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?
5. Explain what is meant by the terms arousal, satiation, and fantasy. Which neurotransmitters correspond to
each and why?
6. Explain the dopamine hypothesis. How does it lead to addiction?
7. List and briefly describe the assessment instruments that could be used with the chemically dependent client.
8. Which medications may be used with the patient recovering from alcohol?
9. Which can be used for the patient with opioid dependence?
10. Explain how effective Zyban or Chantix can be for the nicotine dependent patient.
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 substance abuse is easy.
4. A co-occurring, or dual occurring exists when those with an Axis I or II disorder 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 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.
Multiple Choice Questions:
1. What percentage of Schizophrenic clients abuse drugs?
a. 32%
b. 39%
c. 42%
d. 47%
2. Research into the development of addition suggests that there may be ____ types of neurochemical responses.
a. 2
b. 3
c. 5
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. 31%
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. study drinkers
b. binge drinkers
c. both aand 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-IV 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
each therapist to conduct an interview with a patient presenting with a co-occurring condition. Provide a
“substance of choice” to each client, but do not tell the therapist what it is. What types of questions should be
asked by the therapist and what medications or treatment, if any, should be considered and why?
4. Divide your class into two groups. Have each group take either a pro or con stand on methadone maintenance.
Have them cite research and provide a complete rationale for their positions.
5. Explain why it is so important to utilize “psych” friendly AA recovery groups for patients with co-occurring
conditions.
Read the Case Vignette in this chapter and answer the following questions:
Case Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in the case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in this case?
4. Any other medications that might be considered…what is the rationale?
5. If you were asked to follow-up on this case as the treating therapist, would you offer any additional
suggestions or approaches?
Chapter Thirteen
Answer Key
True/False Questions:
Multiple Choice Questions: