Substance useGeneral

Unless otherwise indicated, all answers are from DSM-IV-TR or from Practice Guideline,

AJP, Supplement, August 2006As of 6Sep08.

Substance Abusemaladaptive patterns

Q. DSM-IV-TR has four major maladaptive patterns listed, of which the pt must have at least one. Name the four.

Substance abusemaladaptive patterns

Ans.

1] Recurring use leads to inability to meet obligations at school, work or family

2] Recurring use when physically hazardous to do so.

3] Use leads to recurring legal problems.

4] Continued use despite persistent social problems associated with use.

Substance abusetime requirement

Q. How long must the maladaptive behaviors last to meet DSM-IV requirements?

Substance abuseTime requirements

Ans. 12 months.

Abuse & Dependence

Q. Can you dx a pt with both alcohol abuse and alcohol dependence?

Abuse and Dependence

Ans. No, Abuse infers that the pt doesn’t qualify for dependence.

[Since DSM-IV-TR, concerns have been raised that one can be dependent and yet never met criteria for abuse.]

Dependencemaladaptive findings

Q. For Dependence, DSM-IV lists 7 maladaptive behaviors or conditions and expects the pt to meet at least 3 of them. List the 7.

Dependencemaladaptive findings

Ans. At least 3 of the following 7:1. Tolerance2. Withdrawal signs3. Pt takes substance more than was intended4. Pt has unsuccessful desire to decrease or stop

taking the substance5. Pt spends a lot of time obtaining the substance6. Pt reduces the time spent on important

activities because of substance use7. Pt continues use despite knowing it has been

problematic.

DependenceHow long

Q. How long must the pt have had the three of more maladaptive signs to qualify for the dx of Dependence?

DependenceHow long

Ans. 12 months.

Polysubstance dependence

Q. Under what circumstances are you to use the dx of “Polysubstance dependence”?

Polysubstance dependence

Ans. 1. Has to have problems resulting from the use of at least

three substances [not including caffeine or nicotine].BUT2. Does not meet the criteria of any single substances.E.g.: DWI from alcohol, poor work performance because of

cocaine, and getting into fights because of PCP.Thus, is not be a common dx. If pt meets criteria for alcohol

dependence and cocaine abuse, they are both to be listed.

Polysubstance abuse

Q. Status of polysubstance abuse in DSM-IV?

Polysubstance abuse

Ans. Not recognized as a disorder in DSM-IV. {If you want to use the concept of polysubstance abuse, you could use “Other Substance Abuse [polysubstance abuse]”}

On Methadone

Q. You have placed your opioid dependent pt on methadone maintenance and he has been without any signs of opioid dependence over the last 5 weeks. What is his dx now?

On methadone

Ans. Opioid dependence, early full remission on agonist therapy.

CAGE

Q. What is “CAGE”?

CAGE

Ans. A screening series of four questions, usually focused on alcohol:

1. Have you ever felt the need to Cut down on drinking?

2. Have you been Annoyed by others criticizing your drinking?

3. Have you felt Guilty about your drinking?4. Have you needed an Eye opener first

thing in the morning.

Substance-induced depressionV. MDD

Q. Deciding whether to dx a pt with a substance-related disorder or with a non-substance-related disorder in a pt who does have abuse/dependence is not always easy. What would tilt you toward a MDD dx in a pt whose abuse/dependence presents with the signs of depressive event? [Three of the four indicators are very obvious.]

Substance-related depressionv. MDD

Ans. The following suggests MDD:1. Family hx of MDD2. Depressive event signs are not seen

exclusively in conjunction with substance use.

3. Depressive signs preceded onset of substance abuse/dependence

4. Depressive signs were seen during extended substance-free periods.

Abuse v.Dependence

Q. What is the difference between abuse and dependence?

Abuse v. Dependence

Ans. Dependence has:

• Tolerance

• Withdrawal or

• Compulsive Use