1. Substance use General Unless otherwise indicated, all answers are from DSM-IV-TR or from Practice Guideline, AJP, Supplement, August 2006 As of 6Sep08.

2. Substance Abuse maladaptive patterns Q. DSM-IV-TR has four major maladaptive patterns listed, of which the pt must have at least one. Name the four.

3. Substance abuse maladaptive patterns Ans. 1] Recurring use leads to inability to meet obligations at school, work or family 2] Recurring use when physically hazardous to do so. 3] Use leads to recurring legal problems. 4] Continued use despite persistent social problems associated with use.

4. Substance abuse time requirement Q. How long must the maladaptive behaviors last to meet DSM-IV requirements?

5. Substance abuse Time requirements Ans. 12 months.

6. Abuse & Dependence Q. Can you dx a pt with both alcohol abuse and alcohol dependence?

7. Abuse and Dependence Ans. No, Abuse infers that the pt doesn’t qualify for dependence. [Since DSM-IV-TR, concerns have been raised that one can be dependent and yet never met criteria for abuse.]

8. Dependence maladaptive findings Q. For Dependence, DSM-IV lists 7 maladaptive behaviors or conditions and expects the pt to meet at least 3 of them. List the 7.

9. Dependence maladaptive findings Ans. At least 3 of the following 7: 1.Tolerance 2.Withdrawal signs 3.Pt takes substance more than was intended 4.Pt has unsuccessful desire to decrease or stop taking the substance 5.Pt spends a lot of time obtaining the substance 6.Pt reduces the time spent on important activities because of substance use 7.Pt continues use despite knowing it has been problematic.

10. Dependence How long Q. How long must the pt have had the three of more maladaptive signs to qualify for the dx of Dependence?

11. Dependence How long Ans. 12 months.

12. Polysubstance dependence Q. Under what circumstances are you to use the dx of “Polysubstance dependence”?

13. Polysubstance dependence Ans. 1.Has to have problems resulting from the use of at least three substances [not including caffeine or nicotine]. BUT 2. Does not meet the criteria of any single substances. E.g.: DWI from alcohol, poor work performance because of cocaine, and getting into fights because of PCP. Thus, is not be a common dx. If pt meets criteria for alcohol dependence and cocaine abuse, they are both to be listed.

14. Polysubstance abuse Q. Status of polysubstance abuse in DSM- IV?

15. Polysubstance abuse Ans. Not recognized as a disorder in DSM- IV. {If you want to use the concept of polysubstance abuse, you could use “Other Substance Abuse [polysubstance abuse]”}

16. On Methadone Q. You have placed your opioid dependent pt on methadone maintenance and he has been without any signs of opioid dependence over the last 5 weeks. What is his dx now?

17. On methadone Ans. Opioid dependence, early full remission on agonist therapy.

18. CAGE Q. What is “CAGE”?

19. CAGE Ans. A screening series of four questions, usually focused on alcohol: 1.Have you ever felt the need to Cut down on drinking? 2.Have you been Annoyed by others criticizing your drinking? 3.Have you felt Guilty about your drinking? 4.Have you needed an Eye opener first thing in the morning.

20. Substance-induced depression V. MDD Q. Deciding whether to dx a pt with a substance-related disorder or with a non- substance-related disorder in a pt who does have abuse/dependence is not always easy. What would tilt you toward a MDD dx in a pt whose abuse/dependence presents with the signs of depressive event? [Three of the four indicators are very obvious.]

21. Substance-related depression v. MDD Ans. The following suggests MDD: 1.Family hx of MDD 2.Depressive event signs are not seen exclusively in conjunction with substance use. 3.Depressive signs preceded onset of substance abuse/dependence 4.Depressive signs were seen during extended substance-free periods.

22. Abuse v.Dependence Q. What is the difference between abuse and dependence?

23. Abuse v. Dependence Ans. Dependence has: Tolerance Withdrawal or Compulsive Use