Ramon Solhkhah, MD and Muhammad Abbas, MD
CHAPTER OUTLINE
■ DEFINITIONAL ISSUES
■ METHODOLOGIC QUESTIONS
■ INCIDENCE AND PREVALENCE
■ DIAGNOSIS AND MANAGEMENT
■ CONCLUSIONS
Despite recent studies showing that levels of adolescent alcohol and drug use have essentially stabilized, they are sufficiently high to remain a major concern. Given recent increases in the illicit use of prescription stimulants and prescription painkillers by teens, it is difficult to claim victory in the “War on Drugs.”
Adolescents who manifest other psychiatric diagnoses in addition to substance use have elicited increasing concern (1–19). In fact, adolescents with substance use disorders (SUDs) exhibit a high prevalence of psychiatric disorders compared to the general population (14,20–25). Studies of treatment-seeking SUD adolescents have documented that 50% to 90% also have non-SUD comorbid psychiatric disorders (14,16,26–31). Not only are specific psychiatric disorders associated with alcohol and drug use but other problems that affect teens—such as suicide, violence, and pregnancy—also are associated with an increased risk of substance use.
In this chapter, the terms dual diagnosis, comorbidity, and co-occurring disorders are used interchangeably to refer to patients who meet the criteria for an SUD and for another psychiatric diagnosis on Axis I or II of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR) of the American Psychiatric Association (1). The term substance use disorderis used to include both abuse and dependence. Adolescents who initially seek treatment for an SUD—the focus of this chapter—may be different from those who seek care for a psychiatric disorder (32,33).
Awareness of the most likely disorders and formulation of an integrated treatment plan are essential. This chapter reviews what are known about comorbidities and offers guidelines for their management and the care of adolescents so affected.
DEFINITIONAL ISSUES
Dual diagnosis issues initially were studied in adults (33–41), leaving the clinician to extrapolate from this research to the adolescent population. More recently, adolescent clinical and community populations have been studied (3,5–10,12,14–16,18,27,42–52).
According to Bukstein and Kaminer (53), however, diagnostic issues related to adolescent substance use continue to be problematic. The criteria that have been developed have not been well validated with adolescents, and there may be some discontinuities between adolescent and adult populations (53,54). When diagnostic criteria are based on problem behaviors, it often is not clear whether the behaviors are the result of substance use or of a coexisting or preexisting problem. Though craving and loss of control are included in the criteria, no studies have established whether these actually are present in adolescents (53). Nosology is only the best attempt to make sense of reality; as a result, an imperfect system designed for adults is used to make substance abuse diagnoses in adolescents (53–56).
METHODOLOGIC QUESTIONS
Some of the methodologic questions are identical for adults and adolescents. In both populations, the course and treatment of the same two disorders may vary depending on which one is the primary—in other words, which disorder preceded the other (35)—and their relative severity (30,32,39,51,57,58). It is not helpful to assume that all patients with dual diagnoses have the same problems and require the same treatment (51). Though a high prevalence of comorbidity has been reported among adolescent inpatients with SUDs (12,14,15,59–63), it is unclear how many exhibit psychiatric symptoms secondary to the SUDs and how many have a primary or coexisting psychiatric diagnosis.
INCIDENCE AND PREVALENCE
Physicians should know the kinds of comorbidities they are likely to encounter in practice. Until recently, however, large-scale population studies did not focus on adolescents. The National Survey on Drug Use and Health (NSDUH) published in 2011 (64) is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). This report is the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, noninstitutionalized population of the United States aged 12 years or older. Approximately 67,500 persons are interviewed in the NSDUH each year. In 2011, an estimated 22.5 million Americans aged 12 or older were current (past month) illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 8.7% of the population aged 12 or older. Among youths aged 12 to 17, the current illicit drug use rate was similar in 2010 (10.1%) and 2011 (10.1%), but was higher than the rate in 2008 (9.3%). Between 2002 and 2008, the rate declined overall from 11.6% to 9.3%.
The Monitoring the Future (MTF) study is a long-term study of American adolescents, college students, and adults through age 50 (65). The 2012 MTF survey encompassed about 45,400 8th, 10th, and 12th grade students in 395 secondary schools nationwide. This survey is sponsored by the National Institute on Drug Abuse (of the National Institutes of Health). Of particular importance in this survey report were findings relating to relatively new synthetic drugs and some relating to the use of more traditional drugs of abuse, like marijuana and ecstasy. Bath salts, so-called because they are sold over the counter as apparently innocuous products like bath salts but really contain strong stimulants, have been given much attention in the news in the past 2 years. The 2012 MTF survey provides the first national survey data on their use. The annual prevalence rates in 2012 appear to be very low, at 0.8%, 0.6%, and 1.3% in grades 8, 10, and 12, respectively. Data on calls to the national poison control centers relating to bath salts suggest that use may have risen rapidly after 2010, peaked in the first half of 2011 (with 3,500 calls about them), but declined by half in the first half of 2012 (1,700 calls), and continued to decline since then. Marijuana use, which had been rising among teens for the past 4 years, continued to rise in 2011 in all prevalence periods for 10th and 12th graders, but in 2012, these increases halted. (Although use among 8th graders had been rising, annual prevalence decreased after 2010.) The use of daily marijuana increased significantly in all three grades in 2010, rising further in all three grades in 2011, and leveled in 2012. Daily use now stands at 1.1%, 3.5%, and 6.5% in grades 8, 10, and 12. In other words, roughly 1 in 15 high school seniors today is a current daily, or near-daily, marijuana user. Synthetic marijuana, which goes by such names as Spice and K2, is an herbal drug mixture that usually contains designer chemicals that fall into the cannabinoid family. The Drug Enforcement Administration (DEA) scheduled them beginning March 1, 2011, making the possession and sale of their most commonly used ingredients no longer legal. Despite this policy intervention, use among 12th graders remained unchanged in 2012 at 11.3%, which suggests either that compliance with the new scheduling has been limited or that those who produce these products have succeeded in continuing to change their chemical formulas to avoid using the scheduled ingredients. In 2012, for the first time, 8th and 10th graders were asked about their use of synthetic marijuana; the annual prevalence rates were 4.4% and 8.8%, respectively. Most of the other individual illicit drugs showed no significant change in use between 2011 and 2012.
Until very recently, studies involving adolescents were smaller and involved clinical populations. Wu et al. (66) examined the prevalence of SUDs among psychiatric patients aged 2 to 17 years in an electronic health record database (n = 11,457). The DSM-IV diagnoses of all inpatients and outpatients at a large university-based hospital were systematically captured between 2000 and 2010. They found that SUD was comorbid with anxiety disorder (AD), mood disorder (MD), conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), personality disorder (PD), adjustment, eating, impulse control, psychotic, learning, mental retardation, and relational disorders. The prevalence of SUD in the 2- to 12-year age group (n = 6,210) was 1.6% and increased to 25% in the 13- to 17-year age group (n = 5,247). A cannabis diagnosis was the most prevalent SUD, accounting for more than 80% of all SUD cases. Among patients with an SUD (n = 1,423), children aged 2 to 12 years (95%) and females (75% to 100%) showed high rates of comorbidities; African Americans were more likely than whites to be diagnosed with CD, impulse control, and psychotic diagnoses, while whites had elevated odds of having AD, ADHD, MD, PD, relational, and eating diagnoses. Patients with an SUD used more inpatient treatment than patients without an SUD (43% vs. 21%); children, females, and African Americans had elevated odds of inpatient psychiatric treatment.
Essau and Cecilia (67) studied comorbidity of SUDs and explored differences in community-based and high-risk adolescents. High-risk adolescents (n = 374) comprised those whose parents have the diagnosis of SUD and who were undergoing a treatment for their SUD. Adolescents from the community (n = 1,035) were recruited from 36 schools in London. Participants were interviewed using the computerized Munich version of the Composite International Diagnostic Interview to access the presence of SUD and other major DSM-IV psychiatric disorders. The lifetime rate of SUD was significantly lower in the community-based (12.3%) than the high-risk (38.3%) groups of adolescents. In both settings, SUD co-occurred highly with other psychiatric disorders. About 52.7% and 62.2% of the community-based and high-risk adolescents with SUD, respectively, had at least one additional disorder. Adolescents with SUD and comorbid disorders were significantly more psychologically distressed, compared to adolescents with SUD only. Adolescents with SUD had significantly lower perceived attachment to parents, but significantly higher attachment to peers compared to adolescents without any psychiatric disorders.
The National Comorbidity Survey—Adolescent Supplement (NCS-A) published in 2010 (68) provides the first prevalence data on a broad range of mental disorders in a nationally representative sample of US adolescents. Merikangas et al. surveyed 10,123 adolescents face-to-face aged 13 to 18 years in the continental United States. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. According to the survey, ADs were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of participants with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2% (11.2% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for SUDs. This survey raised a red flag by showing approximately one in every four to five youth in the United States meets criteria for a mental disorder with severe impairment across their lifetime.
Stowell and Estroff (16) studied 226 adolescents receiving inpatient treatment for a primary substance abuse disorder in private psychiatric hospitals. Psychiatric diagnoses were made 4 weeks into treatment by using a semistructured diagnostic interview. Of the total, 82% of the patients met the DSM-III-R (69) criteria for an Axis I psychiatric disorder, 61% had MDs, 54% had CDs, 43% had ADs, and 16% had substance-induced disorder. Three-fourths of the patients (74%) had two or more psychiatric disorders. Westermeyer et al. (52) found similarly high rates of comorbidity and multiple diagnoses in 100 adolescents 12 to 20 years of age who sought care at two university-based outpatient addiction treatment programs. Of the study group, 22 of 100 had eating disorders (EDs), eight had CDs, seven had major depressive disorder, six had minor depressive disorder, five had bipolar disorder, five had schizophrenia, and four had ADs. Three had another psychotic disorder, three had an organic mental disorder, and two had ADHD.
The distribution of diagnoses as a function of age showed that ED diagnoses and depressive symptoms occurred more frequently in older adolescents (52). Giaconia et al. (44) studied the issue of age in a predominantly white, working-class community sample of 386 individuals who are 18 years old. They compared adolescents who had met the criteria for one of six psychiatric diagnoses, including SUDs, before and after they were 14 years of age. Adolescents with early onset of any psychiatric disorder were six times as likely to have one, and 12 times as likely to have two, additional disorders by the time they were 18 years of age than were those with later onset of psychiatric disorders (44). This finding suggests that the clinician’s index of suspicion for dual diagnosis must be particularly high for younger patients with SUDs.
DIAGNOSIS AND MANAGEMENT
Controversies aside, psychologists, psychiatrists, and other mental health professionals need to treat the patients they encounter. Some of those patients will have a psychiatric diagnosis. Clinicians will serve such patients well if they (a) conduct a comprehensive evaluation of each patient that includes a mental status examination and an inquiry into other psychiatric symptomatology and obtain information from multiple sources; (b) have a high index of suspicion for comorbidity in adolescents whose conditions do not respond to treatment or who present problems in treatment; (c) individualize treatment to accommodate both the substance use and psychiatric diagnoses; (d) obtain a comprehensive history of alcohol, tobacco, and other drug use; and (e) know when to consult an addiction medicine specialist or mental health professional.
There is a paucity of research on pharmacotherapies in adolescents with SUDs. This paucity is partly because of the fact that most people with substance dependence do not get diagnosed until early adulthood. Solhkhah and Wilens (70) and Simkin (6) reviewed the pharmacotherapies used for aversion, substitution, anticraving, and detoxification of alcohol, nicotine, cocaine, and opioid dependence. Disulfiram is the only aversive agent used for the treatment of alcohol. Acamprosate, naltrexone or Vivitrol in injectable form and ondansetron have successfully been used as anticraving agents for alcohol. Nalmefene, a naltrexone derivative, and antidepressants have been tried as anticraving agents with questionable results. Currently, there are no FDA–approved medications for marijuana and cocaine. In substitution therapy, the patient’s drug of abuse is replaced with the supervised administration of related medicine. Such treatment includes methadone and buprenorphine in opioid dependence, benzodiazepines in alcohol dependence, stimulants in cocaine dependence, and nicotine products for nicotine dependence (6,70).
Depressive Disorders
Much has been written about the interplay between depression and substance use (3,18,27,30,39–41,43,48,71,72). The emerging concept is that in adolescents (3,14,27,30,53,72) and adults (39–41), two groups exhibit significant depressive symptoms: those individuals who have a substance-induced MD and those who have a primary depressive disorder. The chief symptom of depression consists of a disturbance of mood, which usually is characterized as sadness or feeling “down in the dumps” and a loss of interest or pleasure. Adolescents may report or exhibit irritability instead of sadness. In addition, their depression may be characterized by guilt, hopelessness, sleep disturbances, appetite disturbances, loss of ability to concentrate, diminution of energy, and thoughts of death or suicide. To meet the DSM-IV-TRdiagnostic criteria, the patient must exhibit or experience depressed mood most of the day, every day, for 2 weeks (1). Patients with a substance-induced MD may exhibit the same depressive symptoms. During the mental status examination, depressed adolescents may seem taciturn and show poor eye contact and a sad-looking face. They may be poorly groomed or drably dressed and may become tearful during the interview. Often, they deny feelings of sadness, though their demeanor states it eloquently. Depression interferes with treatment through lack of concentration, motivation, and hope as well as the tendency toward isolation. Kempton et al. (73) found cognitive distortions, including magnification (all-or-nothing thinking) and personalizing, to be particularly prominent among adolescents with the multiple diagnoses of CD, depressive disorder, and substance abuse. A depressed adolescent may benefit from a specific cognitive intervention for depression (55,74).
Gallerani et al. (75) explored the temporal relation between depression and comorbid psychopathology in adolescent males and females. They studied 240 adolescents and their mothers who either had a history of depression (high risk, n = 185) or were lifetime free of psychiatric disorders (low risk, n = 55). Children (54.2% females) were evaluated in 6th grade (mean age = 11.86, SD = 0.57) to assess current and lifetime diagnoses and then annually through 12th grade. They reported for girls, the rate of depression was high regardless of prior anxiety, whereas for boys, the odds that those with prior subthreshold anxiety would have subsequent subthreshold depression were 1.5 times those of boys with no prior subthreshold anxiety, controlling for risk. In addition, the odds that girls with prior SUDs would have a threshold depressive disorder subsequently were three times those of girls with no prior SUDs, controlling for risk.
A large body of epidemiologic research indicates that anxiety and MDs are highly comorbid with SUDs. Wolitzky-Taylor et al. (76) attempted to assess whether emotional disorders (i.e., anxiety and mood disorders) predict the onset of SUDs, SUDs predict the onset of emotional disorders, or both. The data from baseline assessment (n = 627) and 4 years of follow-up assessments from the NU/UCLA Youth Emotion Project were used to examine this question. The results showed that anxiety and unipolar mood disorders at baseline assessment were associated with later onsets of SUDs. In particular, social anxiety disorder (SAD) at baseline predicted onset of alcohol use disorders (AUDs) and posttraumatic stress disorder (PTSD) predicted the onset of all SUDs. SUDs did not predict any anxiety or unipolar mood disorders with the exception that AUDs predicted the onset of obsessive–compulsive disorder (OCD).
Schuckit (39–41) and Miller (34) stress the importance of distinguishing between primary depressive disorder and substance-induced MD. Studies of adults who abuse substances showed that substance-induced MD dissipates with abstinence, but primary depressive disorders do not and, if left untreated, can interfere with treatment and recovery (34–39,42). Deykin et al. (8,27) interviewed 223 adolescents in residential addiction treatment programs and found that almost 25% met the DSM-III-R (69) criteria for depression. Of these, 8% met the criteria for primary depression, and the other 16% had a secondary MD. Bukstein et al. (77) studied adolescent inpatients on a dual diagnosis unit and reported that almost 31% had a comorbid major depression, with secondary depressive disorder much more common than primary depressive disorder. Unlike adults, the secondary depression in adolescents did not remit with abstinence (3). This finding, if replicated, would argue for more vigorous treatment of depressive syndromes in adolescents.
Effinger and Stewart (78) recently published on the synergistic impact of both depression and substance use and discussed how these disorders contribute to suicide attempts. They also explored the impact of subthreshold presentations of these disorders. They used logistic regression to examine the impact of co-occurring disorder classification on suicide risk attempts. Results indicate that co-occurring disorders had a dramatic impact on suicide attempt risk, with individuals with high severity co-occurring disorders at greatest risk.
Stressful experiences such as childhood trauma and depressive symptoms have both been implicated in the initiation of drug use. Fishbein et al. (79) conducted a study to examine the effects of lifetime traumatic stressors and their intensity on the onset of drug use and the presence and absence of depressive symptoms on final outcome. They studied two types of trauma in a community-based sample of 489 Hispanic preadolescents (aged 10 to 12): (a) the number of lifetime traumatic stressors and (b) seven specific lifetime stressors. They also controlled for new-onset traumatic stressors occurring between years 1 and 2. Primary findings indicate that drug use initiation during early adolescence (e.g., ages 14 to 16) may not be tied to immediate proximal perturbations in risk factors, such as traumatic experiences and depressive symptoms. Rather, the effects of trauma on depression in this sample appear to be established earlier in childhood (ages 10 to 14 or younger) and persist in a relatively stable manner into middle adolescence when the risk for drug use may be heightened.
In another study, 126 adolescents with a DSM-IV diagnosis of major depression, CDs, and SUDs were studied to determine the efficacy of fluoxetine versus placebo. Both groups received cognitive–behavioral therapy (CBT) for their SUD during the 16-week trial. Rates of depression remission were high in both groups, 75% versus 64%, respectively, but rates of abstinence were relatively low. Post hoc analysis predicted that remission of depression was a stronger predictor of change in drug use than medication treatment. Therefore, the implication from this study was that depression symptoms may remit in the context of individual outpatient CBT for SUD without pharmacotherapy of abstinence. However, if depression does not remit within the first month of treatment, it appears that starting fluoxetine, with careful monitoring, even if not yet abstinent, is prudent because ongoing depression may prevent abstinence achievement (80–82). Serotonergic agents like fluoxetine have a very safe profile (FDA black box warning for suicidal ideations notwithstanding) and may be appropriate considering reports that young substance abusers may have a preexisting serotonin deficit (7,13,83).
In a small open trial, 20-mg daily fluoxetine reduced depressive symptoms in substance-abusing adolescents with CD and major depression, with no significant adverse events (84).
If there are doubts about the diagnosis of depression or about how to treat, consultation with a psychiatrist experienced in treating adolescents with SUDs is indicated. If the primary clinician is concerned about possible suicidal behavior, a consultation should be sought without delay (4,43,71).
Bipolar Disorder
The diagnosis of bipolar disorder may be among the most difficult to make in children and adolescents and is even more difficult in teens who use alcohol or other drugs. Issues such as changes in sleeping patterns or mood swings can be symptoms of bipolar disorder, substance use, or even normal adolescence. The diagnosis of bipolar disorder certainly should be considered in substance-using youth, particularly those with a binge pattern.
In bipolar disorder, which often begins during late adolescence (5,44,84), the initial symptoms of mania include a persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, increased purposeful activity, and excessive involvement in pleasurable activities, such as spending money, sexual indiscretions, or substance use (1). Wilens et al. (85) have found an increased risk for SUDs in adolescents with bipolar disorder. They reported that those with adolescent-onset bipolar disorder had an 8.8 times greater risk of developing an SUD than those with childhood-onset bipolar disorder, and no other disorder, including CD, accounted for the risk. Children who were diagnosed and treated appropriately at a younger age had a lower subsequent risk for substance use.
The burden of SUDs among adults with bipolar disorder is well documented. Goldstein and Bukstein (86) in a recent review article studied the burden of SUD in youth with bipolar disorder. According to their report, epidemiologic and clinical studies demonstrate that youth-onset bipolar disorder confers even greater risk of SUD in comparison with adult-onset bipolar disorder. Recent studies of youth with bipolar disorder have not identified SUD (0%) during childhood (<13 years old); however, the prevalence of SUD escalates during adolescence (≥13 years old) from 16% to 39%. SUD among bipolar youth is associated with legal and academic difficulties, pregnancy, and suicidality. Few studies have addressed interventions for this population, although studies are underway. Because bipolar disorder onset most commonly precedes SUD among youth (55% to 83%), there is a window of opportunity for prevention. These include screening for substance use among bipolar youth beginning at age 10 irrespective of other risk factors, education and intervention at the family level, and implementation of preventive interventions that have been successful in other populations.
Some patients use substances, particularly alcohol, to calm themselves during a manic phase. Clearly, some of these symptoms also are seen with substance intoxication. If a patient exhibits these symptoms after a period of abstinence, the diagnosis of bipolar disorder should be considered. Valproic acid, carbamazepine, and other anticonvulsants also are used, as are the atypical antipsychotics, such as aripiprazole, olanzapine, and risperidone (84,85,87). In a study by Geller et al. (10), when lithium was used, not only were the symptoms of mania decreased but the use of alcohol also decreased. In a similar trial, Donovan et al. (11) administered 1,000 mg daily of valproic acid to adolescent subject to temper outbursts and irritability (“explosive mood disorder”) with marijuana abuse, and results showed improved overall functioning on valproic acid along with decreased marijuana consumption.
Clinicians should be aware that although the diagnosis of severe mood dysregulation (SMD) is not found in the DSM-IV-TR, care should be taken in distinguishing SMD from a diagnosis of bipolar disorder (88,89).
Jansen et al. (45) in a cross-sectional population-based study of adults 18 to 24 years old (n = 1,560) in Brazil evaluated the prevalence of episodes of mania and hypomania as well as associated factors and comorbidities. According to the results, the lifetime prevalence of manic and hypo-manic episodes was 7.5% and 5.3%, respectively. Subjects with hypomanic episodes had a higher prevalence of ADs, substance abuse, and suicidality.
Anxiety Disorders
ADs are among the psychiatric conditions most often coexisting in adolescents and adults with SUDs. Typically, these conditions include generalized AD, panic disorder, social phobia, OCD, and PTSD. ADs often are not detected or treated, especially when present in combination with depression or psychoactive SUDs (5,59).
Frojd et al. (60) explored the associations between anxiety and alcohol and other substance use and whether general anxiety or symptoms of social phobia affect the continuity of frequent alcohol use, frequent drunkenness, and cannabis use. They utilized data from the Adolescent Mental Health Cohort Study, a school-based Finnish survey among adolescents aged 15 to 16 years at baseline, to assess prevalence, incidence, and continuity of symptoms of social phobia, general anxiety, frequent alcohol use, frequent drunkenness, and cannabis use (which in this context was smoked “hashish” of unknown constituency) and the associations between the substance use variables and the anxiety variables in 2-year follow-up. Results from the study showed anxiety preceded substance use, while no reciprocal associations were observed. Depression mediated the associations between anxiety and substance use. Symptoms of social phobia did not elevate the incidence of substance use, but general anxiety did. Frequent drunkenness was less significantly associated with anxiety than the other two substance use variables. Comorbid general anxiety increased the persistence of frequent alcohol use while comorbid social phobia decreased its persistence. Continuity of frequent drunkenness and cannabis use was unaffected by comorbid anxiety. As indicated by this study, general anxiety in middle adolescence places adolescents at risk for concurrent and subsequent substance use. The risk may, however, be associated with comorbid depression. Social phobia in middle adolescence may protect from substance use. Adolescents with internalizing symptoms may need guidance in coping with the symptoms even if the symptoms do not fulfill the criteria of mood or anxiety disorder.
In fact, many adolescents (and adults) believe that drugs and alcohol may contribute to reduction of anxiety and stress, and this belief may lead them to initiate or continue use. Sometimes, a closer examination of patients who resist attending self-help meetings may reveal a social phobia or agoraphobia. Social phobia and its importance in terms of early diagnosis cannot be overemphasized. In another longitudinal community-based study of 503 boys in the Pittsburgh Youth Study (61), Marmorstein et al. (61) examined the associations of generalized and social anxiety with (a) age at first use of tobacco, alcohol, and marijuana and (b) interval from first use to first problem use of each substance. Both types of anxiety predicted earlier first use of alcohol and tobacco, and generalized anxiety predicted earlier first use of marijuana. Both types of anxiety predicted the progression from first use to problems related to marijuana. The effect of generalized anxiety tended to be significant above and beyond the effect of delinquency, while the effect of social anxiety on risk for first use of substances was not.
Though many children with social phobia are not recognized early because they are not a behavioral problem in class, children who are referred for evaluation for aggression should be carefully evaluated for social phobia. In a study by Swan (91), the combination of shyness and aggressiveness in boys was a more valid predictor of future cocaine use than a history of aggressiveness alone. Merikangas et al. (92), in the International Consortium of Psychiatric Epidemiology, demonstrated that the onset of ADs was more likely to precede that of SUDs in all countries. Social phobia was highly comorbid with depressive disorder, somatoform disorder, and SUDs in a study of 1,035 adolescents, ages 13 to 17 (92).
The relationship between ADs and substance use among adolescents was also studied by Wu et al. (93) using a sample of 781 adolescents (ages 13 to 17, 52.8% male) from a community survey; they examined gender differences in the co-occurrence of specific ADs with substance use in adolescents. The associations between ADs and substance use differed according to the particular ADs, and forms of substance use were examined by gender. Social phobia was associated with cigarette smoking among boys only. For girls, social phobia appeared to be negatively associated with drug use. For the other ADs, the associations with substance use tended to be stronger among girls. These findings highlight the need to improve clinical recognition of the ADs and to improve treatment access for afflicted adolescents.
To make matters even more confusing, some well-done studies show that teens that never use drugs or alcohol may be at higher risk for ADs later in life.
Panic Disorder
There is a growing body of literature suggesting that panic attacks without panic disorder are associated with increase in a wide range of psychopathology and impairment (94). The National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,653, aged 18 and older, response rate = 70.2%) indicated that panic attacks were significantly associated with increased incidents of generalized AD, panic disorder, social phobia, major depression, dysthymia, mania and hypomania, any AD, and any MD even after adjusting for sociodemographic variables.
Panic attacks are periods of intense discomfort that develop abruptly and reach a peak within 10 minutes. Symptoms include palpitations, sweating, trembling, sensations of shortness of breath or choking, chest discomfort, nausea, dizziness, and fears of losing control or dying. As some of these symptoms also might be seen in substance intoxication or withdrawal, it is important to establish abstinence before making a diagnosis.
Social Phobias
Patients with a social phobia may isolate themselves on an inpatient unit or in a group. A careful interview in which anxiety symptoms and family history of ADs are pursued may be quite revealing.
General anxiety in middle adolescence places adolescents at risk for concurrent and subsequent substance use. Social phobia in middle adolescence may protect from substance use (60).
Behavioral treatment, including relaxation training, often is helpful for ADs (55). The issue of pharmacotherapy is controversial. Many argue that the use of benzodiazepines is contraindicated in anyone with a history of substance abuse. Buspirone hydrochloride and serotonin reuptake inhibitors have been recommended as nonaddictive antianxiety agents (87). Clinical experience and anecdotal reports suggest that for many, buspirone is ineffective. When treating patients who insist that only benzodiazepines are effective, it often is not clear whether the statement represents drug-seeking behavior or a bona fide observation. If abstinence has been established, adequate trials of behavioral or cognitive therapy (55) and alternative medications have failed, and the patient adheres to the treatment and medication regimen, the judicious use of a long-acting benzodiazepine, such as clonazepam, may be justified.
SAD is increasingly being recognized as a prevalent, unremitting, and highly comorbid disorder. Data were analyzed from the National Latino and Asian American Study and the National Comorbidity Survey Replication (95). Both studies utilized the World Health Organization—Composite International Diagnostic Interview, which estimates the prevalence of lifetime and 12-month psychiatric disorders according to the DSM-IV criteria. Latinos reported a lower lifetime and 12-month SAD prevalence and a later age at onset than US-born non-Latino whites. On the other hand, Latinos diagnosed with 12-month SAD reported higher impairment across home, work, and relationship domains than their non-Latino white counterparts. Relative to non-Latino whites, Latinos who entered the United States after the age of 21 years were less likely to have lifetime SAD comorbidity with drug abuse and dependence and more likely to report lifetime SAD comorbidity with agoraphobia.
Posttraumatic Stress Disorder
In clinical reports on adolescents, the incidence of severe trauma and symptoms of PTSD is surprisingly high (8,46,59–63,65,96,97). An adolescent who has been acting out and abusing substances may not have dealt with an earlier trauma, such as physical and sexual abuse or exposure to violence, or with the trauma that may be incurred when abusing substances (62). Symptoms and memories of trauma may manifest themselves only during abstinence.
Adolescents exposed to multiple forms of psychological trauma may be at high risk for psychiatric and behavioral problems (63). One study empirically identified trauma profiles in a national sample of adolescents to ascertain correlates of polyvictimization. Ford et al. (63) in a recent study reported six mutually exclusive trauma profiles (latent classes) in adolescents. Four classes were characterized by high likelihood of polyvictimization, including abuse victims (8%), physical assault victims (9%), and community violence victims (15.5%). Polyvictimization class members, especially abuse and assault victims, were more likely than do youth traumatized by witnessing violence or exposure to disaster/accident trauma to have psychiatric diagnosis and (independent of psychiatric diagnoses or demographics) to be involved in delinquency with delinquent peers. Polyvictimization is prevalent among adolescents and places youth at high risk for psychiatric impairment and for delinquency.
Trauma and the symptoms associated with trauma should to be considered and inquired about to ensure adequate treatment of adolescents who abuse substances. Care should be taken to acknowledge the trauma without arousing anxiety that will interfere with abstinence and substance abuse treatment. Groups that support self-care and a first-things-first attitude may be the best approach; the patient needs to learn to stay safe, and treatment for substance abuse is a most important aspect of safety. Epidemiologic studies have identified recent declines in specific types of adolescent substance use (96). The current study examined whether these declines varied among youth with and without a history of interpersonal victimization or PTSD. Data for this study came from two distinct samples of youth (12 to 17 years of age) participating in the 1995 National Survey of Adolescents (n = 3,906) and the 2005 National Survey of Adolescents—Replication (n = 3,423). Results revealed significant declines in adolescents’ use of cigarettes and alcohol between 1995 and 2005; use of marijuana and hard drugs remained stable. Of importance, declines in nonexperimental cigarette use were significantly greater among youth without versus with a history of victimization, and declines in alcohol use were significantly greater among youth without versus with a history of PTSD.
Effective treatments suggest that integrated PTSD- and SUD-focused cognitive–behavioral and family treatment for adolescents with comorbid abuse-related PTSD and SUD may optimize outcomes for this population (98). In another study comparing treatment as usual to a manualized psychotherapy technique called seeking safety (SS) on adolescents in an outpatient’s setting, a variety of domains at posttreatment, including substance use and associated problems, some trauma-related symptoms, cognitions related to SUD and PTSD, and several areas of pathology not targeted in the treatment (e.g., anorexia, somatization), were significantly better in the SS group. Effect sizes were generally in the moderate to high range. Some gains were sustained at follow-up. Therefore, SS appears a promising treatment for this population, but needs further study and perhaps additional clinical modification (142).
Substance-Induced Mental Disorders
In some patients, the use of substances—particularly alcohol, methamphetamine, marijuana, cocaine, ecstasy, hallucinogens, and inhalants—is associated with acute and residual cognitive damage (1,16,73). Acute symptoms may include impaired concentration and receptive and expressive language abilities as well as irritability. Long-term interference with memory and other executive functions may occur. Mackesy-Amiti et al. (99) studied prevalence of psychiatric disorders among 570 young injection drug users (IDUs) (ages 18 to 25). Young IDU experience major depression, alcohol dependence, antisocial PD, and borderline PD at high rates, and multiple SUDs are common. Surprisingly, ADs in this population appear to be similar in prevalence to young adults in general.
The possibility of a substance-induced dementia should be considered in adolescents who have difficulty coping with the cognitive and organizational demands of a structured and supportive program. Some adolescents will be able to use the program if instructions are simplified and if they comprehend information accurately. Improvement in cognitive functioning may be rapid, but the cognitive functioning of some patients continues to improve for as long as a year or more after cessation of the chemical assault to the brain. Some may be left with residual impairments.
Adolescents and their families should be informed of the cognitive consequences of their substance use in a way that does not engender despair but clearly warns against further alcohol or drug use. The presence of cognitive deficits, if they persist, should be considered in rehabilitation, educational, and vocational planning. Such patients need neuropsychologic evaluation and follow-up.
A longitudinal study of 10 years done by Behrendt et al. (100) reports the association between mental disorders and the risk of AUD. A total of 3,021 community subjects (97.7% lifetime AU) aged 14 to 24 years at baseline were followed up prospectively for up to 10 years. With the possible exception of social phobia and externalizing disorders, they do not promote rapid transition, even if they occur particularly early. Several prior mental disorders (PMDs), such as specific phobia, bipolar disorder, and nicotine dependence, were associated with an increased risk of AUD independent of externalizing disorders. Earlier age of onset of PMD was not associated with rapid transition.
For patients who are exposed to substances of abuse and/ or alcohol prenatally, the presence of fetal alcohol syndrome or alcohol- or drug-related neuropsychiatric disorders after birth should be diagnosed with a substance-induced mental disorder secondary to the drug and/or alcohol exposure. Fetal alcohol syndrome is one of the most preventable forms of mental retardation. The distinct facial features make this disorder easier to diagnose than alcohol-related neuropsychiatric disorders, which have no distinct facial features. In fact, 60% to 90% escape identification in the normal population (101). The effect of prenatal cigarette and marijuana smoking and cocaine use on cognitive ability must also be considered. Prenatal cigarette exposure was associated with lower IQ, poorer auditory functioning, and poorer performance on tests requiring fundamental aspects of visual perceptual performance (102). Marijuana exposure altered neural functioning during visuospatial working memory processing in young adulthood (103). Though cocaine can cause developmental delays and learning disorders, it is clear that findings once thought to be specific to in utero cocaine exposure are more likely associated with alcohol, tobacco, and marijuana and the quality of the child’s environment (104).
In fact, a stimulating home environment and high maternal verbal IQ also predicted higher composite IQ scores. Cocaine-exposed boys had lower scores on the Abstract/ Visual Reasoning subscale, with trends for lower scores on the Short-Term Memory and Verbal Reasoning subscales, as exposure effects were observed across domains (105).
Learning Disorders
Hops et al. (106) found that substance abuse at age 14 or 15 could be predicted by academic and social behavior between the ages of 7 and 9. Therefore, early detection of learning disorders is essential in order to reduce the risk of developing an SUD.
The article investigated the behaviors by surveying a cohort of young people from the age of 12 to 16 years with diagnoses for moderate learning disabilities annually during the last 4 years of compulsory schooling. The findings show that these young people consistently reported lower levels of tobacco, alcohol, and cannabis use compared with those attending mainstream school. No other illicit drug use was reported.
Given that some attentional problems are not readily recognized without proper testing, like processing speed deficits and auditory processing problems (106), clinicians should explore other possibilities for attentional problems. In fact, Tapert et al. (107) have shown that attentional difficulties, not necessarily related to ADHD, predicted substance abuse 8 years later.
Adolescents who had more sleep problems were more likely to use tobacco, alcohol, methamphetamine, cannabis, inhalants, cocaine, ecstasy, and any other illegal drugs. Adolescents with learning difficulties had more sleep problems than those without learning difficulties. This study investigated the relationships among sleep problems, learning difficulties, and substance use in adolescence. The sample comprised 427 adolescents (mean age = 16 years) attending remedial schools and 276 adolescents (mean age = 15 years) attending a mainstream school in Cape Town, South Africa. Participants completed anonymous self-report questionnaires. Results indicated that adolescents without learning difficulties were more likely to use tobacco, methamphetamine, and cannabis, whereas those with learning difficulties engaged in more inhalant use. However, sleep problems remained independently associated with tobacco, cannabis, and inhalant use when learning difficulties were taken into account.
Schizophrenia
Patients who simultaneously meet the criteria for schizophrenia and an SUD are less likely to receive treatment in an addiction treatment program than in a psychiatric unit (32,58). As the late adolescent years are a time when many schizophrenic disorders begin and the use of substances may precipitate an incipient psychosis, patients with this disorder may seek treatment during the early stages of schizophrenia (15,33,35).
Research suggests that psychotic-like experiences (PLEs) in the general population are common, but can reflect either transitory or persistent developmental phenomena (36). Using a general adolescent population, Mackie et al. examined whether different developmental subtypes of PLEs exist and whether different trajectories of PLEs are associated with certain environmental risk factors, such as victimization and substance use. Self-reported PLEs were collected from 409 adolescents (mean age = 14 years, 7 months) at four timepoints, each 6 months apart. They identified the following three developmental subgroups of PLEs: (a) persistent, (b) increasing, and (c) low. Adolescents on the persistent trajectory reported frequent victimization and consistent elevated scores in depression and anxiety. Adolescents on the increasing trajectory were engaging in cigarette use prior to any increases in PLEs and were engaging in cocaine, cannabis, and other drug use as PLEs increased at later timepoints. Results from this study concluded that different developmental subgroups of PLEs exist in adolescence and are differentially related to victimization and substance.
Increasingly, younger schizophrenic patients use substances (33,107,108), some in an attempt to manage or deny their symptoms. Their substance use often interferes with treatment of their psychotic disorder. Such patients are best managed in special dual diagnosis programs for psychotic patients, where the psychosis and the substance use are addressed through integrated mental health and addiction treatment (32,49,58,97,107–110).
There is little research on characteristics related to course and prognosis of early-onset psychosis (37). Schothorst et al. (37) focus on premorbid and prodromal characteristics, treatment history, symptoms and classifications, and differences between subgroups with affective and schizophrenic psychosis. They conducted a chart review to study a group of 129 subjects (12 to 18 years) with psychotic symptoms referred to the University Medical Center in Utrecht. The group was characterized by early but nonspecific treatment, developmental problems (mostly social), and clear prodromal symptoms. Drug abuse, depressive symptoms, and suicidal behavior were also frequent. Being male, a relatively long prodromal phase, school problems, and drug abuse were more indicative of the schizophrenic subgroup. Introversion was characteristic for boys with schizophrenia. Classifications, however, were not stable. These findings suggest that early recognition of psychosis can be enhanced in health and youth care facilities. Careful examination of the prodromal phase seems to be helpful to differentiate between schizophrenic and affective psychosis.
Numerous researches have indicated that there may be a reward deficiency dysfunction in schizophrenia that underlines the use of substances of abuse to compensate for this reward deficiency (80,111) and that clozapine and other atypical agents may be effective in the treatment of co- occurring schizophrenia and SUD (80,112). Green et al. (113) have suggested that clozapine may be effective because of its weak blockade of D2 receptors, its potent blockade of norepinephrine alpha-2 receptors, and its ability to release norepinephrine in the brain, which may allow this medication to ameliorate the brain reward circuit deficit in schizophrenic patients that underlies their substance abuse (80,113). Marijuana and alcohol are the two most frequently used substances in these patients, and marijuana may trigger psychosis in vulnerable individuals. Marijuana in these individuals may be associated with early onset of schizophrenia, and clinicians should be aware of this because marijuana is so widely used by adolescents (80,114).
The CATIE study suggested that drug use–related impairment comorbid with schizophrenia may not be a function of use per se but rather of the severity of use (38). In this study, they divided groups into three, according to baseline data: (a) those with moderate/severe drug use, (b) those with mild drug use, and (c) nonusers of illicit substances. The groups were compared on other baseline characteristics. Significantly poorer outcomes were observed in the domains of psychosis, symptoms of depression, and quality of life for moderate/severe drug users in comparison with both mild users and abstainers. This highlights the importance of comprehensive assessment and treatment of illicit substance abuse in schizophrenia. Long-term treatment approaches that integrate harm reduction strategies may offer promise in maximizing positive outcomes for such dually diagnosed patients.
Attention Deficit Hyperactivity Disorder
Many professionals involved in the treatment of adolescents with SUDs have noted the large number of those who also have ADHD (7,18,19,50,57,115,116). Bukstein et al. (77) postulate that there is no direct connection but that both often coexist with CD. Crowley and Riggs (7) noted comorbidity with affective, anxiety, and antisocial disorders in the patients and their families. In another study, Schubert et al. (117) explored the influence of mental health and substance use problems and criminogenic risk in serious juvenile offenders; 57.5% met the criteria for at least one of the assessed mental health problems (MHPs): affective disorder, anxiety, ADHD, and SUDs. The presence of an SUD showed consistent associations with the outcomes. Current juvenile justice policies that focus treatment efforts on both criminogenic and mental health factors (with particular emphasis on treating SUDs) appear to be well founded.
Cigarette smoking increases the risk for subsequent drug and AUDs among individuals with ADHD (118). In a longitudinal, case–control family studies of boys and girls with and without ADHD ascertained from psychiatric and pediatric sources, 165 individuals with ADHD and 374 controls followed up longitudinally and masked for 10 years. According to the results, youth with ADHD who smoked cigarettes (n = 27) were significantly more likely to subsequently develop drug misuse and dependence compared with youth with ADHD who did not smoke (n = 138, P < 0.05).
Treatment should include behavioral and educational interventions. Pharmacotherapy for adolescents has been controversial (6,78,90). Riggs et al. and Solhkhah et al. (80–82,119) have reported some success with the use of bupropion. Wilens et al. (19) suggested that the use of stimulants to treat adolescents for ADHD may lower the risk of a subsequent SUD. There are few studies on the use of long-acting stimulants in the treatment in adolescents with SUD and ADHD. However, in one study, subjects had a significantly greater reduction in ADHD symptoms (P < 0.001 for all analyses) during treatment with long-acting stimulants compared to placebo. However, there was no significant effect on drug use (120).
Gudjonsson et al. (121) investigated the relationship between ADHD symptoms and cigarette smoking, alcohol use, and illicit drug use. The authors studied 10,987 pupils in the final 3 years of their compulsory education in Iceland (ages 14 to 16 years). The participants completed questionnaires in class relating to anxiety, depression and antiestablishment attitudes, ADHD symptoms, smoking, alcohol consumption, and illicit drug use. According to the results, of the total sample, 5.4% met screening criteria for ADHD. Smoking, alcohol, and illicit drug use were significantly related to ADHD symptoms. In addition, the number of different illicit drugs consumed was significantly higher among the ADHD symptomatic than the nonsymptomatic participants, including the illicit use of sedatives. The main distinguishing illicit drug substances were lysergic acid diethylamide (odds ratio or OR = 8.0), cocaine (OR = 7.5), mushrooms (OR = 7.1), and amphetamines (OR = 6.5). ADHD symptoms predicted smoking, alcohol use, and illicit drug use independent of anxiety, depression, and anti-establishment attitudes. In addition, polysubstance use was linearly and incrementally related to ADHD symptoms with a large effect size.
Riggs et al. have suggested that it is prudent to use non-stimulant medications as a first line when treating comorbid ADHD and SUD. However, prior to starting stimulants, the following questions should be asked: (a) Have other non-stimulant medications been tried or are there specific reasons why stimulants make sense as a first-line treatment? (b) Is the patient a current substance abuser? (c) If so, has the family been warned about specific potential risks involved in using stimulants? (d) Is the patient reliable and can parents be involved in the distribution of the medication and in the treatment plan? (e) If the patient is a current substance abuser, is he/she motivated and actively involved in treatment? (f) Has the patient had an established period of abstinence? (g) Is there a history of amphetamine or other stimulant abuse? (h) If the individual abused stimulants, what was the reason for the use? To get school work done or get high? (80).
Riggs et al. (122) evaluated the efficacy and safety of osmotic-release methylphenidate (OROS-MPH) compared with placebo for ADHD and the impact on substance treatment outcomes in adolescents concurrently receiving CBT for SUDs. OROS-MPH did not show greater efficacy than placebo for ADHD or on reduction in substance use in adolescents concurrently receiving individual CBT for co-occurring SUD. However, OROS-MPH was relatively well tolerated and was associated with modestly greater clinical improvement on some secondary ADHD and substance outcome measures.
Solhkhah et al. (119) evaluated the response of bupropion hydrochloride sustained release (SR) in SUD adolescents with comorbid psychopathology (both ADHD and MD). Fourteen adolescent outpatients were treated naturalistically and followed openly for 6 months. At the 6-month endpoint compared to baseline, treatment with bupropion was associated with clinical and significant reductions in drug use screening inventory (DUSI), ADHD symptom checklist, Hamilton Rating Scale for Depression (HAM-D), and reductions in the clinical global impression scales (CGIs) for ADHD, depression, and substance abuse. The mean daily dose of bupropion SR was 315 mg (in divided doses). No significant adverse events were noted during the follow-up period. Study suggested that bupropion may be an effective medication for the treatment of substance- abusing adolescents with comorbid MDs and ADHD.
There is growing evidence of other cognitive interventions that may assist with the improvement of attention, a major component of ADHD. There are no studies that have used these techniques in the treatment of adolescents with SUD and ADHD, but these may prove helpful in the future (123).
Conduct Disorder and Antisocial Personality Disorder
CD and antisocial PD are the diagnoses that most often co-occur with substance abuse, particularly in males (7,15– 19,30,39,46,52,57,72). Goodman (124) conducted a 3-year longitudinal study to examine the association between substance use and common child MHPs in a British sample of 3,607 youths aged 11 to 16 years. Externalizing (specifically behavioral) problems at baseline independently predicted all forms of substance use, and adjusting for comorbid externalizing problems is vital when investigating the effects of internalizing problems with a particularly strong effect on smoking. In all cases, this association showed a dose–response relationship.
The characteristic symptom of antisocial PD is a pervasive pattern of disregarding and violating the rights of others. The disorder may involve deceitfulness, impulsivity, failure to conform to rules or the law, aggressiveness, and irresponsibility (1). CD has similar criteria but includes manifestations that are likely to be seen in younger persons, such as cruelty to animals, running away, truancy, and vandalism.
Externalizing behaviors such as substance misuse (SM) and conduct disorder (CD) symptoms highly co-occur in adolescence. While disinhibited personality traits have been consistently linked to externalizing behaviors, there is evidence that these traits may relate differentially to SM and CD (125). Conrod et al. aimed to assess whether this was the case, after examining the nature of the relationship between SM and CD symptoms in an adolescent sample (n = 392), using structural equation modeling similar to those found in adults (126). The results showed that CD and SM symptoms were organized hierarchically, with symptoms explaining a single broad, coherent construct of externalizing behavior, but also explaining specific factors of SM and CD that vary independently from the general externalizing factor. Furthermore, disinhibited personality traits related differentially to these factors, with results showing that, even controlling for inhibited personality traits, impulsivity was associated with CD and the common variance shared by CD and SM, while sensation seeking was specifically associated with SM only. Hopelessness was also associated with the common variance shared by SM and CD. Results confirm impulsivity, hopelessness, and sensation seeking as key correlates of externalizing behavior problems in adolescence, identifying them as clear targets for intervention and prevention strategies.
Many researchers have noted that adolescent SUD usually occurs as part of a constellation of problem behaviors (7,46,50,101,116). Cloninger (127) presented an interesting scheme of hereditary factors on three axes that may account for many psychiatric diagnoses and their interrelationships. The three axes are reward dependence, harm avoidance, and novelty seeking. Based on these axes, Cloninger (127) distinguished type 1 and type 2 alcoholic patients. Type 2 alcoholic patients score low on reward dependence and harm avoidance and high on novelty seeking. Younger alcoholic patients with antisocial personality fit the type 2 classification. The higher prevalence of antisocial personality and conduct disorders among younger alcoholic patients may explain why many clinicians find adolescent substance abusers more difficult to treat.
Conduct problems, substance use, and risky sexual behavior have been shown to coexist among adolescents, which may lead to significant health problems (128). Witkiewitz et al. designed a study to examine relations among these problem behaviors in a community sample of children at high risk for CD. A latent growth model of childhood conduct problems showed a decreasing trend from grades kindergarten to 5. During adolescence, four concurrent conduct problem and substance use trajectory classes were identified (high conduct problems and high substance use, increasing conduct problems and increasing substance use, minimal conduct problems and increasing substance use, and minimal conduct problems and minimal substance use) using a parallel process growth mixture model. Across all substances (tobacco, binge drinking, and marijuana use), higher levels of childhood conduct problems during kindergarten predicted a greater probability of classification into more problematic adolescent trajectory classes relative to less problematic classes. For tobacco and binge drinking models, increases in childhood conduct problems over time also predicted a greater probability of classification into more problematic classes. For all models, individuals classified into more problematic classes showed higher proportions of early sexual intercourse, infrequent condom use, receiving money for sexual services, and ever contracting a sexually transmitted disease. Specifically, tobacco use and binge drinking during early adolescence predicted higher levels of sexual risk taking into late adolescence. Results highlight the importance of studying the conjoint relations among conduct problems, substance use, and risky sexual behavior in a unified model.
Horowitz et al. (13) consider many young patients who abuse substances to have a combination of characteristics (such as increased hostility, depression, and suicidal ideation) that suggest an underlying—perhaps neurochemically determined—difficulty with self-regulation and aggression. Adolescents with CDs and antisocial PD need a strong behavioral program with clear limits. If there is a comorbid disorder (such as a mood or attention disorder that can be treated successfully), the adolescent is more likely to do well (7,19,116).
Borderline and Narcissistic Personality Disorders
In addition to psychiatric diagnoses on Axis I, the PDs described on Axis II of the DSM-IV are relevant to the treatment of adolescents who abuse substances (1,127,129– 133). PDs are enduring patterns of inner experience and behavior that affect cognition, interpersonal behavior, emotional response, and impulse control. Personality factors often make an adolescent difficult to treat.
Personality traits have been strongly associated with substance use risk (132). The personality traits constraint (CN) and negative emotionality (NE) have been consistently associated with alcoholism. Elkinds et al. examined the association of personality at age 17 with timing of onset and with prospective prediction of nicotine, alcohol, and illicit drug disorders 3 years later in a twin sample (569 females, 432 males). Earlier onset of alcohol and drug disorders (by age 17) was related to significantly lower CN compared with later onsets (by age 20); high NE was related to either onset. NE, as well as CN, uniquely predicted new onsets of all three types of SUDs by follow-up, with preexisting substance disorders taken into account. Personality traits confer generalized risk for developing any substance disorder, though some traits are more strongly linked with some substance disorders than with others.
Evren et al. (130) evaluated possible interactions between severity of borderline personality features (BPFs), dissociative experiences, and alexithymia among substance- dependent men while controlling for their current age, depression, and anxiety. Participants were 200 substance-dependent men consecutively admitted to a dependency treatment unit. The Borderline Personality Inventory, the Toronto Alexithymia Scale, the Dissociative Experiences Scale, the Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory were administered to all participants. Severity of negative affect, alexithymia, dissociative experiences, and BPF was correlated with each other. Being younger, severity of dissociative experiences, difficulty in identifying feelings, depression, and trait anxiety predicted the severity of BPF in linear regression analysis. These findings suggest that alexithymia and dissociative experiences may be a way of coping with depression and chronic anxiety, but they also seem to be related to the severity of BPF independent of the negative affect and from each other.
Borderline PD is marked by impulsivity and instability of interpersonal relationships, which affect self-image. A marked sensitivity and wish to avoid abandonment, chronic feelings of emptiness, inappropriate and intense anger, and suicidal or self-mutilating behavior are characteristic of borderline PD. In a treatment setting, patients with borderline PD can wreak havoc because of the severe regression often manifested and the divisiveness they often cause among staff.
Clinical and population-based samples show high comorbidity between SUDs and Axis II PDs (131). However, Axis II disorders are frequently comorbid with each other, and existing research has generally failed to distinguish the extent to which SUD/PD comorbidity is general or specific with respect to both specific types of PDs and specific types of SUDs. Authors sought to determine whether ostensibly specific comorbid substance dependence–Axis II diagnoses (e.g., alcohol use dependence and borderline PD) are reflective of more pervasive or general personality pathology or whether the comorbidity is specific to individual PDs. Face-to-face interview data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Participants included 34,653 adults living in households in the United States. Results indicated that substance dependence–Axis II comorbidity is characterized by general (pervasive) pathology and by cluster B PD pathology over and above the relationship to the general PD factor. Further, these relations between PD factors and substance dependence diagnoses appeared to largely account for the comorbidity among substance dependence diagnoses in the younger but not older participants. Our findings suggest that a failure to consider the general PD factor, which we interpret as reflecting interpersonal dysfunction, can lead to potential mischaracterizations of the nature of certain PD and SUD comorbidities.
A pervasive pattern of grandiosity, a need for admiration, and a lack of empathy characterize narcissistic PD. The patient feels unique and entitled to special treatment. A patient with narcissistic PD may have difficulty participating in groups or seeing other people except as need gratifiers.
Both of these PDs can present challenges to the clinician and the treatment staff. Powerful negative feelings, conscious and unconscious (30), are easily aroused by patients who are manipulative and full of rage, who feel entitled, and whose behavior saps the emotional strength of the staff (85). If the treatment of a patient requires a great deal of emotional energy, personality issues likely are involved. In such situations, it is essential to be aware of the effect that such patients exert and to take care of the clinical staff as well as the patient.
Eating Disorders
The incidence of EDs and substance abuse in the adolescent population has increased (17,52,134), so it is not uncommon to find them together. In fact, a fourth of all patients who have an ED either have a history of substance abuse or currently are abusing substances (134).
Substance use problems in eating disorder adolescents are frequent. In a recent paper, the prevalence of regular or risky substance use (RRSU) and substance use disorder (SUD) in adolescents with ED has been reported (134). In this study, the Teen Addiction Severity Index (T-ASI), Youth Self-Report (YSR) scale, and substance use questionnaires were administered to 95 adolescent patients aged 12 to 17 years who fulfilled the DSM-IV-TR diagnostic criteria for anorexia nervosa, bulimia nervosa, and ED not otherwise specified. All patients were consecutively attended at an eating disorders unit. According to this prevalence study, 14.7% presented SUD related to tobacco, 3.2% to cannabis, 1.1% to alcohol, and 1.1% to other substances. Patients with RRSU-SUD of any substance except tobacco were 34.7%. Patients with RRSU-SUD failed more subjects, repeated more school years, and had higher scores on T-ASI scales of problems at school, family function, and social relationships and on YSR scales of delinquent behavior and externalizing problems.
Anorexia nervosa, which involves weight restriction and increased activity, a distorted body image, and an intense fear of losing control and becoming fat (1), is not as prevalent as bulimia in the general population and among persons who abuse substances. Bulimic patients have been found to have a greater risk for substance abuse than restrictive anorexics (135). However, Bulik et al. (136) have also shown that bulimic women with SUD have higher novelty seeking than bulimic women without SUD. Bulimia involves recurrent episodes of binge eating, sometimes accompanied by compensatory measures (such as vomiting or laxative abuse), and a preoccupation with food and weight. Of all EDs, 90% to 95% occur in females (133). Though anorexic patients have a characteristic emaciated appearance, bulimic patients can be any weight. Patients who consistently spend time in the bathroom after meals may be purging.
Disordered eating behaviors and substance use are two risk factors for the development of serious psychopathology and health concerns in adulthood (137). The importance of accurate or inaccurate weight perception among adolescents has received increased interest given documented associations with nutritional beliefs and weight management strategies. In one study, Eichen et al. examined the associations among the perceptions of weight and substance use with disordered eating behaviors among a diverse sample of normal weight and overweight adolescent males and females. They analyzed data from the 2007 National Youth Risk Behavior Survey (YRBS). The sample consisted of 11,103 adolescents (53.4% female; 44% Caucasian, 21% African American; 13% Hispanic; age responses ranged from 12 and under to 18 and over), with 31.5% meeting criteria for being either at risk for obesity or already obese (i.e., overweight). As hypothesized, overestimation of weight among normal weight adolescents and accurate perceptions of weight among overweight adolescents were associated with higher rates of disordered eating behaviors. In normal weight adolescents, use of all three substances (tobacco, binge drinking, and cocaine) was associated with each disordered eating behavior. In contrast, findings revealed differences for overweight adolescents between the type of substance use and disordered eating behavior. Post hoc analyses revealed that gender moderated some of these relationships among overweight individuals.
Persons with an ED may abuse amphetamines to lose weight. Katz (135) postulates that the proneness to substance abuse in bulimic patients may be due to BPFs.
CONCLUSIONS
In sum, psychiatric disorders and SUDs often occur together, complicating assessment and treatment. An awareness of the prevalence and manifestations of psychiatric diagnoses is essential to high-quality treatment of adolescents. An ongoing relationship with a psychiatrist who can be available for consultation as needed is helpful. Clinicians also should keep current on psychopharmacologic interventions (87,138). Often, the use of psychiatric medications such as antidepressants, mood stabilizers, psychostimulants, and others is of benefit. However, care must be taken to avoid potential interactions between the illicit drugs and the prescribed medications (70). Also, self-help groups such as Alcoholics Anonymous, Narcotics Anonymous, or “Double-Trouble” groups for patients with co-occurring psychiatric and addiction disorders can be a useful adjunct to treatment (139–148).
Careful observation, history taking, and appropriate consultation result in better detection and treatment of comorbid disorders and, ultimately, of the initial substance abuse problem.
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