Chapter 5. Diagnostic Tools
If a client is being treated for some other mood, psychological, or character disorder, and it is determined that they are also using substances at a level that meets diagnosable criteria, then there is a “Dual Diagnosis” made. When performing a thorough psychosocial assessment questions regarding the client’s possible drug use will be explored. It is important to know what prescribed medications the person may be using, in addition to the abuse or dependence of those drugs, or other drugs that are illegal. It would be nearly useless to treat or address problems the client may be having (problems doing their job, completing school assignments, conflicted relationships, or emotional problems) if they are concurrently abusing drugs. If the client is using drugs the use itself is either creating or exacerbating the other problems they are experiencing. In order to have reasonable success you must have the client “with you,” but if they are intoxicated, they cannot be. Even when the drug use may have been a reaction to a different problem, the drug use still needs to stop for interventions on other problems to be successful. In other words, until the substance abuse problem is addressed, progress with the other areas of therapeutic concern will be minimal.
For this reason, identifying substance abuse and dependence, if they exist, is a key to successful treatment. After identifying that there is a use of substance involved, the severity of the use is then diagnosed, along with the psychosocial influences that contribute to the use.
The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) differentiates diagnosis of substance abuse and dependence (addiction).
Symptoms of substance dependence include:
A maladaptive pattern of substance use causing significant impairment or distress. This can be manifested by the following occurrences:
- An increased tolerance where a need for more of the drug is needed to get intoxicated or a diminished effect with continued use of the same drug.
- Withdrawal symptoms are manifested or the same or similar substance is taken to relieve or avoid withdrawal symptoms (like methadone for heroine).
- The drug is taken in larger amounts or over a long period of time.
- There is a persistent desire or unsuccessful effort to cut down on using the drug.
- A lot time is spent in efforts to obtain the drug (visiting multiple doctors), use the substance (chain smoking) or recover from its effects.
- Important social, occupational or recreational activities are given up or reduced because of the substance.
- The substance continues to be used in spite of its negative effects.
If three or more of these symptoms exist then the individual may be diagnosed as dependent on the substance.
Symptoms of substance abuse include:
A maladaptive pattern of substance use causing significant impairment or distress manifested by one or more of the following within a 12 month period:
- Recurrent substance use resulting in the failure to fulfill major obligations at work, school, or home.
- Recurrent use when it is physically hazardous to use.
- Recurrent substance use legal problems.
- Continued use in spite of persistent interpersonal problems caused by the use.
Substance abuse is diagnosed only if the symptoms have not met the criteria of dependence. (APA, 1994)
“An estimated 21.6 million Americans in 2003 were classified with substance dependence or abuse (9.1 percent of the total population aged 12 or older). Of these, 3.1 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.8 million were dependent on or abused illicit drugs but not alcohol, and 14.8 million were dependent on or abused alcohol but not illicit drugs.” (SAMHSA 2004)
There are diagnostic tools and questions that a practitioner may use in assessing drug and alcohol use. The following four questions were developed by the American Psychiatric Association as an initial quick assessment to determine if alcohol use needs to be explored further in treatment:
B. CAGE Questionnaire
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?
Item responses on the CAGE are scored 0 or 1; with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.
C. Alcohol Screening Test
Another test that can be used to assess the level of alcohol use and dependence further is available online. This system uses a point system based on the answers to 25 questions. Examples of questions include: “Have you gotten info fights when drinking?”, “Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?” and “Have you ever been told you have liver trouble?” This test can be taken online and seen at this link:
D. PDFA Assessment
The Partnership for a Drug-Free America also provides self-assessment tests that can be used by practitioners to assess the level of substance abuse by a client. These questions include: “Are you unable to stop using drugs when you want to?”, “Do your spouse or parents ever complain about your involvement with drugs?”, and “Have you engaged in illegal activities in order to obtain drugs.” The link to this and other screening tests is here: http://www.drugfree.org/Intervention/Assessing/
In addition, the “Partnership” provides other useful resources including information for local treatment centers. There is also helpful information available to those who have loved ones or friends who may be using drugs or abusing alcohol, and tips to help them.
The tests mentioned, and others like them, assist the healthcare practitioner and the client to view through objective and measurable ways how the use of alcohol may be adversely affecting the client’s life. As in most problem-solving, the first step is to accept that there is a problem.
In addition to assessment through questioning, the trained and informed healthcare professional can detect substance abuse through the observation of behaviors and physical symptoms. These symptoms are addressed more specifically for each drug in the table at the beginning of the course and there is no sense in being repetitive here. It is, however, important to not conclude that every presenting symptom is a sign that someone is using drugs. There are other circumstances that may cause behavioral and physical symptoms to appear that are independent of drug use. For example, a client could reasonably come in after working an overnight shift, presenting drowsiness, difficulty focusing and maybe anxiety if things were tense at work. These represent symptoms of multiple drugs.
End of Chapter