Makamohelo Malimabe
Africa-Press – Lesotho. As highlighted in the previous article, in Part Two we will discuss the unhealthy or rather complicated relationship between substance use and mental illness.
Remember how I stated that we have to be mindful of differences in culture when talking of substance abuse; that remains the case. However, we need to have an idea of a standardised approach that endorses substance abuse.
For this one, I will borrow a page from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) and a few screening tools that we use to assess for substance abuse.
For this one, let us go ahead and adopt a more diagnostic approach. This is likely to benefit colleagues with a special interest in addictions counselling or therapy seekers with limited information to understand what they are struggling with.
So, from a diagnostic perspective there are three things to pay attention to, type or class of drug (10 classes highlighted in the DSM-5-TR), diagnostic criteria and culture related to diagnostic issues.
The DSM-5-TR warns us that all drugs that are taken in excess have in common the ability to directly activate the brain reward systems, which are involved in the reinforcement of behaviours and establishment of memories. This poses the concern of quantity used, which we will discuss shortly.
The DSM-5-TR provides us with Substance-Related and Addictive Disorders, under which there are 10 separate classes of drugs namely alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances.
I absolutely like that the manual indicates these 10 classes are not fully distinct. This is important to know when making a diagnosis because there might be overlapping symptoms depending on the drug of choice.
After this, we inquire about symptoms to determine if the client meets diagnostic criteria. It might be helpful to think of it this way, someone can experience a traumatic event but not meet criteria for post-traumatic stress disorder (PTSD).
Similarly, an individual can be using cannabis but not to a point where they have an addiction. There are 11 criteria to take into consideration. I will not go into this as it is a lengthy discussion point.
What is important to establish is whether the client’s symptoms fit criteria for substance-related use and then determine severity and specifiers. This means mild, moderate, or severe symptoms which can be gathered from client reports or family members.
As you can imagine, these steps are crucial in making clinical decisions or treatment suggestions for the client in question. Even though there is mention of alcohol in the 10 classes of drugs, there is a section allocated to alcohol-related disorders.
This is divided into Alcohol Intoxication, Alcohol Withdrawal, Alcohol-Induced Mental Disorders, and Unspecified Alcohol-Related Disorder. They also have their diagnostic criteria and specifiers.
For example, someone that has alcohol intoxication is likely to also be faced with alcohol withdrawal later on, but it differs with clients. Now, the part I personally find interesting is that there are diagnoses associated with substance classes.
It is near impossible to explain this one without the table. But simply put, some mental disorders are closely linked to the use of certain drugs or vice versa.
These include psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive compulsive disorders, etc. Think of it this way, psychotic disorder is a stand-alone disorder, but try and realise how someone who consumes excess alcohol can develop psychotic disorder.
For bipolar and related disorders, we want to exercise the same caution in that with Bipolar I, diagnostic criteria includes inflated self-esteem or grandiosity, more talkative than usual or pressure to keep talking. As you may very well see, someone with a substance-related disorder is likely to display behaviours that are referred to as “high.
” See how displaying behaviours that qualify as being “high” with grandiosity which presents itself as an expansive or euphoric mood? Basically, what this means is that we have to be mindful in making a mental disorder diagnosis if there is reported excessive substances or alcohol use.
Think of someone whose mood wanes, and they experience depressive highs and lows. They might choose to overuse alcohol or drugs to get a “high” brought about by chemical substances.
When the counsellor consults with this client, do they diagnose them with substance related disorder, alcohol use disorder, or a depressive disorder? This makes you think because no one client can be diagnosed with everything all at once.
Providers also need to be mindful of the severity of the addiction as this informs whether treatment can be offered in outpatient services, or it needs in-patient treatment options.
Sometimes, it becomes an issue of, if the client is impaired from overuse of chemical substances, can you even be successful at offering individual therapy in the traditional sense?
After the DSM-5-TR mouthful, someone might still be unclear on what co-occurring disorders are, seeing how complex it can be to make such diagnoses. Substance Abuse and Mental Health Services Administration (SAMHSA) defines co-occurring disorders as the coexistence of both a mental illness and a substance use disorder.
In his book, Charles Atkins, MD said, “I sometimes use the metaphor that treating co-occurring disorders is like assembling a Thanksgiving meal, where you’re firing – literally – on all burners.
Some things must be carefully watched lest they get ruined, while other dishes can simmer on the back of the stove. The front burner items must be immediately tended to.
” What does this mean in the context of Lesotho? It means multiple things that solicit different responses depending on the who and what.
Personally, I think it requires that we invest in teaching providers the intricacies of mental disorders diagnosis, teaching counsellors treatment planning for people living with co-occurring disorders, for the government to invest in a good addictions recovery centre for in-patient treatment care.
We continue to make the mistake of thinking that Mohlomi psychiatric hospital is the final destination for all mental disorders. We can benefit from an independent addictions and rehabilitation referral centre, with adequately trained stuff.
In part 3, the last article in the co-occurring disorders series, I will highlight measurements commonly used to assess substance-related and addictive disorders, alcohol related disorders, and treatment options including the 12-step AA programme. I will provide local services and resources available in Lesotho.
https://www.thepost.co.ls/insight/substance-use-and-mental-disorders-2/
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