Articles from prior issues of The Advocate

November/December, 1999

Evaluating Clients With Mental Impairments And Substance Abuse
by Peter LeBray, Ph.D. ABPDC, Oregon DDS

COMORBIDITY Significant comorbidity confounds SSA claims involving mental impairments (MI) and drugs and alcohol (DAA). The comorbid incidence per selected MI is: Antisocial Personality Disorder, 80%; Bipolar Disorder, 60%; Schizophrenia, 47%; Major Depression, 23%. Comorbid MI-DAA cases ideally warrant dual assessment, diagnosis and treatment.

ASSESSMENT

Accurate assessment must include:

*Current symptoms-Patterns of symptom variability, responsiveness to intervention, whether MI symptoms precede DAA use. *Careful history-Determining what came first DAA or MI, what symptoms remain when abstinent, knowledge of clinical course of MI.

*Response to treatment-Generally, poor response to MI care may reflect DAA and vice versa.

*Family history-Careful review of both MI and DAA in family system may reveal additional risk factors.

*Collateral information-Reports from credible, knowledgeable third parties can be very useful in addressing chronicity, claimant credibility.

*Physical exam and laboratory findings-Physical signs, symptoms, urine drug screens and observational reports are invaluable. SUBSTANCE DEPENDENCE OR ABUSE

Per DSM-IV criteria, dependence includes substance tolerance, withdrawal, high involvement and continued use despite knowing problems and risks. Abuse often is reactive to an acute event such as role change (divorce, job firing) or loss (death, ruin) without increased tolerance or withdrawal evident. Intoxication is reversible when not complicated by MI. DAA withdrawal can cause distress socially and occupationally over time. Generally, prognosis is poorer with BOTH DAA and MI, along with assessment and management. Prolonged use of certain substances can result in irreversible dementia substantitated with neuropsychological testing.

SELECTED SUBSTANCES

Substance related effects can include: disinhibition, mood shifts, paranoia, transient psychosis (visual hallucinations), agitation, mania, cognitive deficits. Prolonged and extreme use of alcohol and inhalants can result in irreversible substance-induced dementia. Cannabis has a ½ life of 7-10 days and intoxication can present: euphoria, social withdrawal, impaired sense of time, diminished memory, delirium, anxiety or transient paranoia. Cocaine has a sudden effect (1/2 life of 90 minutes) with euphoria, irritability, anxiety and hallucinations including “coke bugs”. Amphetamines, PCP and other drugs often cause euphoria (rush), mania, psychotic symptoms, then changing to paranoia and hyperactive or hostile behavior.

CASE EXAMPLE

A 35 year old claimant was psychiatrically hospitalized three times within an 18 month period. Urine drug studies on each occasion were positive for cocaine. Symptoms included euphoria, anxiety suddenly shifting to profound depression. The file showed a two year period of stability and productivity (work) prior to the first decompensation. Claimant improved at each discharge and DAA MATERIAL was applied given further input from credible third parties (spouse, employers) documenting normal mood, behavior and social skills when not using DAA.

ISSUES

In dual diagnosis cases involving MI and DAA, often it is important to “wait and see”; however, in the adjudicative world this may not be possible. Clear evidence in file must exist to support adaptive abilities exclusive of DAA and in relation to MI. Consideration to co-morbidity, careful and comprehensive MI and DAA histories, consideration to interventions and effects and reliable reports of actual functioning are paramount in DAA-MI claims adjudication.