Psychopathology in drug abusers and their families

Demographic, clinical, and family pedigree data obtained on 350 hospitalized drug-dependent patients showed that 52% also met DSM-III criteria for alcohol abuse or dependence, while 37% met DSM-III criteria for a concurrent axis I psychiatric disorder other than substance abuse. Cyclothymic disorder was significantly more common among cocaine abusers, while generalized anxiety disorder and panic disorder were more common among sedative-hypnotic abusers. Data on 1,478 first-degree relatives revealed that the prevalence of alcoholism and affective disorder was highly correlated with the occurrence of similar psychopathology in the probands. These findings suggest a relationship between drug of choice and comorbid psychopathology, a role for familial factors in the transmission of these disorders, and the importance of diagnostic subtypes in the evaluation and treatment of substance abusers.     

Concurrent and predictive validity of antisocial personality disorder subtyping among substance abusers.

Three hundred seventy inpatient and outpatient substance abusers were divided according to presence and subtype of antisocial personality disorder (APD) into groups comparing: a) adult antisocial behavior (AAB) versus full APD; b) APD with low versus high sociopathy; c) APD with versus without lifetime depression; and d) APD with versus without other axis II disorders. Multivariate regression was used to predict the unique contribution to the variance in baseline and 12-month follow-up measures of substance use, psychiatric severity, and personality. The presence of comorbid axis II pathology was the strongest predictor of baseline severity in all three domains. APD substance abusers with lifetime depression exhibited greater baseline to follow-up reductions in psychiatric severity than those APD substance abusers without a history of depression. All APD subtypes improved over time with treatment, suggesting that this diagnosis does not necessarily indicate poor prognosis.     

Desipramine facilitation of cocaine abstinence in an adolescent.

An adolescent who was simultaneously dependent on cocaine and treated for attention-deficit hyperactivity disorder (ADHD) with dexedrine developed symptoms of severe depression followed by suicidal behavior. The patient was treated for cocaine craving, depression, and ADHD with desipramine on an inpatient adolescent unit for substance abusers with comorbid psychiatric disorder. The Minnesota Cocaine Craving Scale was used to monitor the cocaine craving. Issues about the strategies for the treatment of cocaine craving and the stimulant treatment/abuse dilemma are discussed with a special emphasis on comorbidity in adolescent substance abusers. Suicidal behavior related to cocaine abuse and craving and the application of the cocaine abstinence three phase model to an inpatient setting are illuminated.     

Psychiatric diagnoses of treatment-seeking cocaine abusers

In a sample of 298 cocaine abusers seeking inpatient (n = 149) or outpatient (n = 149) treatment, rates of psychiatric disorders were determined by means of the Schedule for Affective Disorders and Research Diagnostic Criteria. Overall, 55.7% met current and 73.5% met lifetime criteria for a psychiatric disorder other than a substance use disorder. In common with previous reports from clinical samples of cocaine abusers, these overall rates were largely accounted for by major depression, minor bipolar conditions (eg, hypomania, cyclothymic personality), anxiety disorders, antisocial personality, and history of childhood attention deficit disorder. Affective disorders and alcoholism usually followed the onset of drug abuse, while anxiety disorders, antisocial personality, and attention deficit disorder typically preceded drug abuse.     

Subtypes of cocaine abusers

We have characterized five subtypes of cocaine abusers on the basis of clinical presentation, family history data, and response to specific treatment interventions. These include depressed patients who value the euphorigenic effects of the drug, patients with bipolar or cyclothymic disorder who use cocaine to augment manic or hypomanic symptoms or to alleviate depression, adults with ADD, residual type, who find that cocaine has a paradoxical effect of increasing attention span and decreasing motor restlessness, patients with narcissistic and borderline personality disorders who use cocaine for its social prestige and because it bolsters self-esteem, and patients with antisocial personality disorder who use cocaine as part of an overall pattern of antisocial behavior. Although not all cocaine abusers fit neatly into these categories, careful psychiatric evaluation and subtyping is essential in designing a specific treatment program for these patients. As the prevalence rate of cocaine abuse increases, studies that examine the efficacy of various treatment approaches for specific subtypes of cocaine abusers will be essential. It is hoped that our work will be a step in that direction.     

Psychopathology in cocaine abusers. Changing trends

The authors studied a group of 149 hospitalized cocaine abusers as a follow-up to previous research performed in 1980-82, which had revealed a high prevalence of affective disorder in cocaine abusers. The authors hypothesized that the changing epidemiology of cocaine abuse since that time may have been accompanied by changes in the characteristics of patients seeking treatment for dependence on the drug. The cocaine abusers were compared with 293 other drug abusers to see whether clinical changes over time were specific to individuals abusing cocaine. The authors found slightly more affective disorder in the cocaine abusers when compared with the other patients (26.8% vs. 20.1%), with a significantly higher rate of cyclothymic disorder (11.4% vs. 2.7%, p less than .001). Affective illness was significantly more prevalent in the first-degree relatives of the cocaine abusers when compared with the sex-matched relatives of the other patients (p less than .05). Diagnostic trends changed a great deal, however, between the original 1980-82 study sample and the follow-up 1982-86 sample. The rate of affective disorder decreased over time from 50.0% to 21.0% (p less than .01), and the rate of affective illness in the families also declined, from 31.0% to 11.5% in females (p less than .001) and from 14.3% to 2.2% in males (p less than .001). No such change occurred in the comparison group of opioid and central nervous system depressant abusers. The authors conclude that although a substantial number of cocaine abusers suffer from concurrent affective disorder, this form of premorbid psychopathology has become a less important risk factor for the development of chronic cocaine abuse as cocaine use has become more widespread.     

Hostility in heroin abusers subtypes: Fluoxetine and naltrexone treatment

Gerra Gilberto, Giuseppe Fertonani, Amir Zaimovic, Ines Rota-Graziosi, Paola Avanzini, Rocco Caccavari, Roberto Delsignore and Alfio Lucchini: Hostility in Substance Abusers Subtypes: Fluoxetine and Naltrexone Treatment. Prog. Neuropsychopharmacol. & and Biol. Psychiat. 1995, 19(8): 1225–1237.

1. 1. Substance abusers subtypes have been identified considering underlying psychobiological disorder, familial factors, age of onset, legal problems and drug of choice.

2. 2. In the present study the authors submitted 98 male heroin addicted individuals (age 19–28 y) to the Buss Durkee Hostility Inventory (Italian version) and a structured interview concerning social and clinical history; legal problems, age of onset of drug abuse, drug of choice.

3. 3. Serotonergic system sensitivity was evaluated with fenfluramine challenge for PRL assay.

4. 4. Thirty two patients (group A) showed high score for resentment and guilt at BDHI (hostility in), low rate of legal problems, late age of onset, preference for heroin and alcohol. Twenty nine patients (group B) showed high score for assault and irritability at BDHI (hostility out), high rate of legal problems, early age of onset, preference for heroin and cocaine. The other 37 patients (group C) showed aggression score in the normal range at BDHI, no legal problems, late onset of substance abuse, preference for heroin only.

5. 5. PRL responses was blunted in group A (p < 0.001) and significantly decreased in group B (p < 0.05). PRL plasma levels were inversely correlated with HRSD scores.

6. 6. All the patients were included in a treatment protocol with fluoxetine and naltrexone or placebo and naltrexone for 6 months.

7. 7. The treatment was effective in group A with a significant improvement of BDHI results and decrease of craving score, lower level of drop out, lower level of positive urine controls. No significant differences between fluoxetine and placebo effects have been evidenced in patients of group B and C. The present findings suggest that psychopharmacological approach to addiction needs a diagnostic screening for specific subtypes.

     

Substance abuse, comorbidity, and sensation seeking: Gender differences

Two hundred sixty-two probands and 261 of their relatives with DSM-III-R diagnoses of drug and alcohol abuse and/or anxiety disorders completed the Zuckerman Sensation Seeking Scale. It was hypothesised that subjects with both substance abuse disorders and comorbid anxiety disorders would have lower sensetion-seeking profiles than subjects with substance abuse alone. This was confirmed in women, with thrilland adventure-seeking scores showing significant differences between pure substance abusers and those with a comorbid anxiety disorder, lending support to theories that substance abusers are a heterogeneous group. In men, there were fewer significant differences between diagnostic groups. If substance abusers are indeed a heterogeneous group, with some motivated by high sensation-seeking needs, a better understanding of these motivations can lead to more effective strategies of prevention and treatment, according to etiology.     

Posttraumatic stress disorder among substance users from the general population.

OBJECTIVE: The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population. METHOD: The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects). RESULTS: Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD. CONCLUSIONS: These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.     

Influence of antisocial personality subtypes on drug abuse treatment response

This methodological study examined the impact of antisocial personality disorder (APD) and other psychiatric comorbidity on drug use and treatment retention in 513 new admissions to methadone maintenance treatment. Patients were classified into one of four groups: APD ONLY, APD plus other psychiatric disorder (APD MIXED), other psychiatric disorder, and no psychiatric disorder. Patients completed research assessments and were then followed for 1 year of treatment. Patients with APD had longer histories of heroin and cocaine use than non-APD patients and were more likely to meet criteria for cocaine dependence. Distinct clinical profiles emerged that differentiated APD ONLY from APD MIXED. APD ONLY patients exhibited higher rates of cocaine and heroin use, whereas those with APD MIXED exhibited higher rates of benzodiazepine use. Self-report measures supported urinalysis results, but group differences did not affect treatment retention. These differences in clinical profiles should be considered when evaluating treatment performance in substance abusers with APD.     

Psychopathology among substance abusing juvenile offenders

The prevalence of substance abuse and coexisting DSM-III psychiatric disorders was evaluated in 111 juvenile offenders. As expected, a high rate of conduct disorder (91%) was present in both substance abusing and nonsubstance abusing juvenile offenders. However, significantly higher rates of attention deficit disorder and aggressive subtype of conduct disorder were present in those offenders who abused drugs and alcohol (54%). Excluding all conduct and oppositional disorder diagnoses, 39% of substance abusers versus 14% of the nonsubstance abusers demonstrated comorbid psychiatric diagnoses. These findings suggest that careful psychiatric evaluation of juvenile substance abusers may be necessary to optimize treatment planning.     

Crack/cocaine abusers in the general hospital: assessment and initiation of care.

OBJECTIVE: Cocaine, either smoked (as "crack") or taken intranasally, is now a common cause of psychiatric illness. This study was designed to assess the impact of cocaine abuse on a general psychiatric service and an obstetrics service in an urban general hospital and to evaluate a program for engaging affected patients in addiction treatment. METHOD: The charts of 300 general psychiatric patients (not admitted for addiction treatment) and 60 cocaine-abusing prenatal or postpartum patients were reviewed. A treatment referral program based on professionally directed peer leadership was established for patients with cocaine abuse. Results of evaluation and referral of 100 other cocaine-abusing psychiatric patients and the 60 prenatal or postpartum patients were then determined. RESULTS: Fully 64% (N = 191) of the 300 psychiatric patients were diagnosed as substance abusers; 38% (N = 113) of them abused cocaine. Almost one-third of these cocaine abusers had no axis I diagnosis other than substance abuse/dependence, and the majority were homeless. Urine samples were positive for cocaine in a majority of the obstetric patients studied. A majority of the psychiatric patients who were referred through the peer-led program enrolled in outpatient cocaine treatment--three times as many as in the chart review group. Most of the obstetric patients suitable for referral enrolled for treatment as well. CONCLUSIONS: Cocaine abuse may be responsible for a large portion of psychiatric admissions in urban public general hospitals. Cocaine abusers in psychiatric and obstetrics services are apparently responsive to a peer-oriented mode of referral into treatment.     

Pharmacologic treatments of cocaine abuse

Because current studies have small sample sizes and limited controls, firm conclusions or treatment recommendations cannot be made at present, but pharmacologic approaches probably have a place in the treatment of cocaine abuse. Pharmacologic treatments of cocaine abusers may relate to underlying psychiatric diagnoses. Cocaine abusers with adult attention deficit disorder appear to respond well to methylphenidate, but other cocaine abusers have increased cocaine craving when getting this medication. Cyclothymic cocaine abusers appear to respond to lithium with reduced cocaine use. Depressed cocaine abusers, who may constitute about 30 per cent of abusers, have decreased cocaine craving and increased abstinence when treated with desipramine. Other cocaine abusers without underlying psychiatric disorders may also respond well to desipramine if they fail to reduce their cocaine use during psychotherapy.     

Treatment of cocaine dependence and depression.

In common with all other classes of substance use disorders, cocaine dependence has been shown to be strongly associated with depression by community and clinical surveys. Diagnosing depression in cocaine abusers can be challenging because it is difficult to distinguish transient symptoms caused by cocaine from enduring depression syndromes. Nonetheless, both "substance-induced" and "independent" depression syndromes require clinical attention, especially when symptoms have been persistent and severe before entering treatment. Use of antidepressant medications for combined cocaine dependence and depression is supported by a preponderance of evidence from 4 randomized clinical trials (RCTs) that prospectively targeted both depression and cocaine dependence and 7 RCTs in which a post hoc analyses demonstrated efficacy in the subgroup of cocaine abusers with comorbid depression. Notably, most negative studies have evaluated SSRIs while positive studies have used agents such as desipramine or buproprion. A substantial clinical trials literature supports the efficacy of behavioral treatments for general populations of cocaine abusers and of patients with depression but few studies have addressed patients with both disorders. Treatment development and research are needed on models of care that truly integrate strategies for addressing both cocaine use and depression. Recent advances have paved the way for a new generation of research. These include validation of efficacious cocaine treatments, improved diagnostic methods, organization of the Clinical Trials Network and development of guidelines for managing methodological challenges posed by high rates of current medication use and polysubstance abuse in treatment entering cocaine abusers.     

San Diego Suicide Study. II. Substance abuse in young cases

Fifty-three percent of 133 consecutive young suicides had a principal psychiatric diagnosis of substance abuse. Twenty-four percent had an additional principal diagnosis of atypical depression, atypical psychosis, or adjustment disorder with depression. The relationship of the substance abuse to the additional diagnosis was usually obscure, though this subgroup was similar to the group with only substance abuse on a number of factors. Typically, substance abuse was a chronic condition present for nine years. Multiple substance abuse was the norm in these cases, and marijuana, alcohol, and cocaine were the most frequently abused substances. Substance abusers without other principal diagnoses received psychiatric care less frequently than those with additional principal diagnoses.     

Headaches related to psychoactive substance use

Aim

To investigate a possible association between headache and psychoactive substance use.

Methods

1055 psychoactive substance abusers were consecutively admitted. All patients filled out a detailed headache questionnaire and 1015 patients were included.

Results

Twenty seven percent of patients reported having headache. Eighteen percent of patients reported having headache attributed to a substance or its withdrawal and 1.4% had unclassified headache. The most commonly used substances were cannabis (80.5%), alcohol (74.6%), methylamphetamine (18.7%), benzodiazepine (10.4%), volatile solvent (5.8%), cocaine (4.4%), heroin (2.1%), opioids (0.5%), and other substances (1.7%). Fifteen patients reported that onset of headache occurred prior to onset of substance use, while 94.5% had headaches occurred after substance abuse. A higher incidence of headache was found in the benzodiazepine, methylamphetamine, cocaine, heroin, volatile solvent abusers. Seventy-eight percent of headache patients have never sought help from a physician despite the severity and frequency of headache.

Conclusions

In our study, the prevalence of headache among all psychoactive substance abusers was 26.9%. Although this is one-group study without any comparison with non-addict population and associational data must be interpreted with caution, the results of this study indicate a possible relationship may exist between headache and substance use since 94.5% of substance users described headaches after the onset of substance use. The younger start and the longer duration of cannabis use caused the higher incidence of headache, but this correlation was not observed in other substance use. Migraine was far more prevalent in the abusers than in previously reported community populations.     

Differences in substance abuse patterns: multiple drug abuse alone versus schizophrenia with multiple drug abuse.

OBJECTIVE: To compare the lifetime consumption patterns of patients with schizophrenia and multiple substance abuse and multiple substance abusers without schizophrenia. METHOD: Two hundred and thirty in-patients of a specialized rehabilitation facility for young drug abusers were assessed with regard to their lifetime consumption patterns of 16 different classes of psychoactive drugs. While 110 patients had no diagnosis of a schizophrenic disorder, 120 patients had a comorbidity of multiple substance abuse and schizophrenia. RESULTS: Comorbid patients reported a higher lifetime consumption of hallucinogens, whereas multiple substance abusers without schizophrenia showed a higher lifetime consumption rate of cocaine. CONCLUSION: The differences found in lifetime consumption patterns between comorbid patients and substance abusers without psychotic disorder do not support the so-called self-medication hypothesis. Instead, the differences in lifetime consumption of certain drugs might be a result of lower social competence and standing in schizophrenic patients and lower ability to procure certain illicit drugs.     

Trail making test cut-offs for malingering among cocaine,heroin, and alcohol abusers

The Trail Making Test (TMT) is frequently used to screen for cognitive impairments in substance abusers; however, an existing problem is that substance abusers may give poor effort and the TMT results may not be valid. In this study, cutting scores for malingering were developed from three samples drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS), a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 drug abuse treatment programs in 11 cities in the United States. The DATOS enrolled 7689 substance abusers. The three drawn samples were for subjects with primary drugs of abuse. Number of subjects were as follows: alcohol-1000, cocaine/crack-4306, heroin-1548. Data were analyzed to determine number of substance abusers that fell beyond the upper end of the distribution of TMT scores at the ten, five, and one percentiles. These percentiles were set for alcoholics, cocaine abusers, and heroin abusers. The proper use of the cut-off scores is to alert clinicians to the increasingly higher probability of poor effort when a substance abuser in one of the three groups scores beyond the one percent cut-off or his or her sample of primary drug of abuse. Clearly, the use of these cut-offs needs further empirical validation.     

TRAIL MAKING TEST CUT-OFFS FOR MALINGERING AMONG COCAINE,HEROIN, AND ALCOHOL ABUSERS

The Trail Making Test (TMT) is frequently used to screen for cognitive impairments in substance abusers; however, an existing problem is that substance abusers may give poor effort and the TMT results may not be valid. In this study, cutting scores for malingering were developed from three samples drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS), a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 drug abuse treatment programs in 11 cities in the United States. The DATOS enrolled 7689 substance abusers. The three drawn samples were for subjects with primary drugs of abuse. Number of subjects were as follows: alcohol-1000, cocaine/crack-4306, heroin-1548. Data were analyzed to determine number of substance abusers that fell beyond the upper end of the distribution of TMT scores at the ten, five, and one percentiles. These percentiles were set for alcoholics, cocaine abusers, and heroin abusers. The proper use of the cut-off scores is to alert clinicians to the increasingly higher probability of poor effort when a substance abuser in one of the three groups scores beyond the one percent cut-off or his or her sample of primary drug of abuse. Clearly, the use of these cut-offs needs further empirical validation.     

The clinical implications of primary diagnostic groups among alcoholics

Interviews with patients and two resource persons were used to determine primary psychiatric diagnoses in 577 consecutive men entering an alcohol treatment program (ATP) at a veterans hospital. Twelve months later, about 95% of the sample were successfully followed up with a patient and resource person interview to establish the clinical course over the year for the four most populous diagnostic subgroups. At intake into the treatment program, the 432 group 1 primary alcoholic men were older, had a later age at onset of alcoholism, demonstrated a lower intensity of drinking, had fewer antisocial problems, and used fewer categories of drugs than the 60 men in group 2 with primary drug abuse and the 40 men in group 3 with primary antisocial personality disorder. During the follow-up, men in groups 2 and 3 had a greater likelihood of drug use, more police and social problems, and demonstrated higher (more adverse) outcomes on a clinical outcome scale. The nine group 4 men with primary affective disorder at intake demonstrated an increased risk for past suicide attempts and psychiatric care and had a higher rate of affective disorder in first-degree family members. These findings underscore the importance of distinguishing between symptoms (eg, sadness or antisocial problems) and diagnoses and the need to establish primary and secondary labels in substance abusers.