Case Study: Substance Use and the Adolescent

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Over the past decade, cases of substance related disorders have appeared more prevalent in society. From the mental health perspective, research has shown an increase in cases of substance related disorders, particularly with adolescents. This increase has prompted further investigation into adolescent risk and resilience factors, as well as accuracy in diagnosis and appropriate treatment plans. Yet, in cases of adolescent substance use, further investigation is still needed concerning notification rights of parents, legal authorities, and/or case workers.

For this Application, review the client case study and additional learning resources. Consider the characteristics of the client. Which specific characteristics might you consider important in developing a diagnosis? Consider your rationale for assigning particular diagnoses on the basis of the DSM-5. Also, think about what other information or people you may need to include in the assessment in order to make an accurate diagnosis.

The Assignment (3–4 pages)

  • A DSM-5 diagnosis of the client in the case study
  • An explanation of your rationale for assigning the diagnosis on the basis of the DSM-5
  • An explanation of what other information you might need about the client to make an accurate diagnosis
  • A brief description of additional individuals you might include in your assessment and explain why

Be sure to support your postings and responses with specific references to current literature.

3-4 Pages. APA Format. In-text Citations to Support Literature. Minimum of 5 References.

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Blackwell Publishing LtdOxford, UKADDAddiction0965-2140© 2006 American Psychiatric Association, Journal compilation © 2006 Society for the Study of Addiction 2006 1014047 Original Article Cultural issues and psychiatric diagnosis Javier I. Escobar & William A. Vega RESEARCH REPORT Cultural issues and psychiatric diagnosis: providing a general background for considering substance use diagnoses Javier I. Escobar & William A. Vega Department of Psychiatry, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, NJ, USA ABSTRACT Aims To establish a general context on the topic of cross-cultural diagnosis and suggest how it can be applied to substance use disorders. Methods Critical reviews of the literature on psychiatric diagnosis, cross-cultural issues and the concept of ethnicity were conducted to provide a framework for making specific recommendations for substance use diagnoses. Results Cross-cultural diagnosis remains in a state of flux. Key questions on ethnicity and psychopathology have not yet been fully answered by existing research. The broad use of the Diagnostic and Statistical Manual for Mental Disorders (DSM) system world-wide requires a careful look at its cross-cultural applicability. Conclusion For DSM-V, cultural/ethnic issues have to be clearly defined in clear terms that lend themselves to operational definitions. Recommendations should be research-based and testable. Meaningful cultural annotations and a glossary of cultural terms that are applicable in daily clinical practice and not limited to less frequently encountered syndromes (culturebound) would be highly desirable. Keywords Addiction, cross-cultural diagnosis, psychiatric diagnosis, substance use disorders. Correspondence to: Javier I. Escobar, Professor and Chairman, Department of Psychiatry, University of Medicine and Dentistry, Robert Wood Johnson Medical School, 675 Hoes Lane, Piscataway, NJ 08854-5635, USA. E-mail: escobaja@umdnj.edu RESEARCH REPORT INTRODUCTION The goal of this review is to establish a general context on the topic of cross-cultural diagnosis and suggest how it can be applied to substance use disorders. Psychiatric diagnosis has advanced considerably since the development of the third edition of the Diagnostic and Statistical Manual for Mental Disorders, third edition (DSM-III) and there is a good deal of confidence among researchers and practitioners about their ability to make psychiatric diagnoses that seem valid and reliable. Thus, in the last two decades, psychiatric diagnosis has attained an aura of respectability in North America and many other countries of the world. Although reliability of research diagnoses elicited with structured diagnostic instruments is reasonably good, this does not appear to be the case in day-to-day practice. While developed for a North American population, DSM has been exported to the rest of the world, a fact that raises a number of issues about its cross- cultural applicability. The cross-cultural limitations of the DSM system have been raised by many authors, particularly those trained in a sociological or anthropological tradition who practice in North America [1] Despite questions raised about its cross-cultural equivalence, DSM is used widely across the world, particularly for research purposes by investigators who seek publication in North American journals. Albeit imperfect, the DSM system appears to offer a rational, criteria-based framework suitable for research and clinical practice, at least according to anecdotal reports of colleagues from Europe and Latin America. In the following paragraphs we will highlight relevant issues related to ethnicity and psychiatric diagnoses in efforts to provide a general background that may inform the re-examination of substance use diagnostic categories and their applications. To conclude, we will attempt a few specific recommendations on this topic as part of the development of DSM-V. © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 Cultural issues and psychiatric diagnosis KEY DEFINITIONS Race The use of race as a way to classify humans originated with Linnaeus, in his 1758 Systema Naturae. Blumenbach, a German anthropologist, outlined five divisions of race (Caucasians, Mongolian, Ethiopian, American and Malay). However, population and genetic studies have questioned the use of racial divisions for humans as lacking a scientific foundation. Indeed, hundreds of human races have been proposed using anthropological criteria, and the US 1990 census elicited more than 300 races in questionnaire responses [2]. In 1999, the Institute of Medicine (IOM) in its report The Unequal Burden of Cancer [3], recommended that the National Institutes of Health (NIH) re-evaluate the use of ‘race’, defined as ‘a construct of human variability based on perceived differences in biology, physical appearance and behavior’. According to the IOM, the traditional conception of race rests on the false premise that there are natural distinctions grounded in significant biological and behavioral differences but actually rooted in physical features characteristic of diverse continental origins. Therefore this concept lacks any biogenetic or anthropological justification in cancer surveillance and other population research. The IOM advised using the term ‘ethnic group’ instead of ‘race’ in future endeavors. Ethnicity This concept defines the ways in which one sees oneself and how one is seen by others as part of a group on the basis of cultural background and shared historical experience. Common elements often associated with a given ethnic group include skin color, religion, language, ancestry, customs and occupational or regional features. Ethnicity boundaries are dynamic and imprecise, and further confounded with nationality. For proper clinical or research use, the concept should be defined and operationalized precisely. Problems with the ‘ethnicity’ concept While the IOM report suggested that ethnicity was a more neutral, less pejorative term than race, the problem is that it is difficult to define operationally, and often individuals responding to queries do not endorse unambiguously the choices offered in census gathering and other surveys. The ‘Hispanic’ or ‘Latino’ ethnicity group, in particular, is too broad and heterogeneous and it is not possible to draw inferences that universally apply to Hispanics given their diverse origins (traced to more than 20 countries), their various phenotypic admixtures, divergent historical origins and diverse social and educational levels. One consequence of this is that Hispanics were the 41 ethnic group most likely to endorse ‘mixed race’ in the latest US Census. Race and ethnicity issues in the United States Historically, there has been a long-standing preoccupation in the United States with race and ethnicity issues, particularly a need to label ethnic and racial groups for operational reasons such as population enumeration and health assessments. Interestingly, since 1997 the US Office of Management and Budget (OMB), the agency that ultimately determines NIH’s population taxonomy, recognizes only two categories of ‘ethnicity’. These are ‘Hispanic’ or ‘Latino’ versus neither. However, despite the IOM report, OMB continues to recognize five categories of ‘race’, namely, Asian, American Indian or Alaska Native, Native Hawaiian, or other Pacific Islander, black or African-American and white, and these continue to be used in the literature. An essential point is that the US ethnic and race categories, which are growing more inaccurate with the passage of time in the United States, are even less useful when used in other nations. Thus, while many countries in western Europe, the Pacific and even Latin America have their own immigrant sets and minority groups, ethnic categories are not articulated the way they are in the United States. International studies have shown that US ethnic categories have little meaning elsewhere. For example, a study of depression and painful symptoms in several Latin American countries reported that a great majority of people in Mexico and Argentina did not identify themselves as ‘Hispanics’ [4]. Also, according to reports from the Fogarty International Center, US ethnic and racial categories cannot be properly applied to international research projects funded by NIH (personal communication, 2004). Ethnicity and medicine In US clinical medicine, references to race are standard in clinical rounds and medical records, and continue to be an integral part of clinical patient documentation. For example, a medical history or a clinical presentation invariably starts as the ‘. . . -year-old Hispanic, African American, Asian or White male or female presenting with such and such a symptom’, possibly reflecting the historical importance in the pregenomic era of racial background for diagnosing disorders such as sickle cell anemia, Tay Sachs disease, thalassemia and cystic fibrosis, among others. Unfortunately, used in such a fashion the concept of ‘ethnicity’ is imperfect as it is too often inferred by the examiner on the basis of observed traits. For obvious reasons, the use of ethnic identification and concerns about cultural orientation have had significantly more influence in psychiatry and psychology compared with the rest of medicine. For example, anthropologically and socially oriented psychiatrists © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 42 Javier I. Escobar & William A. Vega continue to insist on the formal use of the ‘cultural formulation’, a process that takes into account the person’s cultural identity and background for formulating diagnosis and treatment plans. Indeed, the Review of Psychiatry, the traditional text updating progress in psychiatry in North America, states that ‘a consideration of culture is essential in the process of the interview, case formulation, diagnosis and treatment of culturally diverse individuals’ [5]. The relevance of ethnic or cultural formulation has gained visibility following the recent Surgeon General’s report on ‘health disparities’ (which in psychiatry have only applied to access and treatment quality issues rather than disorder phenomenology or diagnosis). This has led to positive developments such as the requirement that ‘cultural competence standards’ (ensuring practitioner’s awareness on such issues as culturally related attitudes, symptoms, language and interpretation of clinical data) be developed in state systems in efforts to improve access and quality of care. However, it has been difficult to define with any precision the key ethnic issues, or a modus operandi, to be taken into account for making valid psychiatric diagnoses. Also, specific applications of this to the area of substance use disorders are not documented clearly. Country of origin and immigrant status In our view, these are less ambiguous items, easier to define and elicit precisely and have proven less controversial and transferable for international use. For example, epidemiological studies in the United States have shown that these variables, and related markers such as age of arrival and time in country among immigrants, have utility for demarcating important differences in levels of psychopathology and general health. The observation that immigrants from Latin America have superior health and mental health status than those born in the United States [6–8] was coined the ‘the Latino paradox’ by Scribner [9], who suggested that much could be gained from identifying the determinants of these differences. These findings illustrate the utility of carefully constructed demographic descriptors for deriving subgroup comparisons. Regarding issues of self-report veracity about substance use, and potential variations among and within ethnic groups, it has yet to be demonstrated that these problems have resulted in serious under-reporting or systematic biasing of substance use information. ‘Universalistic’ versus ‘relativistic’ perspectives In cultural psychiatry, the terms ‘emic’ and ‘etic’ illustrate these two perspectives in diagnosis. The concept of emic (from phonemics) refers to culture-specific patterns of psychopathology, while the concept of etic (from phonetics) presupposes that psychopathology is universal. Kraepelin was perhaps the first to use the universalistic (etic) approach to psychopathology. This approach signified a departure from a system of classification based on etiological assumptions, and was representative of philosophical realism or positivism that was ultimately incorporated into diagnostic classifications in North America by the pioneering research group at Washington University in St Louis. These criteria, known as the St Louis or Feighner criteria, set the pace for the new diagnostic developments that would evolve into the Research Diagnostic Criteria (RDC) and then the DSM-III classification. The emic, or ‘relativistic’, point of view observes psychiatric disorders within their respective cultural context and argues that the content of psychiatric diagnosis will vary to some degree inherently by cultural context. This is the position adopted by anthropologically, socially oriented psychiatrists, particularly in North America. In the case of alcohol disorders, this tradition is represented in the subtypes of alcoholism [10]. There is evidence that intra-ethnic group variance in emic perspectives exists in self-rated health among Latinos underscoring the difficulty of applying specific criteria of illness and dysfunction with acceptable precision [11]. To the extent that normative definitions of severity or of ambiguous symptoms are inferred by individuals of differing cultural backgrounds during psychiatric evaluations, some cultural variance can be anticipated in applying diagnostic criteria. Strategies for overcoming these challenges to diagnostic accuracy are not readily available for practitioners. Evolution of psychiatric diagnosis Diseases cause symptoms and these are experienced and expressed by patients and elicited by physicians. Obviously, unpleasant physical symptoms are easier to define and recognize than psychological or behavioral manifestations. Physical characteristics such as sweating or trembling are not necessarily symptomatic of a disorder just because they are ‘physical’. A. J. Lewis [12] coined the term ‘psychological dysfunction’, which he defined as a deviation from a standard of normal psychological functioning. With scientific progress, the hope was that these ‘psychological dysfunctions’ would be linked eventually to abnormalities of biological functioning [13]. Relevant examples of these are symptoms such as obsessions and other psychological dysfunctions that can be defined precisely, may have biological underpinnings and can be separated clinically from one another (e.g. ‘phobias’, ‘thought insertion’, etc.). In traditional psychopathology, there has been an effort to utilize well-defined symptoms as much as possible and a tendency to avoid the inclusion of purely social or experiential factors in criteria and definitions. The more exclusive the social component in defining deviance, the less applicable is the symptom label. For example, undesirable behaviors defined in purely social terms such as drug addiction, shoplifting © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 Cultural issues and psychiatric diagnosis and vandalism are relatively easy to define reliably. However, while biological theories can be invoked to help explain some aspects of these behaviors in some people, they are highly unlikely to account for a useful proportion of the variance or to offer a comprehensive explanation [13]. As disease theories become more successful in providing a solid basis of knowledge about abnormalities of psychological and biological functioning, the dimensional aspects of measurement within and between clinical syndromes become apparent. According to Wing et al. [13], a system of clinical measurement cannot be purely categorical or purely dimensional. The most obvious example of the dimensional approach is in defining severity of symptom types (be it for investigation, treatment purposes or assessment of outcomes), but the symptoms themselves have to be defined first. In the last two decades, there has been a mushrooming of the type and number of psychiatric diagnoses. Thus, the very few classical psychiatric syndromes refined over one-and-a-half centuries such as mania, melancholia, hysteria and hypochondriasis, rose to 14 in the Washington University Criteria, exceeded 100 in DSM-III, and topped the 300 mark in DSM-IV. Despite the progress made, and the revolutionary process of building diagnoses, the official additions to the DSM books often reflect capricious actions of committees or opinions of single individuals [14]. Language and translation issues Considering socio-linguistic implications is a critical step in adapting diagnostic instruments and criteria to other countries. Equivalence has to be attained in a number of dimensions (semantic, conceptual and technical). Even words such as ‘depression’ and ‘anxiety’ are difficult to translate precisely into some languages. Also, certain somatic or mental experiences that are clearly a sign of disease in some cultures may be very important to patients from these specific cultural backgrounds, but others pay little attention to them (‘loss of semen’ is viewed as a significant problem in India, but is given little or no attention in other countries). Embarrassment or loss of face may be a reason for suicide in some cultures, while it may be irrelevant in others. Symptoms such as tremor, a common physical symptom and a sign of pathology in most cultures, may be advantageous in Mali, where ‘trembling hands’ is a sign of virility [15]. Heuristic models for psychiatric diagnosis The definition of disease, disorder or abnormality is a critical element for classification systems. There are several models for psychological abnormalities in the literature. A biological model defines abnormality using biological criteria; a statistical model defines it as deviation from the norm; a subjective discomfort model as suffering experi- 43 enced by an affected individual; a subjective value model defines it as what is viewed as undesirable for society. Because all these models are incomplete, Wakefield [16] proposed that the definition of abnormality requires both social and biological criteria. He proposed a ‘harmful dysfunction analysis’ as a model for developing meaningful diagnoses in psychiatry and psychology. This model uses a ‘Darwinian’ principle, of failure of systems to function as designed by natural selection, and was proposed to apply to both physical and mental diseases. Key elements of the model are, first, subjective value that a condition is harmful or undesirable and, secondly, objective identification of a malfunctioning internal mechanism [16]. This has stimulated lengthy, philosophical, epistemological and methodological debates [17]. KEY QUESTIONS RELATED TO ETHNICITY AND PSYCHOPATHOLOGY A critical issue is to examine whether or not symptoms and syndromes can be reliably elicited and recognized, not only as part of research collaborations launched to confirm the ‘universality’ of psychiatric syndromes and the reliability of structured diagnostic instruments, but in ‘real world’ day-to-day clinical practice. That the system is far from perfect in this particular instance can be deduced from a recent statement by the system’s pioneer, Robert Spitzer, quoted as saying that ‘to say that we’ve solved the reliability problem is just not true. It has been improved. But if you are in a situation with a general clinician, it’s certainly not very good’ [14]. Even the fidelity of clinical research interviews with field interviews using fully structured diagnostic interviews for case ascertainment are inconsistent, although substance disorders have been the most likely to achieve adequate ‘procedural validity’ compared to non-addictive disorders. World Health Organization (WHO) international studies These studies have provided strong support for the universal presence of major mental disorders such as depression and schizophrenia. In depression, the weight of somatic and affective dimensions and narrative context may differ from culture to culture [18]. For example, major depression is conceptualized differently in Native American populations, involving at least five illness categories [19]. In anxiety syndromes there is significant cross-cultural variation in type of specific fears as well as associated somatic, dissociative and affective symptoms [20]. Obviously, culture ‘colors’ these syndromes and their basic elements may not be elicited or recognized everywhere. A few syndromes have been designated as ‘culture-bound’, indicating their exclusive presence in some countries. Nevertheless, if proper training is provided and struc- © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 44 Javier I. Escobar & William A. Vega tured instruments are used to elicit the symptoms, an acceptable level of comparability is usually possible in international clinical and epidemiological studies [21]. WHO classifications and culture WHO endorses a universalistic view of psychiatric disorders. Curiously, in international settings, there seems to be much less preoccupation with cultural psychiatry in clinical practice than is the case in the United States. Thus, international classifications have been much less concerned about cross-cultural issues. There have been a few exceptions: the tenth edition of the International Classification of Diseases (ICD-10) incorporated an international psychiatric lexicon that contains a description of culture-bound syndromes as well as an international casebook [21]. Also, the more recent ICD-10 Diagnostic Criteria for Research included an appendix on crosscultural issues [21]. The contribution of epidemiology to cross-cultural diagnosis Comparative studies in the United States and abroad have supported the ‘universalistic’ view of psychiatric diagnosis by showing that major disorders can be elicited in many countries and various ethnic groups through the use of structured interviews, such as the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI). The WHO World Mental Health Surveys reported diagnostic data using population samples with rigorous epidemiological designs and reported wide international variability in rates of DSM-IV disorders and in related impairments, especially for drug dependence [22]. Similar population differences were reported in the United States. Two epidemiological studies showed lower prevalence rates for psychiatric disorders in Mexico-born Mexican Americans compared with non-Hispanics and that years in the United States influenced these trends [23,24]. This was particularly salient for substance use disorders, a finding validated with anonymous urine toxicology screening [25]. While instruments appeared to work well in these studies, it is not clear if these low rates were influenced by such factors as differential reporting of symptoms due to misunderstanding or social desirability, or non-equivalence of certain symptoms or syndromes. However, the prevalence rates in Mexico-born Mexican Americans were very similar to those found in Mexico City using the same instrument [26]. These results have been replicated in at least one other large national surveys in the United States [27]. A recently published study on American Indians [28] found that alcohol disorders and post-traumatic stress disorder (PTSD) were more common in American Indian populations compared to other populations. Interestingly, the prevalence of depression was low, a finding the authors attribute to cultural factors. Diagnoses of major depression were based on the endorsement of at least five of the nine major depressive episode symptoms and yielded low prevalence. Patients with disorders sought help primarily from traditional healers, not physicians. Diagnoses such as psychoses are excluded from studies of Native American populations because of cultural concerns (seeking of ‘visions’ is a trait traditionally nurtured in those cultures). Also, cognitive dysfunction elicited with the Mini Mental Status Examination could not be utilized in the Epidemiologic Catchment Area (ECA) study due to educational and linguistic issues [29]. Somatic presentations In most cultures, the presentation of personal/social ‘distress’ in the form of somatic complaints appears to be the norm [30]. Dominant cultural tendencies influence the expression of ‘proper’ behavioral displays for each society, reciprocally influenced by the culture of current medical practice [31]. Thus, patients tend to develop symptoms that are ‘medically correct’ (what doctors expect and understand) and cluster commonly into recognizable patterns. Moreover, a great majority of these patients present to primary care and a large proportion of them are found to have psychiatric disorders including substance abuse/ dependence [32,33]. Tien et al. [34] reported that high levels of unexplained physical symptoms predicted ‘extreme alcohol use’ in an epidemiological sample, and concluded that self-reported somatization symptoms could add to the detection of severe substance abuse. Because somatic presentations appear to be more common in developing societies, and the symptoms themselves may differ across cultures [31], they need to be incorporated in the diagnostic formulations. Diagnostic disparities A number of clinical reports have documented that clinicians are more likely to give a diagnosis of psychosis, or to prioritize signs of substance abuse over other primary disorders, in minority patients, particularly African Americans [35–37]. A recent study using a large data set in a mental health system found that clinicians in a large mental health system diagnose psychosis in African Americans and depression in Latinos disproportionately [38]. The reasons for this are unclear, and potentially include information variance, deficiencies in patient–clinician communication and inadequate diagnostic criteria. The frequent presentation of psychotic symptoms by certain ethnic groups with common mental disorders and medical conditions (e.g. Latinos and African Americans) contributes to diagnostic ambiguities and misdiagnoses, yet empirically supported guidelines to assist clinicians are not available [39]. © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 Cultural issues and psychiatric diagnosis DSM-IV’S CULTURAL APPENDIX The increased visibility and enhanced political voice of some minority psychiatrists within the American Psychiatric Association (APA) would eventually bring awareness on culture to the official diagnostic manual. In 1988 the APA appointed a task force, one of whose subcommittees addressed the area of cultural issues in psychiatric diagnosis. While a specific proposal for a ‘cultural axis’ never came forward, there were ambitious recommendations including a complementary cultural formulation, cultural statements in the introduction to manual, annotations under each diagnostic category and a glossary of culture-specific terms. However, the major piece related to culture in DSM-IV is a brief appendix placed at the end of the rather massive manual. This section outlines the relevance of culture and provides an exhaustive list of ‘culture bound syndromes’. Many of those entities included in the appendix are rare, uncommon conditions, some poorly defined and others that can be classified in areas of general psychopathology. As a result they have limited practical relevance as they are encountered infrequently by a majority of practicing psychiatrists in the United States and other countries. It is our impression that in its current state the appendix is of limited utility in the absence of additional technical information and supporting research to provide guidance to clinicians. Many of the general recommendations provided are based on anecdotal, ‘commonsense’ observations. They are, of necessity, very broad because inadequate research is available to develop guidelines for practitioners working with ethnically diverse patients. A major challenge is that given the heterogeneity of these groups, research is not easily generalized. On the biological side, there are only a few pharmacogenetic clues from recent research that appear to be practically relevant only to certain Asian American groups and we await research advances for other ethnic groups. Other than endorsing and promoting ‘cultural competency’ (a field which is struggling to define its clinical domain aside from language) the cultural appendix does not offer either an adequate framework or clinical guidelines for the scope of applications originally envisioned. Regrettably, the research envisioned as an essential step in implementing the cultural formulation into clinical practice has not been advanced adequately, resulting in inadequate empirical validation. RECOMMENDATIONS FOR DSM-V AND ICD-11 REGARDING CULTURAL AND ETHNIC ISSUES Beyond the general recommendations already made by Alarcon et al. [40], regarding culture/ethnicity issues in DSM V we wish to add the following caveats: 45 1 Cultural/ethnic issues have to be clearly defined in clear terms that lend themselves to operational definitions. 2 The ‘ethnicity’ concept has to be defined much more precisely. Demographic descriptors are needed that coincide with ethnic subgroup variations in prevalence of substance disorders and related patterns of patient presentation of disorders including beliefs and behaviors that have value for refining cultural aspects of DSMV. For example, Mexican Americans, Puerto Ricans, Cubans, South Americans and other Latino populations should not continue to be blended into a ‘Hispanic’ group for the sake of convenience, as research is showing significant differences among these groups in prevalence of DSM-IV disorders and use of services. Moreover, behavioral genetics research involving even one Latin American nationality of mixed historical ancestry (Indian, African and European) must contend with complex genetic heterogeneity. 3 Ethnicity can be characterized according to (a) the ethnic group to which that person most closely relates, (b) their ethnic ancestry, which may range from one to four categories, (c) the language spoken by their parents and (d) the language most commonly spoken at home. In analyses of ethnic influences on substance use symptoms and syndromes we recommend that these elements be entered as variables rather than one overarching ‘ethnic group’ variable. In this regard, there is a need for nationally representative surveys that are either larger than those conducted so far or over-sample populations of interest. 4 Recommendations should be research-based and testable. The necessary research in this area should be articulated in a more practical, hierarchical fashion, so that these goals can become attainable in stages. 5 At the current level of knowledge, a well-defined research program is needed to support and justify a cultural axis with practical utility or scientific validation. 6 An effort should be made to provide crisp, practical examples, including illustrative clinical vignettes in key areas. The use of brief, precise, illustrative appendices may be helpful. 7 Also, meaningful cultural annotations and a glossary of cultural terms that are applicable in daily clinical practice and not limited to less frequently encountered syndromes (culture-bound) would be highly desirable. Of high value for practitioners would be explanations of terms used in different cultures to express signs and symptoms of specific DSM disorders and information about cultural assumptions regarding substance use problems and related behaviors and impairments. 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Beyond the Funhouse mirrors: research agenda on culture and psychiatric diagnosis. In: Kupfer D., First M. B., Regier D. A., editors. A Research Agenda for DSMV, pp. 219–81. Washington, DC: American Psychiatric Press; 2003. © 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101 (Suppl. 1), 40–47 Understanding Adolescent Substance Abuse: Prevalence, Risk Factors, and Clinical Implications Jason J. Burrow-Sanchez From a developmental perspective, adolescence is a time of gaining independence, experimentation, and taking risks. One area of experimentation associated with adolescence is substance use. For counselors working with adolescents who use or abuse substances, or both, it is important to understand the scope of the problem and ways to effectively work with this population. This article provides counselors with current information on adolescent substance abuse and suggestions for clinical work. and the data from the MTF provide a reasonable picture of the level of substance use for adolescents across the United States. Data from the 2002 MTF report, based on a nationally representative sample of more than 43,000 adolescents in the 8th, 10th, and 12th grades, are presented in Figures 1 and 2. As can be seen in the figures, alcohol, cigarettes, and marijuana were the most frequently reported drugs used by adolescents in each grade. More specifically, Figure 1 presents data for adolescents who reported at least a one-time use of a specific drug during their lifetime. The data on lifetime use provide an estimate of the number of adolescents who have experimented with a particular substance. Figure 2 presents data for adolescents who reported using a specific substance in the past 30 days. The data for the past 30 days provide an estimate of the number of frequent users of a particular substance. Alcohol was reported as being the most used substance across all adolescents in the sample. For example, more than 70% of adolescents in the 12th grade reported having used alcohol in their lifetime, and Adolescence is an important developmental period for young people. They are faced with a number of challenges, including gaining a greater sense of independence, strengthening relationships with peer groups, and planning future career goals, during this period of their lives. In addition, one of the many challenges that adolescents face in the United States is the decision about whether to use substances. Although some experimentation with substances is typical for many young people, fortunately most adolescents who experiment with drugs do not go on to develop substance abuse problems later in life (Newcomb, 1995; Shelder & Block, 1990). A small portion of adolescents, however, do develop problems with substances that substantially affect their development and future adult lives. The purpose of this article is to describe the prevalence of adolescent substance use, the associated risk of developing a substance abuse problem and the protective factors that militate against developing this type of problem, and the four key clinical areas for counselors to consider when working with adolescents with substance abuse problems. For purposes of this article, the terms substances and drugs are used interchangeably. Prevalence of Adolescent Substance Use and Abuse Most adolescents are exposed to substances (e.g., alcohol, marijuana) at some point in their young lives and subsequently make decisions about their use of them. One important source of information on the prevalence of adolescent substance use comes from the Monitoring the Future National Results on Adolescent Drug Use: Overview of Findings, 2002 (MTF) study (Johnston, O’Malley, & Bachman, 2003). MTF is a longitudinal research project that has consistently collected data on the reported use of substances in national samples of adolescents since 1975, FIGURE 1 Percentage of 8th-, 10th-, and 12th-Grade Students Reporting Lifetime Use of Various Substances Note. Data from Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2002 (NIH Publication No. 03-5374) by L. D. Johnston, P. M. O’Malley, and J. G. Bachman, 2003, Bethesda, MD: National Institute on Drug Abuse. Jason J. Burrow-Sanchez, Department of Educational Psychology, University of Utah. Correspondence concerning this article should be addressed to Jason J. Burrow-Sanchez, Department of Educational Psychology, University of Utah, 1705 Campus Center Drive, Room 327, Salt Lake City, UT 84112-9255 (e-mail: sanchez_j@ed.utah.edu). © 2006 by the American Counseling Association. All rights reserved. Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 283 Burrow-Sanchez FIGURE 2 Percentage of 8th-, 10th-, and 12th-Grade Students Reporting Past 30-Day Use of Various Substances Note. Data from Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2002 (NIH Publication No. 03-5374) by L. D. Johnston, P. M. O’Malley, and J. G. Bachman, 2003, Bethesda, MD: National Institute on Drug Abuse. almost 50% reported using alcohol in the past month. The above data clearly indicate that many adolescents report an experimental use of certain substances; however, a much smaller percentage report frequent use of substances (Johnston et al., 2003). Smaller percentages of adolescents report current use or abuse, or both, of substances as indicated by data from the National Survey on Drug Use and Health (NSDUH; Substance Abuse and Mental Health Administration [SAMHSA], 2003b). The 2002 NSDUH included a sample of 68,126 individuals ages 12 and older in the United States, and data from this survey are used to provide national prevalence estimates on drug-related behaviors. For example, 11.6% of adolescents ages 12 to 17 years were estimated to be current (i.e., use within the past month) illicit drug users in 2002 (SAMHSA, 2003b). Furthermore, 8.9% of this age group could be classified with a diagnosis of substance abuse or dependence based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). In addition, the estimated rates of current illicit drug use for adolescents ages 12 to 17 years varied according to race/ethnicity: White (12.6%), African American (10%), American Indian/Alaskan Native (20.9%), Asian (4.8%), Hispanic (10.%), and two or more races (12.5%). In sum, the data from the NSDUH reveal that in 2002 more than 11% of the adolescent population was using drugs on a regular basis and that almost 9% met the diagnostic criteria for a substance use disorder. Some of the major theoretical and practical reasons that roughly 10% of the adolescent population may transition from experimental use of substances to more frequent use or abuse, or both, are discussed in the following section. The Development of Substance Abuse Problems There are many theories regarding the reasons why certain individuals develop problems with substances. Popular theories include a range of diverse views such as 12-step-ori- 284 ented approaches, psychoanalytic, behavioral/cognitive–behavioral, and family systems (see Leeds & Morgenstern, 2003; McCrady, Epstein, & Sell, 2003; Rotgers, 2003; Wallace, 2003). For example, one of the more popular theories about the development and maintenance of substance abuse is cognitive–behavioral. Cognitive–behavioral theory combines learning theory (e.g., classical, operant), cognition, and social learning (e.g., modeling; Rotgers, 2003). Generally, cognitive–behavioral theorists believe that substance abuse originates in an interaction between the person and his or her environment. Regarding adolescents, when they are faced with stressful situations (e.g., argument with a parent), they may manage these situations by using relevant coping skills. Most adolescents develop and use a range of healthy coping skills (e.g., talking it out, calming down); however, others possess a more limited set of coping behaviors, some of them unhealthy (e.g., using drugs), to manage the stressful situation. Thus, cognitive–behavioral therapists typically work with adolescents to increase their coping skills in order to successfully manage difficult situations. Other theoretical approaches are briefly discussed in the Treatment Approaches for Adolescent Substance Abuse section later in the article. Regardless of the specific theory about substance abuse, most researchers agree on the influence of risk and protective factors related to the development of a substance abuse problem in children and adolescents (Benman, 1995; Clayton, 1992; Hawkins, Catalano, & Miller, 1992; Weinburg, 2001). A risk factor is typically defined as anything that increases the probability of a person using drugs, whereas a protective factor is anything that protects or decreases the probability of a person using drugs (Clayton, 1992). For example, a risk factor for substance abuse may be having a parent with a drug abuse problem, and a protective factor may be having high academic achievement in school. Risk and protective factors are found in all contexts (e.g., school, family, peers) of an adolescent’s life and are mediated and moderated by variables such as age, gender, and ethnicity (Hawkins et al., 1992; Moon, Hecht, Jackson, & Spellers, 1999; Vega & Gil, 1998). In general, the higher number of risk factors present for a given adolescent, the more at risk he or she is for developing substance abuse problems. Risk Factors Hawkins et al. (1992), in their seminal article, defined two categories of risk factors for adolescents: contextual (e.g., drug laws, availability of drugs) and individual (e.g., temperament, family practices). Two influential contextual risk factors are current drug laws and the availability of substances. For example, lower legal drinking ages and lower taxation of alcohol are risk factors for the potential use and abuse of alcohol in a given geographical region. When the legal age of drinking is increased, fewer alcohol-related traffic incidents are reported (Saffer & Grossman, 1987). Similarly, a higher taxation of alcohol in a geographic area is related to overall decreases in consumption (Levy & Sheflin, 1985; Saffer & Grossman, 1987). Another influential con- Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 Understanding Adolescent Substance Abuse textual risk factor is availability of drugs. The availability of drugs will vary across communities, partly related to the laws of the geographic region and the social norms of that area regarding drug use. In general, the more available drugs are in a given community, the more likely it is that adolescents will report using them (Gorsuch & Butler, 1976; Maddahian, Newcomb, & Bentler, 1988). For example, data from the NSDUH provide estimates that more than 50% of adolescents ages 12 to 17 years consider marijuana fairly or very easy to acquire in their communities (SAMHSA, 2003b). Furthermore, marijuana is the third most common drug used by adolescents in the United States (see Figures 1 & 2). The risk factors described above are by no means exhaustive, and additional contextual factors (e.g., poverty, neighborhood conditions, cultural norms about drug use) also need to be considered when working with adolescents. The second category of risk factors defined by Hawkins et al. (1992) includes individual risk factors. Individual risk factors are such things as experiencing problem behaviors from an early age (e.g., aggressiveness, negative moods and withdrawal, impulsivity), having a coexisting mental health diagnosis (e.g., conduct disorder, attention deficit hyperactivity disorder [ADHD], depression) or a learning disorder, problems in the family (e.g., low bonding to parent, parent abuse of substances, poor parenting practices), problems in school (e.g., low academic achievement, low commitment to school), association with drug-using peers, and early initial use of drugs (Benman, 1995; Hawkins et al., 1992; Weinburg, 2001). Two influential individual risk factors for adolescents are having a family member who abuses substances and associating with drug-using peers. For example, the risk of using drugs increases when an adolescent has a parent or older sibling who uses drugs (Brook, Whiteman, Gordon, & Brook, 1990; Johnson, Schoutz, & Locke, 1984). In addition, adolescents who associate with drug-using peers have consistently been found to have higher levels of drug use (Barnes & Welte, 1986; Kandel & Andrews, 1987; Weber, Graham, Hansen, Flay, & Johnston, 1989); therefore, when an adolescent associates with other people (e.g., family member, peer) who use drugs, his or her risk of substance use increases. Although the risk factors described increase the probability of an adolescent using or abusing substances, protective factors act to buffer the adolescent against such risks. Protective Factors As previously noted, protective factors decrease the probability that an individual will use or develop problems with drugs. Even though peer groups become more important during adolescence, parents still have much influence on adolescent behavior. For example, parental attitudes toward drug use are related to adolescents’ drug use behavior (Hawkins et al., 1992). Recent data from the NSDUH indicate that adolescents who were 12 to 17 years old and who were less likely to use drugs also perceived that their parents would strongly disapprove of drug use (SAMHSA, 2003b). Journal of Counseling & Development ■ Summer 2006 ■ More specifically, of the 89.1% of adolescents who perceived that their parents would strongly disapprove of their using marijuana, only 5.5% had used it in the past month (SAMHSA, 2003b). These data, therefore, suggest that parents’ views of drug use are likely to influence children’s drug use behavior. Additional examples of protective factors include good mental health, exposure to effective parenting practices (e.g., high monitoring, consistency, clear limits), association with prosocial peers, high achievement in school, good problem-solving skills, and strong connections to positive community organizations (e.g., church, youth groups; Glantz & Sloboda, 1999; Hawkins et al., 1992). Protective factors act to increase the adolescent’s ability to resist pressures to use or abuse substances, or both. Although no single protective factor has been shown to prevent drug use, the higher the quantity and quality of protective factors that are present, the stronger effect they will have on limiting drug use in adolescents (Newcomb, 1995). The remainder of the article addresses four key clinical areas for counselors to consider when working with adolescents who have substance abuse problems. Four Key Clinical Areas for Counselors This section provides a description of four key clinical areas that are important for counselors to consider when working with adolescents who use or abuse substances, or both. In each area, the relevant research is cited for further review and the counselor is provided with ideas and suggestions for clinical practice. The four key clinical areas are (a) establishing a working relationship, (b) assessing the severity of the problem, (c) identifying a treatment approach, and (d) acknowledging the potential for relapse. Establishing a Working Relationship With the Adolescent One of the potential difficulties in working with adolescents with substance abuse problems is that they are typically reluctant to talk openly about their drug abuse and will tend to underreport it (Winters, Stinchfield, Henly, & Schwartz, 1992). In most cases, adolescents with substance abuse problems are referred to counselors by juvenile justice courts, schools, parents, or some other entity (Muck et al., 2001). By the time adolescents reach a counselor’s office for substance abuse concerns, they most likely feel (or concretely know) they are in trouble with someone (e.g., parents, school officials, probation officer). They may also anticipate that adults in positions of authority (e.g., parents, counselors) will tell them such things as “You must stop using immediately” and “This is a bad thing you are doing.” Therefore, it is not unreasonable for adolescents with substance abuse problems to approach the counseling situation with a high degree of resistance. Working with the adolescent’s resistance (not against it) is one of the most important first steps in building a therapeutic relationship with the young client (Miller & Rollnick, Volume 84 285 Burrow-Sanchez 2002). Building a sense of trust and understanding early in the relationship will help to reduce the adolescent’s resistance to talking about his or her substance use. One particular strategy is to initiate a discussion with the adolescent about what will be done with the information discussed in treatment. For example, many adolescents will be apprehensive about discussing their drug use history because they fear that the information will be given to others (e.g., parents, probation officers). Initiating a discussion about the limits of confidentiality and what will be done with the information they provide can go a long way toward lowering adolescents’ resistance to talking about their substance use in an initial session. A second strategy a counselor can use to lower resistance is to listen for information about challenges that the adolescent is currently facing (e.g., mandated treatment, problems at home, school) and to use the skills of reflection to echo his or her statements in a way that communicates the counselor’s understanding (e.g., empathy) of his or her situation (Miller & Rollnick, 2002). The use of this technique allows the adolescent to feel heard by the counselor and typically leads to greater exploration of the issue at hand. Counselors will likely find that adolescents initially respond better in therapy when the environment is supportive and nonthreatening and the emphasis is on understanding the problem instead of placing blame on the adolescent (Baer & Peterson, 2002). Lowering adolescents’ resistance allows them to communicate more openly about their substance use and leads to a more accurate assessment of the problem. Many of the strategies for lowering resistance in substance abuse counseling are drawn from the concepts and techniques of Motivational Interviewing (MI) developed by Miller and Rollnick (2002). MI is a brief counseling intervention designed to reduce a client’s ambivalence toward change while increasing his or her motivation to engage in the behaviorchange process. One of the central premises of MI is that clients come to the counseling session with various levels of motivation in regard to behavior change. The level of client motivation is thought to be related to one of five stages of change suggested by Prochaska, DiClemente, and Norcross (1992). From a MI perspective, the counselor works collaboratively with a client to address his or her ambivalence and reduces barriers toward behavior change. Simultaneously, the counselor reinforces the client’s behaviors that are congruent with the desired behavior change. In addition, it is important for the client to feel understood and supported by the counselor within the context of the working relationship in order for MI to be most effective. Counseling strategies in MI are largely drawn from a clientcentered perspective and include skills such as active listening, reflection, and reframing. A manualized treatment, based on MI, called Motivational Enhancement Therapy (MET) was evaluated in a large-scale national study of alcohol treatments (Project Match Research Group, 1997). The interested counselor can obtain a copy of the MET manual 286 from the National Institute on Alcohol Abuse and Alcoholism (see Miller, Zweben, DiClemente, & Rychtarik, 1995). More detailed information on the use of MI with adolescents can be found in Baer and Peterson (2002). Assessing the Severity of the Substance Abuse Problem Understanding the level of the adolescent’s drug use or dependence will assist the counselor in determining the extent of the problem and what type of treatment will be most appropriate (e.g., outpatient, inpatient treatment). For example, adolescents with some experimental use of substances will require a lower level of treatment (e.g., psychoeducation) compared with an adolescent with a long-standing drug abuse problem (e.g., intensive outpatient, inpatient). It is important for the counselor to keep in mind that some level of experimentation with substances is highly likely for many adolescents during their development, as can be seen from the statistics on drug use presented earlier (Johnston et al., 2003). However, the counselor will need to make a distinction between experimental use and abuse/dependency in order to match the appropriate level of treatment needed. Winters (2001) recommended considering adolescent substance use along a continuum of problem severity, with six categories anchored with abstinence on one end; then followed by the categories of experimental use, early abuse, abuse, and dependence; and recovery on the opposite end. The recovery category includes adolescents who have relapsed and gone through each of the above categories more than once (Winters, 2001). When assessing the adolescent’s history of substance use, it is important for counselors to keep in mind that clients initially tend to underreport their substance use because of some of the resistance issues previously discussed; therefore, an assessment that takes place in the context of a working relationship with low client resistance (even if the relationship is new) will likely produce a more accurate picture of the adolescent’s level of substance use. Specific content areas for counselors to assess include the types of drugs being used by the adolescent and the frequency of use (e.g., daily, weekly, monthly). For example, counselors should identify the adolescent’s preferred drug (e.g., marijuana) as well as any other drugs (e.g., alcohol, methamphetamine) that are part of the problem. In addition, they should establish the initial onset of drug use by the adolescent and relevant time lines for all drugs used. In general, an earlier initial use of substances predicts more problems with substances in the future (Anthony & Petronis, 1995; Hawkins et al., 1992). One of the instruments that has been used for research purposes and can be applied in clinical settings is the Timeline Follow Back (TLFB; Sobell & Sobell, 1992). This instrument was originally developed to be used with adults regarding their alcohol use but has been adapted for use with adolescents (Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004; Waldron, Slesnick, Brody, Turner, & Peterson, 2001). It can be administered as a Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 Understanding Adolescent Substance Abuse semistructured interview, a paper-and-pencil measure, or on a computer and is available in several languages (Sobell & Sobell, 2003). The TLFB is designed to retrospectively record an adolescent’s drug use over a specified period of time (e.g., past 30–90 days). Administration time depends on the length of time probed; however, the typical administration time ranges from 10 to 30 minutes. Scoring time is minimal, and scoring can be completed by hand or computer. The counselor can tailor the TLFB to record the levels of use for the most relevant drugs and time periods for a specific adolescent. The TLFB can also be administered at different points in time (e.g., pretreatment, posttreatment) to assess for any change in levels of drug use. In addition, the use of an instrument such as the TLFB will likely increase the accuracy of recall, given that relevant memory cues (e.g., birthday, holidays) for the adolescent can be indicated on the time line. In sum, understanding the types of drugs being used and the frequency of use will help the counselor obtain a clearer picture of the actual drug problem. Two additional areas the counselor should assess include the adolescent’s reasons for drug use and the existence of any co-occurring disorders. For example, the counselor can ask the adolescent about reasons (e.g., coping with stress, self-medicating for depression) and any negative consequences (e.g., problems with law enforcement, physical symptoms) of drug use. Assessing this area with the adolescent will help illuminate both the positive and negative consequences of drug use. Exploring the consequences of drug use with the adolescent can assist him or her in understanding the pros and cons of changing problem behavior or of not changing the behavior (Miller & Rollnick, 2002). The counselor should also assess for the presence of any cooccurring disorders, including, but not limited to, conduct disorder, ADHD, depression, anxiety, and learning disorders (Riggs, 2003; Weinburg, 2001). Greenbaum, Foster-Johnson, and Petrila (1996) estimated that approximately 50% of adolescents who abuse substances have a co-occurring disorder; therefore, screening for the presence of any cooccurring disorders should always be part of the assessment process for substance abuse. In addition, counselors may have access to outside sources of information (e.g., parents, teachers, probation officer) regarding the adolescent’s history of drug use. As needed, outside information should be gathered with the full awareness of the adolescent in order to promote trust and lower resistance in the relationship. Screening instruments can also be used to obtain more information about an adolescent’s level of substance use and related problem behaviors (Winters, 2001). Initially, some adolescents may be more comfortable answering questions on a paper-and-pencil measure rather than talking to a counselor about their drug use. There are many screening instruments available for adolescents that can be used as a more objective assessment of a potential drug problem and related areas. Screening instruments are typically self- Journal of Counseling & Development ■ Summer 2006 ■ report, and the number of items range from fewer than 20 to more than 100. Some instruments are designed to focus on a specific drug (e.g., alcohol); others are more global and cover a wide range of substances and potential problem areas (e.g., mental/physical health, family relationships). For example, the Problem-Oriented Screening Instrument (POSIT; Rahdert, 1991) is a 139-item measure that was developed to screen for problems in 10 specific areas, including substance abuse, mental/physical health, family relationships, and peer relations, among others. The POSIT is designed to be used with adolescents from 12 to 19 years of age and can be easily administered and scored by a range of professionals in a variety of settings (e.g., schools, medical clinics, drug treatment programs). The questions are designed to be answered in a “yes” or “no” format. It can be administered as a paper-andpencil measure or on a computer. Administration time for the paper-and-pencil version is approximately 20 to 25 minutes, and hand scoring takes about 2 minutes. The POSIT, which can be obtained from the National Clearinghouse for Alcohol and Drug Information, is available both in English and Spanish versions. The use of screening instruments, such as the POSIT, provides the counselor with more objective assessment information and indicates other potential problem areas (e.g., family/peer relations). Decisions about the selection of an instrument will depend on many factors, typically including (a) type of information needed; (b) adequate psychometric properties; (c) appropriate norms; (d) length; and (e) ease of use, scoring, and so forth. The counselor will also need to be familiar with the technical aspects (e.g., proper administration, norms, validity) of any screening instrument prior to its use. The length of this article prohibits a detailed review of adolescent substance abuse screening instruments; however, the interested counselor is referred to other sources (see Winters, 2001; Winters, Latimer, & Stinchfield, 2001) for more specific information on this topic. In sum, accurately assessing the scope of the problem will assist the counselor in determining the severity of substance use or abuse and the need for treatment. Treatment Approaches for Adolescent Substance Abuse In 2002, more than 156,000 adolescents between the ages of 12 to 17 years (8.3% of all treatment admissions) were admitted to substance abuse treatment facilities in the United States (SAMHSA, 2004). The three types of approaches most frequently used for substance abuse treatment are outpatient, residential, and inpatient. For example, 74% of all treatment facilities offer regular outpatient services, whereas 44% offer intensive outpatient services (SAMHSA, 2003a). In contrast, only 26% of all facilities offer residential treatment, and 4% offer inpatient treatment in a hospital. In addition, 37% of all substance abuse treatment facilities offer specialized services for adolescents (SAMHSA, 2003a). Volume 84 287 Burrow-Sanchez For adolescents, the most common substance treatment models identified by Muck et al. (2001) are 12-step, cognitive– behavioral, family-based, and therapeutic communities models. Twelve-step approaches, also referred to as the Minnesota Model or Alcoholics Anonymous (AA), generally view the addiction to substances as a disease; therefore, individuals must consistently manage their health behavior (i.e., sobriety) during the remainder of their lives and strive toward maintaining abstinence from substances (Winters, Stinchfield, Opland, Weller, & Latimer, 2000). In contrast, cognitive–behavioral approaches view substance abuse from a learning perspective and believe that individuals can learn ways (e.g., coping skills) to make changes in their lives (Monti & Rohsenow, 2003; Rotgers, 2003). Family-based approaches, also referred to as family systems, view substance abuse problems from the contexts of the overall immediate family system, extended family system (e.g., child–grandparent), and family subsystems (e.g., child–parent, siblings; Ozechowski & Liddle, 2000). Thus, family-based approaches treat individuals within the context of the family system and use theory and strategy from family therapy models such as multisystemic, structural, strategic, functional, and cognitive–behavioral (Liddle & Rowe, 2004; Muck et al., 2001). Finally, therapeutic communities are generally long-term (up to 2 years) residential treatment facilities that view individuals with substance abuse problems as experiencing a disruption in normal psychosocial development (Jainchill, 1997; Muck et al., 2001). The goal of therapeutic communities is to provide a safe and highly structured environment for the individual to develop the necessary personal and social skills needed to function in daily life without the use of substances (Jainchill, 1997). All of the above treatment models have been tested, with varying degrees of success, for their efficacy with adolescents (Deas & Thomas, 2001; Muck et al., 2001; Williams & Chang, 2000). In a recent comprehensive review of the outcome of substance abuse treatment with adolescents by Williams and Chang, the authors were not able to determine the comparative effectiveness of different treatment types because of “insufficient evidence” in the literature. They were, however, able to determine that outpatient family therapy currently appears to be more effective than other forms of outpatient treatment for adolescents (Williams & Chang, 2000). In another review of adolescent treatment research, Deas and Thomas stated that “it is premature to conclude that one modality is more effective than another” (p. 187). They did suggest that family-based and cognitive–behavioral treatments seem to be promising approaches for treating adolescent substance abuse; however, more controlled research is needed (Deas & Thomas, 2001). As these reviews suggest, there is currently no definitive answer about what type of treatment works best to treat adolescent substance abuse; however, one can conclude from the research that treatment is more effective than no treatment for adolescents, involving the adolescents’ families in the treatment process is important for success, and aftercare 288 programs should be available to the adolescent (Williams & Chang, 2000). Therefore, counselors are encouraged to use treatments that are based on evidence, include supportive others (e.g., family, relatives), and provide support to adolescents to minimize the potential for relapse. Acknowledging the Potential for Relapse It is not safe to assume that adolescents with a substance problem will completely recover and abstain from substances after treatment services terminate. In fact, there is a high rate of relapse for adolescents who complete treatment programs (Pagliaro & Pagliaro, 1996; Williams & Chang, 2000). For example, it is estimated that approximately 50% of adolescents will relapse within the first 3 months after the completion of treatment (Pagliaro & Pagliaro, 1996). Williams and Chang found that the posttreatment variables most related to successful treatment outcome included participation in aftercare and social support from others (e.g., parents, peers). Given these findings, counselors are encouraged to discuss the potential for relapse with the adolescent and the importance of attending aftercare services to support the gains made in treatment. Examples of aftercare include follow-up appointments with the treatment counselor over a specified period of time (e.g., 3 to 12 months) and attendance in peer support groups offered by community agencies or school districts (Gonet, 1994). Adolescents may also find support when participating in self-help groups such as AA or Narcotics Anonymous (McCrady, Horvath, & Delany, 2003). Some adolescents will likely find that participation in aftercare services provides the necessary support they need to cope with a relapse; however, the research in this area is still limited (Williams & Chang, 2000). The skills to prevent relapse can also be integrated into the treatment process to assist the adolescent in managing slips and relapses. A slip is generally defined as a brief period of temporary substance use, whereas a relapse is defined as full-blown return to a previous drug-using behavior (Fisher & Harrison, 2000). The prevention of relapse from a cognitive– behavioral view generally teaches individuals how to identify potential high-risk relapse situations, use appropriate coping skills for such situations, and effectively manage times when slips occur (Monti & Rohsenow, 2003; Witkiewitz & Marlatt, 2004). For example, coping-skills treatment approaches teach individuals how to minimize the effect of a slip when it occurs so that it will not develop into a complete relapse (i.e., the previous drug-using behavior; Monti & Rohsenow, 2003). Therefore, given the high likelihood that many adolescents will relapse after the completion of treatment, counselors are encouraged to address the issues of aftercare and relapse prevention in their clinical work with clients. Summary On the basis of the current research, there is little doubt that many adolescents experiment with and use drugs in their Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 Understanding Adolescent Substance Abuse schools and communities (Johnston et al., 2003). From a developmental perspective, adolescence is a time of gaining independence, experimentation, and taking risks. One area of experimentation associated with adolescence is substance use. Fortunately, only a small percentage of adolescents who experiment with substances go on to develop more severe problems (Newcomb, 1995; Shelder & Block, 1990). Certain risk factors are related to the development of substance abuse problems in adolescents, whereas certain protective factors provide a buffer against drug use and abuse (Benman, 1995; Hawkins et al., 1992; Newcomb, 1995; Weinburg, 2001). In addition, four key clinical areas for counselors to consider when working with adolescents with substance abuse problems are establishing a strong working relationship, accurately assessing the severity of the problem, identifying and understanding the major treatment approaches, and acknowledging the potential for relapse. Finally, it is especially important for counselors with limited training in substance abuse to familiarize themselves with the clinical areas mentioned above. Counselors who have the necessary education and training will be better equipped to serve the growing numbers of adolescents with substance abuse problems in the United States. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anthony, J. C., & Petronis, K. R. (1995). Early-onset drug use and risk of later drug problems. Drug & Alcohol Dependence, 40, 9–15. Baer, J. S., & Peterson, P. L. (2002). Motivational Interviewing with adolescents and young adults. In W. R. Miller & S. Rollnick (Eds.), Motivational Interviewing: Preparing people for change (2nd ed., pp. 320–332). New York: Guilford Press. Barnes, G. M., & Welte, J. W. (1986). Patterns and predictors of alcohol use among 7–12th grade students in New York State. Journal of Studies on Alcohol, 47, 53–62. Benman, D. S. (1995). Risk factors leading to adolescent substance abuse. Adolescence, 30, 201–208. Brook, J. S., Whiteman, M., Gordon, A. S., & Brook, D. W. (1990). The role of older brothers in younger brothers’ drug use viewed in the context of parent and peer influences. Journal of Genetic Psychology, 151, 59–75. Clayton, R. R. (1992). Transitions in drug use: Risk and protective factors. In M. Glantz & R. Pickens (Eds.), Vulnerability to drug abuse (pp. 15–51). Washington, DC: American Psychological Association. Deas, D., & Thomas, S. E. (2001). An overview of controlled studies of adolescent substance abuse treatment. The American Journal on Addictions, 10, 178–189. Fisher, G. L., & Harrison, T. C. (2000). Substance abuse: Information for school counselors, social workers, therapists, and counselors. Needham Heights, MA: Allyn & Bacon. Glantz, M. D., & Sloboda, Z. (1999). Analysis and reconceptualization of resilience. In M. Glantz & J. Johnson (Eds.), Resilience and development: Positive life adaptations (pp. 109–126). NewYork: Kluwer Academic/Plenum. Journal of Counseling & Development ■ Summer 2006 ■ Gonet, M. M. (1994). Counseling the adolescent substance abuser: School-based intervention and prevention. Thousand Oaks, CA: Sage. Gorsuch, R. L., & Butler, M. C. (1976). Initial drug abuse: A review of predisposing social psychological factors. Psychological Bulletin, 83, 120–137. Greenbaum, P. E., Foster-Johnson, L., & Petrila, A. (1996). Cooccurring addictive and mental disorders among adolescents: Prevalence research and future directions. American Journal of Orthopsychiatry, 66, 52–60. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64–105. Jainchill, N. (1997). Therapeutic communities for adolescents: The same and not the same. In G. DeLeon (Ed.), Community as method: Therapeutic communities for special populations and special settings (pp. 161–177). New York: Praeger. Johnson, G. M., Schoutz, F. C., & Locke, T. P. (1984). Relationships between adolescent drug use and parental drug behaviors. Adolescence, 19, 295–299. Johnston, L. D., O’Malley, P. M., & Bachman, J. G. (2003). Monitoring the future national results on adolescent drug use: Overview of key findings, 2002 (NIH Publication No. 03-5374). Bethesda, MD: National Institute on Drug Abuse. Kandel, D. B., & Andrews, K. (1987). Processes of adolescent socialization by parents and peers. International Journal of the Addictions, 22, 319–342. Leeds, J., & Morgenstern, J. (2003). Psychoanalytic theories of substance abuse. In F. Rotgers, J. Morgenstern, & S. T. Walters (Eds.), Treating substance abuse: Theory and technique (pp. 67–81). New York: Guilford Press. Levy, D., & Sheflin, N. (1985). The demand for alcoholic beverages: An aggregate time-series analysis. Journal of Public Policy and Marketing, 4, 47–54. Liddle, H. A., & Rowe, C. L. (2004). Advances in family therapy research: Bridging gaps and expanding frontiers. In M. P. Nichols & R. C. Schwartz (Eds.), Family therapy: Concepts and methods (6th ed., pp. 395–435). Boston: Allyn & Bacon. Liddle, H. A., Rowe, C. L., Dakof, G. A., Ungaro, R. A., & Henderson, C. E. (2004). Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs, 36, 49–63. Maddahian, E., Newcomb, M. D., & Bentler, P. M. (1988). Adolescent drug use and intention to use drugs: Concurrent and longitudinal analyses of four ethnic groups. Addictive Behaviors, 13, 191–195. McCrady, B. S., Epstein, E. E., & Sell, R. D. (2003). Theoretical bases of family approaches to substance abuse treatment. In F. Rotgers, J. Morgenstern, & S. T. Walters (Eds.), Treating substance abuse: Theory and technique (pp. 112–139). New York: Guilford Press. McCrady, B. S., Horvath, A. T., & Delany, S. I. (2003). Self-help groups. In R. H. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (3rd ed., pp. 165–187). Boston: Allyn & Bacon. Volume 84 289 Burrow-Sanchez Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1995). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Vol. 2, Project MATCH Monograph Series). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Monti, P. M., & Rohsenow, D. J. (2003). Coping skills training and cue exposure treatment. In R. H. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (3rd ed., pp. 165–187). Boston: Allyn & Bacon. Moon, D., Hecht, M., Jackson, K., & Spellers, R. (1999). Ethnic and gender differences and similarities in adolescent drug use and refusals of drug offers. Substance Use and Misuse, 34, 1059–1083. Muck, R., Zempolich, K. A., Titus, J. C., Fishman, M., Godley, M. D., & Schwebel, R. (2001). An overview of the effectiveness of adolescent substance abuse treatment models. Youth & Society, 33, 143–168. Newcomb, M. D. (1995). Identifying high-risk youth: Prevalence and patterns of adolescent drug abuse. In E. Rahdert & D. Czechowicz (Eds.), Adolescent drug abuse: Clinical assessment and therapeutic interventions (NIDA Research Monograph 156, pp. 7–38). Rockville, MD: U.S. Department of Health and Human Services. Ozechowski, T. J., & Liddle, H. A. (2000). Family-based therapy for adolescent drug use: Knowns and unknowns. Clinical and Family Psychology Review, 3, 269–298. Pagliaro, A. M., & Pagliaro, L. A. (1996). Substance use among children and adolescents. New York: Wiley. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behavior. American Psychologist, 47, 1102–1114. Project Match Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29. Rahdert, E. (Ed.). (1991). The adolescent assessment/referral system manual (DHHS Publication No. ADM 91-1735). Rockville, MD: National Institute on Drug Abuse. Riggs, P. D. (2003). Treating adolescents for substance abuse and comorbid psychiatric disorders. NIDA Science and Practice Perspectives, 2, 18–28. Rotgers, F. (2003). Cognitive-behavioral theories of substance abuse. In F. Rotgers, J. Morgenstern, & S. T. Walters (Eds.), Treating substance abuse: Theory and technique (pp. 166–189). New York: Guilford Press. Saffer, H., & Grossman, M. (1987). Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Journal of Legal Studies, 16, 351–374. Shelder, J., & Block, J. (1990). Adolescent drug use and psychological health: A longitudinal inquiry. American Psychologist, 45, 612–630. Sobell, L. C., & Sobell, M. B. (1992). Timeline Follow-Back. In R. Litten & J. Allen (Eds.), Measuring alcohol consumption (pp. 41–72). Totowa, NJ: Humana Press. 290 Sobell, L. C., & Sobell, M. B. (Eds.). (2003). Alcohol consumption measures (2nd ed.). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Substance Abuse and Mental Health Administration. (2003a). National survey of substance abuse treatment services (NSSATS): 2002. Data on substance abuse treatment facilities (DASIS Series: S-19, DHHS Publication No. SMA 03-3777). Rockville, MD: Substance Abuse and Mental Health Administration, Office of Applied Studies. Substance Abuse and Mental Health Administration. (2003b). Results from the 2002 national survey on drug use and health: National findings (NHSDA Series H-22, DHHS Publication No. SMA 03–3836). Rockville, MD: Substance Abuse and Mental Health Administration, Office of Applied Studies. Substance Abuse and Mental Health Administration. (2004). Treatment episode data set (TEDS): 1992–2002. National admissions to substance abuse treatment services (DASIS Series: S-23, DHHS Publication No. SMA 04-3965). Rockville, MD: Substance Abuse and Mental Health Administration, Office of Applied Statistics. Vega, W. A., & Gil, A. G. (1998). Drug use and ethnicity in early adolescence. New York: Plenum Press. Waldron, H. B., Slesnick, N., Brody, J. L., Turner, C. W., & Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at 4-month and 7-month assessments. Journal of Consulting and Clinical Psychology, 69, 802–813. Wallace, J. (2003). Theory of 12-step-oriented treatment. In F. Rotgers, J. Morgenstern, & S. T. Walters (Eds.), Treating substance abuse: Theory and technique (pp. 9–30). New York: Guilford Press. Weber, M. D., Graham, J. W., Hansen, W. B., Flay, B. R., & Johnston, C. A. (1989). Evidence for two paths of alcohol use onset in adolescents. Addictive Behaviors, 14, 399–408. Weinburg, N. Z. (2001). Risk factors for adolescent substance abuse. Journal of Learning Disabilities, 34, 343–351. Williams, R. J., & Chang, S. Y. (2000). A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138–166. Winters, K. C. (2001). Assessing adolescent substance use problems and other areas of functioning: State of the art. In P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 80–108). New York: Guilford Press. Winters, K. C., Latimer, W. W., & Stinchfield, R. (2001). Assessing adolescent substance use. In E. F. Wagner & H. B. Waldron (Eds.), Innovations in adolescent substance abuse interventions (pp. 1–29). New York: Pergamon. Winters, K. C., Stinchfield, R. D., Henly, G. A., & Schwartz, R. H. (1992). Validity of adolescent self-report of alcohol and other drug involvement. International Journal of the Addictions, 25, 1379–1395. Winters, K. C., Stinchfield, R. D., Opland, E., Weller, C., & Latimer, W. W. (2000). The effectiveness of the Minnesota Model approach in the treatment of adolescent drug abusers. Addiction, 95, 601–612. Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug problems: That was Zen, this is Tao. American Psychologist, 59, 224–235. Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 Substance Related and Addictive Disorders Substance Related and Addictive Disorders Program Transcript [MUSIC PLAYING] FEMALE SPEAKER: He's-- he's always doing things on the computer. He talks on the telephone, texting. He never stops, not even to eat. He never eats much anymore. MALE SPEAKER: Eat your veggies. Drink your milk. Eat your veggies. Drink your milk. Who needs to eat? Seen any good movies lately? I like horror movies, myself. Zombies, especially. The fast ones. FEMALE SPEAKER: There's no alcohol or drugs in our house, none. We've never done that. We don't leave drink wine. That's why I wanted our minister to talk to him. MALE SPEAKER: Talk about zombies. FEMALE SPEAKER: He's the one who suggested that we come here and talk to because he was thinking that maybe something's going on. MALE SPEAKER: Yuck! I hate booze. I don't do drugs, either. I say no every day. FEMALE SPEAKER: Personally, I think it's the music he's listening to. MALE SPEAKER: Oh, brother. FEMALE SPEAKER: I mean, the screaming. It's so aggressive and angry. MALE SPEAKER: Feels good. FEMALE SPEAKER: Maybe you agree with your mom that you've been depressed and angry in the past, Do you remember, maybe, why you felt that way? MALE SPEAKER: Because I'm stupid. FEMALE SPEAKER: You're not stupid, honey. See, he had to repeat the fifth grade, so he's a year behind all his friends at school. MALE SPEAKER: They're not my friends. You hate my friends. ©2013 Laureate Education, Inc. 1 Substance Related and Addictive Disorders FEMALE SPEAKER: I don't hate them. It's just I don't think you should be hanging around boys who are that much older than you. Substance Related and Addictive Disorders Additional Content Attribution IMAGES: Images provided by http://www.istockphoto.com/ MUSIC: Creative Support Services Los Angeles, CA Dimension Sound Effects Library Newnan, GA Narrator Tracks Music Library Stevens Point, WI Signature Music, Inc Chesterton, IN Studio Cutz Music Library Carrollton, TX Special Thanks: Fairland Center/Region One Mental Health ©2013 Laureate Education, Inc. 2 Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 12 Substance Use, Eating, and Sexual Disorders The Boundaries of Substance Use and Addiction Substance use and addiction provide an instructive instance of how difficult it can be to define a boundary between normality and mental disorder. We live in a culture in which most people drink alcohol and in which excess intake from time to time is far from unusual. Since the 1960s, one could say much the same about marijuana. Also, the definition of addiction has become broader. The chapter in DSM-5 now includes addictions to behaviors, not only to substances. The main modification in DSM-5 is that there are no longer any categorical difference between substance use and addiction. The media have duly noted that more people can be diagnosed as having an addiction. But what determines the boundary between use and addiction? DSM, in its various editions, has focused on maladaptive patterns of use leading to “clinically significant impairment or distress.” But that is a vague concept that lacks a precise definition. Less sensitive criteria such as “committing illegal acts” have been removed, and a new criterion of “craving” has been added. Even so, deciding what is or is not clinically significant requires a judgment call. Does impairment depend on losing one’s job and/or losing intimate relationships? Can one be sure that these outcomes would not have happened anyway? One is on safer ground in focusing on the 152 EBSCO : eBook Collection (EBSCOhost) - printed on 7/3/2018 10:59 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 12 S ubs ta nc e Us e, Ea ti ng, a nd S e x u a l D i so rd e r s | 1 5 3 physical effects of substance use. But those sequelae only emerge after years of use. These boundary problems help to explain why substance use disorders have such a high prevalence in epidemiological studies. In the Epidemiologic Catchment Area study, approximately 10% of all men in the United States met lifetime criteria for alcoholism (Robins & Regier, 1991). In the National Comorbidity Survey Replication (NCS-R), 13.2% met lifetime criteria for alcohol abuse, and with a further 5.4% for alcohol dependence, the total was more than 18% (Kessler et al., 2005a). Reflecting the tendency of alcoholism to remit over time, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant et al., 2004b) reported a 12-month prevalence for alcohol abuse of 4.7%, with 3.8% for dependence. A high lifetime prevalence of alcoholism could be a cause for alarm, given that many who abuse alcohol never seek treatment. But it is also possible that these numbers are inflated by an overly broad definition of the disorder. Substance Use and Addiction in DSM-5 DSM-5 defines a substance use disorder as a maladaptive pattern leading to clinically significant impairment or distress for at least 12 months. These features must meet 2 or more of the following 11 criteria: recurrent substance use leading to a failure to fulfill major role obligations, associated with social and interpersonal problems, in situations that are physically hazardous, tolerance (need for increased amounts or diminished effect of the same amount), withdrawal effects, taking the substance in larger amounts and for longer than intended, unsuccessful efforts at cutting down, spending time to obtain or use the substance, giving up other activities, continuing despite the problem, and craving the substance. (This last criterion—“craving or a strong desire or urge to use a specific substance”—is new). A previous criterion describing legal problems has been dropped because it is not predictive of dysfunction. There EBSCO : eBook Collection (EBSCOhost) - printed on 7/3/2018 10:59 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 154 | Part II Specific D i ag n ose s are severity specifiers, depending on the number of criteria met (greater than 4 is considered severe). DSM-5 also describes course specifiers (early full remission, early partial remission, sustained full remission, and sustained partial remission on agonist therapy in a controlled environment). Each drug follows the same general guidelines. Clinicians are also asked to specify whether physiological dependence is present. The term “dependence” is reserved for tolerance and/or withdrawal symptoms. This definition is broad and dimensional, but many patients can be diagnosed if they meet only two criteria, which is a rather lower bar (Martin et al., 2011). Yet it goes along with the manual’s overall philosophy, which is to include subclinical phenomena within a spectrum. The chair of the workgroup (O’Brien, 2011) defended these changes. “Dependence” was eliminated because it is a confusing concept that conflates physical and psychological need for a substance. The logic depends on research suggesting that addiction is dimensional (Hasin & Beseler, 2009). Thus, each disorder can be rated on a continuum of severity, coded for physiological dependence, with addictions coded for severity (Shields et al., 2007). In the past, the term “addiction” always required physiological dependence. It might increase stigma to use this term for binge drinkers and for anyone else who misuses alcohol. Once again, viewing everything on a continuum seems to run the danger of watering down diagnostic concepts. Moreover, different clinical presentations may require different treatment. One question is whether DSM-5 will make addiction diagnoses more frequent. An Australian survey (Mewton et al., 2011) found that using the DSM-5 criteria could lead to a 60% increase in prevalence in substance use disorders as a whole. An American study (Agrawal et al., 2011) found only a 10% increase with the new criteria. Either way, this would be a significant change. This brings us back to the same problem: the absence of a clear boundary between using and having an addiction. Everything depends on assessment of impairment. At what point is a patient who drinks to excess failing to meet major role obligations? In EBSCO : eBook Collection (EBSCOhost) - printed on 7/3/2018 10:59 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 12 S ubs ta nc e Us e, Ea ti ng, a nd S e x u a l D i so rd e r s | 1 5 5 severe cases, the answer is obvious. In the more common and milder cases, it may not be. Behavioral Addictions DSM-5 applies the same concepts to “behavioral addictions.” Pathological gambling is an example. In the NCS-R (Kessler et al., 2008), this diagnosis had a lifetime prevalence of 0.6%, although it was highly comorbid with other disorders. Gambling problems have a similar form and function to substance abuse. There is an attraction to this behavior, resulting in failure to perform major role obligations, as well as continuance despite negative consequences. DSM-5 has therefore moved “disordered gambling” from the DSM-IV group of impulse disorders to the substance use group. Yet other addictive behaviors are still classified elsewhere. Bulimia nervosa also resembles an addiction in that the process of binging and purging can provide quick relief from dysphoric emotions (Brisman & Siegel, 1984). Another example is self-harm, common in borderline personality disorder, which can be addictive because it provides immediate relief for dysphoric emotions (Linehan, 1993). Internet addiction, a more recent phenomenon, was not included in DSM-5. (A proposal for this diagnosis is listed in Section III.) Research has described people who give up all other activities to be (or to live) online (Block, 2008). Yet caution is needed because one would have to define a boundary between addiction and the difficulty many people have in ending sessions on the Internet. We also do not know whether this problem is a reflection of other mental disorders or a disorder in its own right. The development of these new addictive behaviors can be explained by Shorter’s (1993) concept of a “symptom pool.” Many symptom...
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Running Head: PSYCHOLOGY

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Behavioral Addiction
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PSYCHOLOGY

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Behavioral Addiction

The client is likely to be suffering from behavioral addiction. This is found in the DSM-5
alongside substance addiction disorders. The things that are revealed by the female speaker about
the male speaker point out the fact that he has some behavioral severe addiction disorder which
has compromised his social life considerably. This has affected his relationship with others in the
house (Cutting, 2016).
First of all, the male speaker is an adolescent. His condition is specifically behavioral
addiction because there is no statement, either from the female speaker or the male speaker
himself that tells that he is addicted to alcohol or other substances. The male speaker says that “I
hate Booze!” This indicates that he never takes alcohol. He goes further to say that he says no to
drugs every day. The female speaker says that there is no alcohol in the house (Azizi Nejad,
2014).
The things that point out directly to behavioral addiction as the main problem that the
male speaker might be having include the fact that he is always ...


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