Co-Occurring Disorders - Terms Related To Substance-Related and Addictive Disorders

Criteria for a Diagnosis of Substance Abuse 1:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

Criteria for a Diagnosis of Substance Dependence 1:

1. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of the substance.

Schizophrenia:

2 or more active phase symptoms (delusions, hallucinations, disorganized speech, disorganized or catatonic behavior); negative symptoms (flat, affect, loss of drive, poverty of speech, etc.); deterioration in functioning. At least 6 month duration (at least 1 month of active phase symptoms; the rest can be prodromal or residual phase symptoms). The symptoms are 6 months or more for diagnosis of Schizophrenia.

Delusional Disorder:

2 or more non-bizarre delusions (delusions about events that are plausible). Functioning is usually not too impaired; if there is impairment, it is directly related to the delusions. Duration at least 1 month.

Criteria for a Diagnosis of Substance Abuse 2:

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

Criteria for a Diagnosis of Substance Dependence 2:

2. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance (refer to the DSM-IV-TR, Criteria A and B of the criteria sets for withdrawal from the specific substances). b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

Criteria for a Diagnosis of Substance Abuse 3:

3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

Criteria for a Diagnosis of Substance Dependence 3 & 4:

3. The substance is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

Criteria for a Diagnosis of Substance Abuse 4:

4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

Criteria for a Diagnosis of Substance Dependence 5 & 6:

5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use.

Criteria for a Diagnosis of Substance Dependence 7:

7. The substance use is continued despite knowledge of having a persistent or recurrent physical or mental health problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Figure 2-1. Level of Care Quadrants:

A conceptual framework that classifies settings within which clients with COD are treated. The four quadrants are based on relative symptom severity, rather than by diagnosis.

Mental Health Service System:

A mental health program is an organized array of services and interventions wit a primary focus on treating mental disorders, whether by providing acute stabilization on ongoing treatment. There programs may exist in a variety of settings, such as traditional outpatient mental health centers (including outpatient clinics and psychosocial rehabilitation programs or more intensive inpatient treatment units.

Key Program Mental Health-Based Programs:

A mental health program is an organized array of services and interventions with a primary focus on treating mental disorders, whether by providing acute stabilization or ongoing treatment. These programs may exist in a variety of settings, such as traditional outpatient mental health centers (including outpatient clinics and psychosocial rehabilitation programs) or more intensive inpatient treatment units.

Terms Related to Systems:

A program is a formally organized array of services and interventions provided in a coherent manner at a specific level or levels of care in order to address the needs of particular target populations. Each program has its own staff competencies, policies, and procedures. Programs may be operated directly by public funders (e.g., States and counties) or by privately funded agencies. An individual agency may operate many different programs. Some agencies operate only mental health programs, some operate only substance abuse treatment programs, and some do both. An individual, licensed healthcare practitioner (such as a psychiatrist or psychologist) may offer her or his own integrated treatment services as an independent practitioner.

Substance Abuse Treatment System:

A substance abuse treatment program is an organized array of services and interventions with a primary focus on treating substance use disorders, providing both acute stabilization and ongoing treatment. Substance abuse treatment programs that are more advanced in treating persons with COD may offer a variety of interventions for mental disorders (e.g., psychopharmacology, symptom management training) within the context of the ongoing substance abuse treatment.

Criteria for a Diagnosis of Substance Abuse A:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

Key Programs Substance Abuse Treatment Programs A:

A. A substance abuse treatment program is an organized array of services and interventions with a primary focus on treating substance use disorders, providing both acute stabilization and ongoing treatment.

Criteria for a Diagnosis of Substance Dependence A:

A. Substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

Schizotypal Personality Disorders:

Acute discomfort in relationships, cognitive or perceptual distortions, and eccentricities of behavior. Odd beliefs, odd appearance.

Episodes of Treatment:

An individual with COD may participate in recurrent episodes of treatment involving acute stabilization (e.g., crisis intervention, detoxification, psychiatric hospitalization) and specific ongoing treatment (e.g., mental-health-supported housing, mental-health day treatment, or substance abuse residential treatment). It is important to recognize the reality that clients engage in a series of treatment episodes, since many individuals with COD progress gradually through repeated involvement in treatment.

Anxiety Disorders Point I:

Anxiety disorders. As with mood disorders, anxiety is something that everyone feels now and then, but anxiety disorders exist when anxiety symptoms reach the point of frequency and intensity that they cause significant impairment. In addiction treatment populations, the most common anxiety syndrome seen is that associated with early recovery, which can be a mix of substance withdrawal and learning to live without the use of drugs or alcohol.

Key Programs Substance Abuse Treatment Programs B:

B. Substance abuse treatment programs that are more advanced in treating persons with COD may offer a variety of interventions for mental disorders (e.g., psychopharmacology, symptom management training) within the context of the ongoing substance abuse treatment.

Criteria for a Diagnosis of Substance Abuse B5:

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Bipolar:

Bipolar. A person with bipolar disorder cycles between episodes of mania and depression. These episodes are characterized by a distinct period of abnormally elevated, expansive, or irritable mood. Symptoms may include inflated self-esteem or grandiosity, decreased need for sleep, being more talkative than usual, flight of ideas or a feeling that one's thoughts are racing, distractibility, increase in goal-directed activity, excessive involvement in pleasurable activities that have a high potential for painful consequences (sexual indiscretions, buying sprees, etc.). Excessive use of alcohol is common during periods of mania.

Interventions Point II:

Both substance use and mental disorder interventions are targeted to the management or resolution of acute symptoms, ongoing treatment, relapse prevention, or rehabilitation of a disability associated with one or more disorders, whether that disorder is mental or associated with substance use.

Brief Psychotic Disorders Point I:

Brief Psychotic Disorder: Schizophrenia symptoms for at least 1 day but less than 1 month. Brief Psychotic - The common characteristics of these disorders are symptoms that center on problems of thinking. The most prominent (and problematic) symptoms are delusions or hallucinations.

The Comprehensive Continuous Integrated System of Care model (CCISC):

CCISC is a model to bring the mental health and substance abuse treatment systems (and other systems, potentially) into an integrated planning process to develop a comprehensive, integrated system of care. The CCISC is based on the awareness that COD are the expectation throughout the service system. The entire system is organized in ways consistent with this assumption. This includes system-level policies and financing, the design of all programs, clinical practices throughout the system, and basic clinical competencies for all clinicians.

Cluster A:

Cluster A: Hallmark traits of this cluster involve odd or eccentric behavior. It includes paranoid, schizoid, and schizotypal personality disorders.

Cluster B:

Cluster B: Hallmark traits of this cluster involve dramatic, emotional, or erratic behavior. It includes antisocial, borderline, histrionic, and narcissistic personality disorders.

Cluster C:

Cluster C: Hallmark traits of this cluster involve anxious, fearful behavior. It includes avoidant, dependent, and obsessive-compulsive personality disorders.

• Cultural Competence:

Cultural competence when viewed as the next stage on this continuum, includes an ability to "examine and understand nuances" and exercise "full cultural empathy." This enables the counselor to "understand the client from the client's own cultural perspective".

• Cultural Proficiency:

Cultural proficiency is the highest level of cultural capacity. In addition to understanding nuances of culture in even greater depth, the culturally proficient counselor also is working to advance the field through leadership, research, and outreach.

• Cultural Sensitivity:

Cultural sensitivity is being "open to working with issues of culture and diversity". Viewed as a point on the continuum, however, a culturally sensitive individual has limited cultural knowledge and may still think in terms of stereotypes.

Brief Psychotic Disorders Point II:

Delusions are false beliefs that significantly hinder a person's ability to function. For example, a client may believe that people are trying to hurt him, or he may believe he is someone else (a CIA agent, God, etc.). Hallucinations are false perceptions in which a person sees, hears, feels, or smells things that aren't real (i.e., visual, auditory, tactile, or olfactory).

Interlinking Systems:

Depending on the life area affected at a given moment, individuals with COD may present themselves at different venues. For example, a person who experiences an array of problems in addition to the COD—such as homelessness, legal problems, and general medical problems—may first be seen at a housing agency or medical clinic. Historically, the distinctive boundaries maintained between systems have impeded the ability of individuals with COD to access needed services.

Depression:

Depression. Instead of just feeling "down," the client might not be able to work or function at home, might feel suicidal, lose his or her appetite, and feel very tired or fatigued. Other symptoms can include loss of interest, weight changes, changes in sleep and appetite, feelings of worthlessness, loss of concentration, and recurrent thoughts of death.

Schizoid Personality Disorders:

Detachment from social relationships and restricted range of emotional expression. Emotionally cold, detached, not affected by criticism or praise, solitary.

Antisocial Personality Disorders:

Disregard for and violations of the rights of others. Must bet at least age 18; there must be evidence of conduct disorder by age 15.

Paranoid Personality Disorders:

Distrust and suspiciousness such that others' motives are interpreted as malevolent. Bears grudges.

Psychotic Disorders Drugs

Drugs (e.g., cocaine, methamphetamine, or phencyclidine) can produce delusions and/or hallucinations secondary to drug intoxication. Furthermore, psychotic-like symptoms may persist beyond the acute intoxication period.

• Dual diagnosis enhanced programs

Dual diagnosis enhanced programs have a higher level of integration of substance abuse and mental health treatment services. These programs are able to provide primary substance abuse treatment to clients who are, as compared to those treatable in DDC programs, "more symptomatic and/or functionally impaired as a result of their co-occurring mental disorder". Enhanced-level services "place their primary focus on the integration of services for mental and substance-related disorders in their staffing, services and program content".

Levels of Service:

Each level of care includes several levels of intensity indicated by a decimal point. For example, Level III.1 refers to "Clinically Managed Low-Intensity Residential Treatment." A client who has COD might be appropriately placed in any of these levels of service. These levels of care are as follows:

•Level 0.5:

Early Intervention

Histrionic Personality Disorders:

Excessive emotionality and attention seeking. Believes relationships are more intimate than they are; overly dramatic.

Narcissistic Personality Disorders:

Grandiosity, need for admiration, and lack of empathy. Exploitation of others; sense of entitlement; preoccupied with fantasies of unlimited success, power, brilliance, beauty, or idea love.

•Level 3:

High Intensity Community Based Services

Person-Centered Terminology Point I:

In recent years, consumer advocacy groups have expressed concerns related to how clients are classified. Many take exception to terminology that seems to put them in a "box" with a label that follows them through life, that does not capture the fullness of their identities. A person with COD also may be a mother, a plumber, a pianist, a student, or a person with diabetes, to cite just a few examples.

Borderline Personality Disorders:

Instability in relationships, self-image, and affect, marked impulsivity. Frantic efforts to avoid abandonment; idealization, then devaluation of others; chronic feelings of boredom or emptiness; self harm.

Integrated Interventions:

Integrated interventions are specific treatment strategies or therapeutic techniques in which interventions for both disorders are combined in a single session or interaction, or in a series of interactions or multiple sessions. Integrated interventions can include a wide range of techniques. Some examples include

Integrated Treatment:

Integrated treatment refers broadly to any mechanism by which treatment interventions for COD are combined within the context of a primary treatment relationship or service setting. Integrated treatment is a means of actively combining interventions intended to address substance use and mental disorders in order to treat both disorders, related problems, and the whole person more effectively.

•Level II:

Intensive Outpatient/Partial Hospitalization Treatment

Interventions Point I:

Intervention refers to the specific treatment strategies, therapies, or techniques that are used to treat one or more disorders. Interventions may include psychopharmacology, individual or group counseling, cognitive-behavioral therapy, motivational enhancement, family interventions, 12-Step recovery meetings, case management, skills training, or other strategies.

•Category I:

Less severe mental disorder/less severe substance disorder Locus of Care - Primary health care settings

•Category III:

Less severe mental disorder/more severe substance disorder Locus of Care - Substance Abuse System

•Level 2:

Low Intensity Community Based Services

Mania:

Mania. This includes feelings that are more toward the opposite extreme of depression. There might be an excess of energy where sleep is not needed for days at a time. The client may be feeling "on top of the world," and during this time, the client's decision-making process might be significantly impaired and expansive and he may experience irritability and have aggressive outbursts, although he might think such outbursts are perfectly rational.

Terms for Co-Occurring Disorders:

Many terms have been used in the field to describe the group of individuals who have COD (most of these terms do not reflect the "people-first" approach used in this TIP). Some of these terms represent an attempt to identify which problem or disorder is seen as primary or more severe. Others have developed in the literature in order to argue for setting aside funding for special services or to identify a group of clients who may benefit from certain interventions. These terms include:

•Level IV:

Medically Managed Intensive Inpatient Treatment

•Level 6:

Medically Managed Residential Services

•Level 4:

Medically Monitored Non-Residential Services

•Level 5:

Medically Monitored Residential Services

•Category II:

More severe mental disorder/less severe substance disorder Locus of Care - Mental health system

•Category IV:

More severe mental disorder/more severe substance disorder Locus of Care - State hospitals, jails/prisons, emergency rooms, etc...

•Level I:

Outpatient Treatment

Obsessive-Compulsive Personality Disorders:

Preoccupation with orderliness, perfectionism, and control. Workaholic, controlling, cannot delegate, inflexible.

Schizoaffective Disorder:

Psychotic symptoms with manic or depressed mood, coupled with psychotic symptoms occurring without mood symptoms for at least 2 weeks.

•Level 1:

Recovery Maintenance Health Management

Person-Centered Terminology Point II:

Referring to an individual as a person who has a specific disorder—a person with depression rather than "a depressive," a person with schizophrenia rather than "a schizophrenic," or a person who uses heroin rather than "an addict"—is more acceptable to many clients because it implies that they have many characteristics besides a stigmatized illness, and therefore that they are not defined by this illness.

•Level III:

Residential/Inpatient Treatment

Schizophreniform Disorder:

Schizophreniform symptoms for at least 1 month but less than 6 months.

Avoidant Personality Disorders:

Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Avoids social interaction; fears criticism, disapproval, and ridicule.

Dependent Personality Disorders:

Submissive, clinging behavior (excessive need to be taken care of ). Difficulty making decisions, initiating projects, or doing things alone; needs others to assume responsibility for most areas of life.

Levels of Service:

Substance abuse counselors also should be aware that some mental health professionals may use another system, the Level of Care Utilization System for Psychiatric and Addiction Services. This system also identifies levels of care, including

Substance Dependence Term:

Substance dependence also known as drug dependence is an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use.

Program Types

The ASAM PPC-2R (ASAM 2001) describes three different types of programs for people with COD:

Anxiety Disorders Point II:

This improves with time and addiction treatment. However, other anxiety disorders that may occur, but need particular assessment and treatment, are social phobia (fear of appearing or speaking in front of groups), panic disorder (recurrent panic attacks that usually last a few hours, cause great fear, and make it hard to breathe), and posttraumatic stress disorders (which cause recurrent nightmares, anxiety, depression, and the experience of reliving the traumatic issues).

•CAMI:

chemically abusing mentally ill, or chemically addicted and mentally ill.

•COPSD:

individuals with co-occurring psychiatric and substance disorders.

•MICD:

mentally ill chemically dependent.

•MISA:

mentally ill substance abuser.

•MISU:

mentally ill substance using.

•SAMI:

substance abusing mentally ill.

• Addiction only services:

• Addiction only services. This term refers to programs that "either by choice or for lack of resources, cannot accommodate patients who have mental illnesses that require ongoing treatment, however stable the illness and however well-functioning the patient" .

Advice to the Counselor: Antisocial Personality Disorders:

• Confront dishonesty and antisocial behavior directly and firmly. • Hold clients responsible for the behavior and its consequences. • Use peer communities to confront behavior and foster change.

Advice to the Counselor: Mood and Anxiety Disorders:

• Differentiate between mood disorders, commonplace expressions of depression, and depression associated with more serious mental illness. • Conduct careful and continuous assessment since mood symptoms may be the result of substance abuse and not an underlying mental disorder. • Combine addiction counseling with medication and mental health treatment.

• Dual diagnosis capable (DDC):

• Dual diagnosis capable (DDC) programs are those that "address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning". Even where such programs are geared primarily to treat substance use disorders, program staff are "able to address the interaction between mental and substance-related disorders and their effect on the patient's readiness to change—as well as relapse and recovery environment issues—through individual and group program content" .

Advice to the Counselor: Psychotic Disorders:

• Screen for psychotic disorders and refer identified clients for further diagnostic evaluation. • Obtain a working knowledge of the signs and symptoms of the disorder. • Educate the client and family about the condition. • Help the client detect early signs of its re-occurrence by recognizing the symptoms associated with the disorder.

Integrated Interventions 6:

•Combined psychopharmacological interventions, in which an individual receives medication designed to reduce cravings for substances as well as medication for a mental disorder

•Comorbid disorders.

•Comorbid disorders.

Integrated Interventions 3:

•Dual recovery groups (in which recovery skills for both disorders are discussed)

Integrated Interventions 2:

•Dual recovery mutual self-help meetings

•Dually diagnosed:

•Dually diagnosed.

•Dually disordered:

•Dually disordered.

Integrated Interventions 5:

•Group interventions for persons with the triple diagnosis of mental disorder, substance use disorder, and trauma, or which are designed to meet the needs of persons with COD and another shared problem such as homelessness or criminality

Integrated Interventions 1:

•Integrated screening and assessment processes

•MICA —mentally ill chemical abuser:

•MICA—mentally ill chemical abuser. This acronym is sometimes seen with two As (MICAA) to signify mentally ill chemically addicted or affected. There are regional differences in the meaning of this acronym. Many States use it to refer specifically to persons with serious mental disorders.

Integrated Interventions 4:

•Motivational enhancement interventions (individual or group) that address issues related to both mental health and substance abuse or dependence problems

Comprehensive Continuous Integrated System of Care model CCISCs are grounded in the following assumptions A:

•The four-quadrant model is a valid model for service planning.