Psychiatric Disturbance

Substance abuse can occur conjointly with virtually any Axis I or Axis II psychiatric disorder. This has important treatment implications, the most obvious of which is that for some individuals, alcohol or drug consumption may constitute an attempt at self-medication. Hence, treatment of the primary disorder may in some circumstances be sufficient to ameliorate the substance use disorder. Alternatively, prolonged drug abuse may precipitate a psychiatric disturbance, either directly by inducing neurochemical changes or indirectly through stress or maladjustment concomitant to a substance abusing lifestyle. A major task is therefore to delineate the type and severity of psychiatric morbidity that may be present and to determine whether it preceded or developed after the substance use disorder.

Structured diagnostic interviews have been increasingly utilized in the objective formulation of substance use disorder diagnoses, as well as other psychiatric diagnoses. Several instruments, all with good psychometric properties, are currently available. The Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, & Gibbon, 1987) is presently the most frequently used instrument. Other structured interviews are the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, &Ratcliff, 1981) and the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer, Endicott, & Robins, 1975). There are some important differences among the SCID, DIS, and SADS. In contrast to the SCID and SADS, which are semistructured interviews requiring a high level of clinical skill to administer and interpret, the DIS is fully structured, so that it can be administered by paraprofessionals.

Three diagnostic interviews are available for adolescents. These include the Diagnostic Interview Schedule—Revised for Children (Costello, Edelbrock, & Costello, 1984), the Kiddie Schedule for Affective Disorders and Schizophrenia (Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982), and the Diagnostic Interview for Children and Adolescents (Wellner, Reich, Herianic, Jung, & Amado, 1987). Each of these interviews also has a version that can be administered to a parent, so as to ensure accuracy of the evaluation.

By employing a structured psychiatric interview, it is possible to relate substance use involvement with psychiatric status. Myriad configurations of co-morbidity are possible. The pattern of comorbidity has important ramifications for treatment. For example, if an affective disorder preceded the substance use disorder and is still present at the time of the assessment, it would suggest the need to treat this disorder as the primary condition.

Self-report questionnaires can also yield important information by quantifying the presence and severity of psychiatric disorder that is not severe enough to warrant a diagnosis but may nonetheless be a contributor to, or a consequence of, substance abuse. Thus, self-rating scales may provide a more valid picture of the severity of psychopathology than that afforded by only an interview. For example, the MMPI (Hathaway & McKinley, 1951) contains three validity scales that measure the person's test-taking attitude; hence, truthfulness and a response bias toward either over- or underreporting symptoms are documented. A disadvantage is that the MMPI profile does not yield a diagnosis. However, the configuration of scores in the 10 basic scales, in conjunction with the many specialized scales, makes it possible to identify personality disorders, family problems, health disturbances, and social maladjustment comprehensively.

Other self-report rating scales can be employed when either time or expertise is not available to conduct a structured interview or obtain an MMPI profile. The most commonly used test in this regard is the Symptom Checklist 90—Revised (Derogatis, 1983). This self-rating scale is brief and easy to score. Severity of psychopathology is quantified across nine dimensions of psycho-pathology.

The importance of evaluating psychopathology in the substance use disorders cannot be overemphasized. Treatment of the underlying psychiatric disorder may itself, in many cases, be sufficient to ameliorate a substance use disorder. For this reason, it is essential to document the type, onset, and presentation of psychopathology as it relates to alcohol or drug use behavior. In addition, documentation of psychiatric illness in other family members, using instruments such as the Family History Chart (Mann, Sobell, Sobell, & Pavan, 1985) and the Family Informant Schedule and Criteria (Manuzza, Fryer, Endicott, & Klein, 1985), can assist in obtaining a clear picture of the primary psychiatric disorder.

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