Recognizing a Drug Problem

After reading this chapter, you should be able to answer the following questions:

Determining that a person has a drug problem is generally easy to do. True or False?

Tough-love approaches are always the best strategies to use if your loved one has a drug problem. True or False?

Depression and anxiety commonly occur with drug problems. True or False?

Many people with drug problems are also anxious in social situations. True or False?

Therapy and treatment can improve lives dramatically. True or False?

Ambivalence about drug use is normal. True or False?

A referral will generally hurt a client. True or False?

Co-occurring Mental Health Symptoms Psychotic behavior is the most obvious cluster of mental health symptoms to identify. Psychotic means that the person has a mental disorder that contributes to sensations or beliefs that are not real. Sensations that are not real are referred to as hallucinations, and they can be perceived by means of any of the senses. For example, auditory hallucinations often are perceived as voices or noises that in reality have not occurred, and sometimes these voices command the person to do things he or she does not want to do. Visual hallucinations, sometimes experienced as visions, amount to seeing things that are not real. Hallucinations also can be tactile (touch related), including the perception of feeling something in the body that in reality is not happening; or olfactory, which involves smelling things that are not there. Sometimes people even perceive tastes that are not really experienced.

Delusions, on the other hand, are persistent beliefs or belief systems that are not based in reality and often cause the person experiencing them to be anxious or paranoid. Many of these delusions have a theme (a common thread), which frequently involves feelings of threat, concerns about being personally targeted by a conspiracy, obsessive thoughts, or inordinate concerns about ill health. If a person has both hallucinations and delusions, these experiences tend to feed off one another and confirm one another's content. Hallucinations tend to support the delusional beliefs, and the delusions usually are related to the hallucinations. However, you can have the experience of one without the experience of the other, meaning that some people have delusions without hallucinations and some have hallucinations without delusions.

Although hallucinations and delusions are common symptoms of schizophrenia, psychotic mood disorders (depressive or bipolar), and a few other disorders, ASE STUDY it must be noted that these symptoms can be experienced by anyone under stress. For example, if you are tired enough, you may believe you saw something run out in front of your car in the middle of the night when in fact it was simply a shadow. Or perhaps you think you hear someone calling your name, and when you turn around, no one is waving to you or even looking your way. Hallucinations can happen to anyone if the circumstances are right, and sometimes we may even engage in delusional thinking for brief periods of time. So it is critical not to determine a diagnosis on the basis of one symptom, but rather on the basis of a pattern of symptoms.

Psychotic disorders can be effectively treated with medicines if properly diagnosed and if the person is referred to appropriate treatment. Antipsychotic medication has been found to control symptoms, and a new generation of atypical antipsychotic medications has fewer side effects for users. However, after the psychotic symptoms are controlled, it is strongly advised that you include cognitive behavioral skills training as part of therapy to teach the person to care for himor herself appropriately (see Chapter 5). A sizeable percentage of people with psychotic disorders also misuse drugs, but in relative terms, the occurrence of psychotic behavior in society is small. When these symptoms occur, the most challenging task is to try to determine their source-which may be related to a psychotic disorder, but also can be related to drug use, since many substances (such as methamphetamine and hallucinogens) can cause psychotic symptoms and even lead to psychotic breaks (referred to as drug-induced psychosis) in clients.

Unlike psychosis, depressive symptoms do commonly occur among people with drug problems. Depression can include psychotic symptoms, but that tends to happen very rarely and only in extremely severe cases. Depressive symptoms that may be observed include dysphoria (sadness), inertia (lack of energy or movement), suicidal ideations and behavior, psychomotor retardation (sluggishness) or restlessness, anhedonia (not experiencing pleasure, even from things that may have given great joy in the past), significant weight change (excluding that from active dieting), problems concentrating or thinking, insomnia or hypersomnia (sleeping a lot more than usual), thoughts about death, and dark thoughts toward the self, including self-denigration. Another key factor to consider is whether these symptoms are noted to be interfering with a person's life in a noticeable way. There are two general types or patterns of depression that are most commonly observed. One is called Dysthymia. Dysthymia is the kind of depression in which a person seems to have the blues generally all the time. In Dysthymia, sometimes the blues become full-blown depression and debilitate the person, but at other times the person simply seems constantly down in the dumps, and perhaps irritable and difficult to be around because of his or her negativity or cynicism. The other type of depressive pattern is called Major Depression, which is debilitating for a person and tends to be more acute than Dysthymia. (People with Dysthymia often do experience Major Depression from time to time, however.)

Some people have a seasonal pattern to their depression, meaning that the degree of depression changes throughout the year. The pattern of depression revolves around the relative amount of sunlight available, so that depression onset may occur in the fall, worsen in the winter, diminish with the return of spring, and subside completely in the summer. This type of condition is called Seasonal Affective Disorder (SAD), and it is much more commonly seen in northern latitudes in this hemisphere (or in far southern latitudes in the southern hemisphere). Researchers have tracked changes in substance use among people who have SAD, and have found a profound increase in use during the depressive cycle (winter) for a great many people. Many clients with SAD told me they were using more during the darker months to self-medicate their symptoms (recall the discussion about self-medicating in Chapter 1). Professionals should be aware that a cyclical pattern of substance use that seems to mirror changes in seasons may suggest underlying SAD, even if this condition has not been previously diagnosed. This would be especially true for people who live in the northernmost areas of the United States. SAD may be missed if a professional is not actively looking for a seasonal pattern to drug use.

If a family member notices any of the symptoms previously mentioned in a loved one, then it may be that the loved one is depressed and should be evaluated by a mental health professional. If a loved one is expressing suicidal thoughts, or it is discovered that he or she has put his or her affairs in order (has sold or given away significant amounts of personal property, written a will, settled debts, etc.), then it would be critical to get help for that person as quickly as possible. Suicide is a major concern with people who abuse drugs, since a majority of suicides in the United States are attempted under the influence of drugs or alcohol.

Mental health professionals are legally bound in many states to assess for possible harm to self. Because of the high comorbidity of depression and suicidal behavior with drug use, clinicians working with drug users need to be aware of the particular laws and procedures for reporting possible harm to self within the states in which they are practicing. Generally speaking, it is important to assess all clients with drug problems for possible depression and suicidal ideations, as well as for a history of suicidal behavior (see Chapter 4 for more details on assessing depression). The treatment of choice for depression is usually a combination of psychotherapy (like cognitive behavioral therapy or interpersonal therapy- see Chapter 5) and pharmacotherapy (antidepressants). In addition, another difficult task is determining which came first, the depression or the drug use. Depression can be a natural consequence of rebound effects and withdrawal processes that occur after chronic and acute substance abuse, so it is very commonly seen in drug-using clients. However, some clients I have worked with have told me that they remember being blue or depressed long before they ever touched a drink or a drug, so depression is not always a consequence but instead may be an antecedent.

Another type of mood disorder that commonly co-occurs with drug problems is Bipolar Affective Disorder. Bipolar disorders include depression as a symptom (one of two emotional poles - hence, bipolar), but they also include mania or hypomania, which is a period of high energy and potentially other problematic and high-energy symptoms. Loved ones may observe symptoms like sleeplessness (for days on end), irritability, and excitability; extreme behavior related to, and obsession with, religiosity, sex, spending, and pleasure seeking; grandiosity (beliefs of exaggerated self-worth, superhuman power, strength, etc.); very rapid, constant, and sometimes incoherent speech; poor judgment; or racing thoughts (as described by the person experiencing them). Again, a key factor to consider is whether more than one of these symptoms are occurring at once and whether these symptoms are interfering with the person's life. A manic episode is frequently followed by a down cycle of depression and a physical crash, during which the person may sleep a lot and be very de-energized. Anyone who observes these symptoms in a friend or loved one should be advised to seek an assessment of the person by a mental health professional.

However, one difficulty is that many drugs cause behaviors that mimic mania. In some cases, the person may not be manic per se, but rather may be intoxicated on a stimulant drug. It is up to professionals to determine whether the symptoms are drug induced or whether there is something more than drug effects contributing to the behavior. Professionals also need to be aware that the risks of suicide among people with bipolar disorders are quite high even during the manic or hypomanic phases (which actually may provide them with the energy to carry out the act), so care should be taken to assess for suicide risks. Bipolar disorders are very treatable, by using mood-stabilizing drugs and sometimes antipsychotics to treat the symptoms, and cognitive behavioral skills training to change dysfunctional coping styles (see Chapter 5).

RESEARCH FRONTIERS
Treating Co-occuring Disorders

For years, psychiatric and drug abuse disorders were not even treated together. Now we know they commonly co-occur, which means for many years clients were getting only partial treatment. Even today we are still not sure how to treat these co-occurring conditions simultaneously in a consistently effective way with both psychotherapy and pharmacotherapy (see Chapter 5). The next century is likely to see many advances in both pharmacotherapy and psychotherapy to treat co-occurring conditions. There are effective methods to treat drug abuse and to treat other co-occurring psychiatric disorders. The next frontier in research is to learn how to combine these approaches in a way that can treat multiple disorders at once!

Another set of symptoms commonly observed among people with drug problems revolves around anxiety. Besides observing the more obvious symptoms of worry and restlessness, loved ones might notice exaggerated and extended fightor- flight (sympathetic nervous system) responses, in which the person appears high-strung, uptight, and on edge; expressions of extreme fearfulness or exaggerated concerns about something bad happening to the person or to his or her family; or panic attacks, in which the loved one feels like he or she may die and worries that there may be some physical problem (like a heart attack, stroke, cancer, etc.) even though a medical doctor finds nothing wrong. In addition, the person may be very afraid of certain objects, experiences, or situations, and may do everything possible to avoid them. People who have experienced trauma in the past may sometimes feel like they are reliving the traumatic event, and may have anxiety and worry resulting from that trauma, including problems with nightmares while sleeping and possibly flashbacks of the experience while awake. People with drug problems may be at greater risk for experiencing trauma, since drug use leaves them vulnerable to victimization and can lead them into certain situations where violence can occur to them.

There is a wide variety of disorders with anxiety as a principle feature. One specific one is Generalized Anxiety Disorder, and its major feature typically involves being constantly worried, with particular themes of worry in specific areas of the person's life (e.g., a theme of exaggerated worry about a loved one getting hurt or sick). Another expression of anxiety is Panic Disorder, which is typified by multiple panic attacks that sometimes seem to come out of the blue. Obsessive-Compulsive Disorder is another form of anxiety and is typified by repetitive behaviors that are debilitating, such as repeated hand washings that cause skin damage, extreme concern about germs or health, and other extreme habits that may involve checking and rechecking, obsessive counting, or even ritualistic behavior patterns that are repeated over and over again. Yet another anxiety disorder related to the experience of trauma is Posttraumatic Stress Disorder (PTSD), and it may occur after a person has been confronted with a horrible disaster or an event that threatened death.

Having phobias (fears about objects, experiences, or situations) is a common experience for people with drug problems. For instance, Social Phobia or anxiety is frequently observed. Some of my clients have told me that their drug use started as a way to cope with anxiety and fears related to social situations. People with Social Phobia tend to get embarrassed very easily, often are perfectionists (which sets them up to judge themselves and others harshly), usually have performance-related anxiety in social situations, and try to avoid social situations as much as possible because of concerns about embarrassment and failure. Agoraphobia also is a commonly experienced disorder among people who have drug problems. Agoraphobia often leads to an avoidance of places (like an elevator, bridge, or crowded supermarket) where the person may feel trapped. Because of fears of being trapped, the person often stays at home a great deal and will avoid certain places at all costs. Agoraphobia can develop as a result of Social Phobia and Panic Disorder because the person is afraid of being embarrassed in a place where she or he cannot escape public observation.

Professionals should be aware that anxiety often co-occurs with depression, so it is reasonable that if you determine one is present in a client, you should assess for the other. Again, one of the challenges of assessing anxiety among people with drug problems is that many substances can induce anxiety by withdrawal symptoms, by overwhelming life consequences that may occur because of drug use, or by long-term neurochemical changes (similar to depression) that some substances cause in the brain. The client presentation can be complicated since anxiety tends to increase after a person quits using the substances, which means that for some time after a change in drug use, it will be difficult to sort out whether the anxiety is a result of physiological rebound or an underlying anxiety disorder.

Finally, benzodiazepines (tranquilizers) are the most commonly abused drugs by people with anxiety disorders. Even though researchers have found that benzodiazepines actually contribute to making anxiety worse in the long run (even though they may provide some short-term reductions in anxiety) because of their rebound effects, many physicians are still routinely prescribing these anxiolytic drugs to treat anxiety. Anxiety patients often carry spare amounts of these drugs (called safety signals) in their pockets for security purposes and tend to overuse and even abuse benzodiazepines in an effort to control anxiety symptoms. Professionals who suspect comorbid anxiety with drug abuse also should assess the client's use of benzodiazepines, and professionals working with anxiety patients should routinely assess for abuse of tranquilizers. The treatment of choice for anxiety disorders is cognitive behavioral therapy (see Chapter 5), which is highly successful in treating them, and in some cases the use of antidepressant medications may be helpful to control symptoms.

Sometimes personality disorders may co-occur with drug abuse. There are three commonly found among people who have drug problems: Antisocial, Narcissistic, and Borderline Personality Disorders. Antisocial personalities are defined by lack of concern about rules, disdain for authority, and sometimes utter lack of regard for the welfare of other people. Antisocial Personality Disorder often is defined by its behavior, including manipulation of others for personal gain, cruelty to others (and animals), criminal behavior, and a desire to take risks and seek thrills. Again, identifying these qualities as a pattern of behavior rather than a single or isolated incident is important before making a judgment that your client has this problem. As mentioned in Chapter 1, Antisocial Personality Disorder is likely overdiagnosed among drug users because drug use often includes illegal activities to support the drug use behavior.

However, if a person who has a drug problem is consistently breaking rules, defying authority, manipulating people, and seemingly acting without a heart or without a conscience toward others, then you may wish to consider whether Antisocial Personality Disorder may be co-occurring with the drug use. Many more men meet criteria for this disorder than women, but there are women who do meet these criteria. Sometimes borderline (described later in this section) behavior can be mistaken for antisocial, and certainly there can be overlap between the two disorders. However, clients with whom I've worked who have borderline features generally have the capacity to care about other people, whereas people who are antisocial may not have this capacity.

If the client is an adolescent or child and engaging in antisocial behavior, then comorbid Conduct Disorder should be considered, although such behavior also may indicate an Oppositional-Defiant Disorder if there is little deviant behavior but lots of arguing and defying the wishes of authorities such as parents and teachers. Adult antisocial behavior is difficult to treat but usually involves use of behavior modification (see Chapter 5) through the use of incentives. Conduct Disorder and Oppositional-Defiant Disorder can be successfully treated with behavior modification and by modifying the youth's environment (e.g., using multisystemic therapy or the community reinforcement model-see Chapter 5). In some cases, Narcissistic Personality Disorder can cluster with both drug abuse and antisocial behavior. People with this disorder typically display grandiosity, selfishness/self-centeredness, exploitation of others, beliefs about being gifted and special, arrogance, an excessive preoccupation with self and personal appearances, and the need to have others affirm how special they are. Sometimes these qualities are difficult to separate from antisocial behavior, but key differences center around the criminal behavior and the ability to inflict physical cruelty found in antisocial behavior. Effective treatment for Narcissistic Personality Disorder includes cognitive behavioral therapy as well.

Finally, people with Borderline Personality Disorder often use drugs and alcohol. Borderline Personality Disorder is defined by acts of self-harm, including self-mutilation behavior such as cutting, burning, and picking behavior; and by poor judgment and impulsive acts that may place the person at high risk for being victimized and for other adverse consequences. Emotional dysregulation is common among people with this disorder. For example, you may witness emotional lability, over- or underreacting emotionally to certain situations, rage and out-of-control behavior, and an avoidance of emotional situations or intimacy. Borderline clients often engage in black-and-white thinking and behave in an allor- nothing fashion. They can appear quite competent at one level even when they are utterly confused, and can appear quite needy one moment and completely rejecting of social support in the next moment.

As Marsha Linehan (1993) has noted, this personality disorder is typified by dialectical behavior (extremes, like love-hate, at either end of a particular behavioral spectrum, sometimes within the space of a few moments). Some professionals have great difficulty working with people who have this disorder. This is primarily because they do not set personal limits in professional interactions and because borderline clients sometimes have very unpredictable behavior, including significant numbers of suicidal and parasuicidal acts that keep professionals always on their toes. The treatment of choice for this disorder is dialectical behavior therapy (also see Chapter 5).

Professionals working with a suicidal drug client may wish to determine whether the person meets criteria for Borderline Personality Disorder. Borderline clients often have a history of suicidal behavior and high utilization of health and mental health care services. Most people who meet criteria for Borderline Personality Disorder are women, but not all. As mentioned, some professionals find it difficult to work with borderline clients without becoming very upset or cynical. If you cannot work with such a client respectfully, then it is recommended that a referral be made to someone who can (see Chapter 3). Treating the client with dignity is important if trust and a solid therapeutic alliance are to develop.

Remember that it is important to assess for suicidality when working with any client with a history of suicidal and parasuicidal behavior. Not only ideations should be assessed, but also plans, lethality of plans, means to carry out those plans, and proximity of means. You would surprised at how often such clients carry lethal doses of pills, razor blades, or even guns in their purses, pockets, or backpacks during such an assessment interview with intentions to use these items. (Please see the extended discussion about suicide assessment in Chapter 3.)

Co-occurring Physical Health Symptoms

Other commonly co-occurring conditions are not necessarily related to mental health disorders. For example, co-occurring health problems such as chronic pain or a neurocognitive dysfunction related to a head injury or other insult (both mentioned previously) can accompany a drug problem. Impulsive behavior by a person with a drug problem can be a sign of an unrecognized head injury. Even if a person has an accident and seeks medical attention, he or she may not be adequately assessed for a head injury. If the injury occurs when the person is intoxicated, it is difficult to make such an assessment due to the drug or alcohol impairment. Sometimes the results of such an injury do not become obvious until much later. Since the risk for falls, auto accidents, victimization, and other sources of head injuries is elevated for people when intoxicated, and because many of those accidents may not be adequately cared for (the person may not even have a memory of the injury or accident), it is critical for professionals to remember that an undiagnosed head injury could be an explanation for certain patterns of irrational behavior they may observe.

In addition, pain often is used as an excuse for drug-seeking behavior in health care clinics, dental offices, emergency departments in hospitals, and other primary care clinics. I have heard about some people seeking and receiving unnecessary surgical and dental procedures in order to obtain pain medicines. The abuse of prescribed medicines is one of the fastest growing drug problems in the United States, and a great deal of this behavior is related to pain behavior (although some of it begins as an attempt to reduce anxiety symptoms, as mentioned). Certainly, repeated visits for different ailments or injuries should be treated with suspicion by physicians, nurses, and dentists, especially if the presentation of the problem does not fit the description of the pain.

Arthur W. Blume. Treating Drug Problems (Wiley Treating Addictions series) (2005)