Chapter Thirteen
Summary
Many patients presenting with various axis I conditions also use or abuse substances. We only tend to get
concerned when a client demonstrates detrimental effects on his/her social and occupational functioning. This
includes, but is not limited to, loss of control or compulsive use, the development of chemical tolerance, and
impairment or failure in meeting life’s major obligations such as work.
Research demonstrates that 61% of those with bipolar illness, 47% of those with schizophrenia, 39% of those
with a personality disorder, 33% of those with OCD, and 32% of those with an affective disorder abuse substances.
Determining whether the substance abuse condition or the mental illness came first may be, well, difficult. Taking
good history and determining if there is significant family history for mental illness or substance abuse is the first
order of business. Research has demonstrated that chronic alcohol use does in fact lead to depressive illness.
Some research believes that addiction is not simply a direct effect of the drug on the brain, but a pathological
relationship one has with the drug. Further, when humans pursue gratification, they experience three basic types of
neurochemical responses: arousal, satiation, and fantasy. Each relates to a specific neurotransmitter. For example,
arousal involves norepinephrine and dopamine; satiation with GABA, and fantasy with serotonin.
Most drugs of abuse including cigarettes involve increasing the concentrations of dopamine in the brain’s
reward centers. Thus, most abusers start off seeking the “high,” but end up just using to avoid withdrawal. Treatment
centers tend to follow their own particular treatment philosophy. Some include more of a traditional “moral” model
like a 12 step AA program. Others may utilize a “rational recovery” model. In any case, treatment must not assume
that all mental health problems are caused by patient’s chemical abuse, nor is the use a result of attempting to “self
medicate” mental illness. Research has suggested that the patient’s level of rapport and alliance with the treating
clinician may in fact lead to more days of abstinence.
Specific Discussion Questions:
1. How should a clinician determine if a patient’s substance abuse is becoming problematic?
2. What is meant by the term “tolerance?”
3. What types of questions should a clinician ask to determine which disorder (substance abuse or Axis I / II)
came first? Why is this important?
4. What do researchers mean when they assert that chemical addition is not simply a direct effect of a drug on
one’s brain?
Possible True/False Questions:
1. Sixty-one percent of those with a Bipolar diagnosis typically abuse chemicals.
2. As many as 83% of those with a Personality Disorder may abuse drugs.
3. Once obtaining history, determining the nature and use of substances may be possible.
4. A co-occurring, or dual occurring exists when those with any DSM 5 disorder also abuse chemicals.
5. Behavioral activities themselves can produce chemical changes in the brain similar to those produced by
exogenous drugs.
6. Typically those seeking arousal use drugs that increase arousal like cocaine and stimulants.
7. The painful feeling of withdrawal involves an increase in dopamine 3 receptor sites seeking dopamine.
8. Antabuse is better used with a steady drinking patient, while ReVia/Depade is better to use with a patient
who binges.
9. Topamax and Campral may be helpful in reducing craving and days of abstinence for those who drink.
10. L-alpha-acetylmethadol or LAAM has properties similar to methadone, yet only needs to be administered
three times per week.
11. Stress and environmental factors may be large triggers for relapsing.
12. NAC has been found to be helpful in preventing cocaine relapse.
Multiple Choice Questions:
1. What percentage of Schizophrenic clients abuse drugs?
a. 32%
b. 39%
c. 42%
d. 47%
2. In a 2014 national survey, nearly ___ million people met criteria for a substance use disorder.
a. 4
b. 10
c. 22
d. None of these
3. Which neurotransmitter corresponds to satiation?
a. GABA
b. norepinephrine
c. serotonin
d. dopamine
4. What percentage of OCD patients are known to abuse substances?
a. 22%
b. 29%
c. 33%
d. None of these
5. The typical daily dose of disulfiram is about:
a. 125-250 mg
b. 100-175 mg.
c. 50-75 mg.
d. 10-15 mg.
6. Naltrexone or ReVia is usually given daily at _____ mg.
a. 25
b. 50
c. 75
d. None of these
7. Antabuse or disulfiram is usually given to patients who are:
a. steady drinkers
b. binge drinkers
c. both and b
d. neither a nor b
8. Acamprosate is known to inhibit _______.
a. GABA
b. dopamine
c. glutamate
d. serotonin
9. The typical daily dose of methadone for a patient on maintenance is about:
a. 10-20 mg.
b. 15-35 mg.
c. 50-70 mg.
d. None of these
10. LAAM is a longer acting analog methadone that need only be administered:
a. Once per week
b. Twice per week
c. Three times per week
d. Four times per week
11. Buprenorphine or Subutex is used in opioid withdrawal and has which major advantage?
a. Only given once per week
b. Has no withdrawal upon discontinuance
c. Its agonist effects diminish at higher doses.
d. Both a and b.
12. “Ultra rapid detox” involves which of the following medications?
a. methadone
b. LAAM
c. ReVia
d. naloxone
13. All of the following dopamine agonists have been used in cocaine treatment except:
a. Ibogain
b. Bromocriptine
c. Amantadine
d. Mazindol
14. Which of the following antidepressants has been approved for cigarette smoking cessation?
a. Paxil
b. Cymbalta
c. Pristiq
d. Bupropion
15. Which of the following class of medications appears to offer some hope to those with sexual addictions?
a. MAOIs
b. SSRIs
c. Tricyclics
d. Benzodiazepines
Alternative Class Assignments and Essay Questions:
1. Explain why it is important to take adequate history information from a patient with a co-occurring condition
such as mental illness/substance abuse or substance abuse/ADHD.
2. Have your class construct a list of commonly seen DSM-5 disorders and the typical substance abuse patterns
reported with each group.
3. Divide your class into pairs. With one person role playing the client and the other acting as therapist, instruct
Case 1 and 2 Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in each case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in each case?
Answer Key to Possible True/False and Multiple Choice Questions
Chapter Thirteen
Multiple Choice Questions: