psychopathology

Because substance abuse disorders (SUDs) are among the most common psychiatric conditions in the United States, approaching 9% prevalence of individuals aged 12 or older, I anticipate that it would be extremely difficult to function as a Licensed Mental Health Professional (LMHP) without being a Licensed Alcohol and Drug Counselor (LADC) as well.  (Blaney & Millon, 2009, p. 280)  Just out of curiosity, are most of the people in my cohort also going to pursue the LADC license?

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I was surprised to see a lack of diagnostic distinction for individuals at different developmental points in life.  Early onset (Type 2, or Type B) SUDs are typically associated with very different etiologies and outcomes, but the treatment options for the two types are similar.  Is there any speculation where there is a lack of a specific treatment options for these divergent types of SUDs?  As was suggested in the text, it seems self evident that engaging in preventative measures on behalf of people whom “are not yet symptomatic but evidence various characteristics of a known subtype” seems to be in order.  (Blaney & Millon, 2009, p. 282)

“The familial link for alcohol use disorders is widely established in the research literature.”  (Blaney & Millon, 2009, p. 282)  It remains unclear which familial association is most responsible for the increased risk, because both genetic and environmental factors play significant roles.  Exposure to parental SUDs, for example, exerts both a genetic and environmental predisposition that can reliably predict development of SUDs in the children.

I expected more discussion regarding multiculturalism when it came to alcohol and expectancies.   Differences in family structures (nuclear vs. extended) and media influences, in particular, have a great deal of impact on the development of expectations regarding the effects of alcohol and other substances.  The admission that expectancies are modifiable gives us some hope for cognitive-behavioral treatments.

I was suitably surprised that the gender gap is narrowing for both alcohol and illicit drugs over time.  (Blaney & Millon, 2009, p. 284)  “Telescoping” refers to the fact that women experience problems faster, meet criteria for abuse and dependence in a shorter time, and present for treatment earlier (at similar levels of consumption).  This would appear to suggest that women are more vulnerable to the physical and mental consequences of alcohol use and abuse.  Women experience more psychiatric comorbity when compared to men.  (Blaney & Millon, 2009, p. 285)

I disagree with the statement that “substance use does not directly lead to violence or criminal behavior.”  (Blaney & Millon, 2009, p. 285)  Here is just one example… I think this particular example is an excessive use of force, but the reality is this gentleman would have had no issues if he kept his hand out of the cookie jar.

Comorbidity is the rule not the exception when it comes to SUDs.  There are several factors that may contribute to this astonishing fact, among them the fact that “base rates of common psychiatric disorders naturally result in co-occurrence.”  (Blaney & Millon, 2009, p. 287)  Additional support may be found in the likelihood of seeking treatment (due to the comorbid disorder, exacerbation of sub-clinical symptoms, common genetic factors, and/or shared environmental risk factors.  Comorbid disorders, especially SUDs, complicate diagnosis and treatment.  Substance use and abuse can decrease medication adherence, cause side effects, and “potentiate some psychotropic medications increasing the potential for overdose.”  (Blaney & Millon, 2009, p. 287)  Mood disorders, anxiety disorders, eating disorders, ADHD, and ASPD (as well as schizophrenia and other psychoses) were all implicated as being “highly comorbid” with SUDs.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

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