Patience is the virtue when it comes to accurate diagnosis and treatment of substance dependence, according to Marc A. Schuckit, M.D., professor of psychiatry at the University of California at San Diego and director of alcohol and drug abuse treatment programs at the San Diego Veterans Affairs Medical Center and Scripps Memorial Hospital.
Because alcohol- and drug-dependent patients tend to develop high rates of symptoms usually associated with common psychiatric syndromes, practitioners often fail to diagnose substance dependence and instead jump to treat more familiar disorders. The risk that such circumstances will occur is understandable given statistics that two of every three alcohol- or drug-dependent individuals meet the criteria for psychiatric disorders (mainly other substance-use disorders and antisocial personality disorders) and one of every three such individuals meets the criteria for anxiety or depressive disorders. The fact that in the majority of cases, these symptoms will disappear if the drug or alcohol is discontinued is the basis of Schuckit's approach.
The nuances of substance abuse diagnosis are subtle but not elusive and depend on careful examination of a complex of symptoms.
"Individual symptoms alone do not make a diagnosis," Schuckit emphasized. "It is the pattern over time."
To accurately diagnose substance-related disorders , practitioners must understand that in the majority of alcohol- and drug-dependent patients, psychiatric symptoms are almost always temporary and that symptoms of substance withdrawal, which also cause patients to seek treatment, are exactly the opposite of the effect produced by the drug. Furthermore, to make the final differentiation between substance-induced morphology and long-term psychiatric disorders, practitioners must commit to evaluating patients for four to six weeks following a period of abstinence.
Schuckit admitted that diagnosis is complicated because dependence can be intermittent-periods of use followed by abstinence-and because in alcohol dependence there is a 20% spontaneous remission rate. But he nonetheless asserted that it is a disservice to the patient and wheel-spinning for the practitioner to make a premature diagnosis of underlying psychosis based on lack of familiarity with the dynamics of substance dependence and its progression.
Schuckit limited his attention to the three commonly abused drug classes most likely to produce psychopathology-depressants, stimulants and opiates. He pointed out that in all cases, these substances cross the blood-brain barrier to produce mood change, the desired effect for which the individual is striving.
Along with symptoms associated with mood alteration-a feeling of being laid back with depressants and of being hyper-alert with stimulants-physiological symptoms can provide clues to dependence. Depressants such as alcohol, prescription sleeping pills and antianxiety medications are also muscle relaxants and decrease autonomic function, which means a patient in withdrawal would thus present as anxious, suffering from insomnia, with high heart and respiratory rates and elevated body temperature. During withdrawal such patients are also likely to be depressed and may suffer from panic attacks.
Other symptoms common with depressants include the confusion often associated with organic brain syndrome, which also disappears when the drug is discontinued, and hallucinations and auditory delusions, which although temporary can last up to two months. (Look for an otherwise clear orientation to time and place, despite either.) The alcoholic, particularly, appears paranoid while drinking but this clears when the drinking stops.
Stimulant-dependent individuals, in addition to high energy levels and restlessness, will complain about not being able to eat or sleep and exhibit increased autonomic function. While in withdrawal, they will sleep and eat too much and be languid.
Opiates produce a floating feeling, decrease the cough reflex and slow down the gut's movement, so symptoms of withdrawal will include a runny nose, diarrhea and generalized pain.
At the next step in diagnosis, the practitioner should apply what Schuckit calls a timeline, whereby details of a patient's history are plotted against predictable dependence patterns. In the case of alcoholism, this means the first drink at age 13, first drunk at age 15, first problem at age 18, first symptoms of dependence between ages 25 and 40, leading to death at age 60.
Plotting a meaningful patient history also requires understanding the difference between dependence and abuse; the two concepts are not interchangeable. Dependence will reveal itself in repetitive problems in multiple aspects of a patient's life, and practitioners should question all patients about: 1) relationships with family and friends, including milestones such as divorce, disputes and estrangement; 2) problems in school or on the job; 3) any history of automobile, industrial or personal accidents; 4) arrests, including traffic violations; and 5) recurrent health problems. A pattern of simultaneous problems in at least three areas, despite which the individual continues to drink or use, indicates dependence, while abuse involves repetitive problems in one area such as failure to fulfill major role obligations, substance use in hazardous situations and legal problems, while the individual continues to drink or use. The lifetime risk for dependence is 10% in men, regardless of age or race, and 3% to 5% for women. Approximately 6% of those who abuse a substance will evolve into dependence.
Schuckit also reminded practitioners to be alert for age-related deviation from such patterns. In older patients, for example, physiological symptoms are likely to be more evident at lower substance doses while in younger individuals, behavior problems are more often prevalent.
Responses from a woman who complains she has always suffered from depression, despite her own description that she had previously sought help for her depression only during six weeks when she was not drinking, combined with a history of problems with her husband that intensified six years into her marriage at around the age of 35, would add weight to a deferential diagnosis of substance dependence rather than major depression.
A family history of abuse is also another factor to be considered. Statistics indicate a fourfold increase in alcoholism among children born to alcoholic parents, regardless of who raises them. Alcoholism in the parent who rears the child does not increase the risk. Furthermore, Schuckit's own research indicates that an early high tolerance for alcohol in sons of alcoholics correlates with later dependence.
The initial charting of symptoms to verify a dependence-produced pattern as opposed to that associated with independent psychological disorders can be further supported by laboratory tests (a GGT or gamma-glutamyltransferase) greater than 30 U per L or high levels of blood lipids and uric acid are indicative of someone who is drinking four to six drinks a day.
Once a tentative differential diagnosis is established, the next step brings the clinician onto more familiar ground. In overcoming the substance-dependent individual's predictable denial about his or her condition, the clinician needs to intervene in a way that helps the individual understand the considerable health risks to which dependence exposes him or her. In the case of alcoholics that means heart disease, cancer, accidents and suicide. The goal of what are likely to be multiple intervention attempts is not only to begin the treatment process but confirm the original diagnosis. Patients still using depressants and opiates must undergo a period of detoxification, wherein the clinician's job is to help control discomfort without administering substitute mood-altering medication. Schuckit sees no benefit in using antidepressants with a suspected substance abuser's depressive episodes.
"I would be inclined to use cognitive therapy and wait it out," he counseled. Although 40% of alcohol-dependent individuals will appear to be suffering from a major depression one week after abstinence, typically the depression will clear within three to four weeks. If after four weeks, psychiatric symptoms persist, then likely a diagnosis of a major disorder is justified, as long "as the full-blown complex of symptoms is present," Schuckit said.
Otherwise treatment for withdrawal includes a good physical to establish that there are no other existing medical conditions; good nutrition; rest; and whatever medicines might be needed to control physiological symptoms (decongestants and medication for diarrhea in opiate withdrawal, for example). The clinician should expect withdrawal symptoms to follow a continually declining course: onset after approximately eight hours of abstinence, peak at day 2, diminish at day 3, disappear in three to six months.
Far and away the practitioner's biggest challenge will come on another patch of familiar ground-helping the recovering substance-dependent patient remain motivated and build the life skills to stay sober, in order that he or she may be among the 70% of individuals who remain abstinent after a year.
"My goal," Schuckit said, "is the optimum level of function at the least cost and pain."