Co-occurring Alcohol and Other Drug

and Mental Health Conditions in

Alcohol and other Drug Treatment
Settings

Session 2:
Classification
of Mental
Disorders
1

Comorbidity Guidelines

Refer to:

Chapter 5

Classification - Key Points

Disorders represent particular combinations

of signs and symptoms grouped together to
form criteria as per DSM-IV-TR
Certain number of criteria need to be met
within a certain time frame for a person to
be diagnosed as having a disorder
Not all AOD workers are able to formally
diagnose the presence or absence of
mental health disorders
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Classification Key Points

(2)

Diagnoses of mental health disorders

should only be made by suitably
qualified and trained health professionals
Useful for all AOD workers to be aware of
characteristics of disorders so are able to
describe and elicit mental health
symptoms when undertaking screening
and assessment, and to inform
treatment planning
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Symptoms without
Diagnosis

Classified as mental health disorder must

meet diagnostic criteria
However, large number in AOD services
who display symptoms but do not meet
criteria
(Eg: anxiety but without an anxiety
disorder)
Can still impact significantly on
functioning and treatment outcomes
5

Categories of MH Disorders in
Comorbidity Guidelines

Mood disorders
Anxiety disorders
Personality disorders
Psychotic disorders
Substance-induced disorders

Mood Disorders

Major depressive episodes

Manic episodes
Mixed episodes
Hypomanic episodes.

Major
depressive
episode
Depressed mood

Hypomanic
episode
Normal mood

Manic
episode

Elevated mood

Major Depressive Episode

Some of following symptoms experienced
nearly every day for at least 2 weeks:
Depressed mood or loss of interest or
enjoyment in activities
Reduced interest or pleasure in almost
all activities
Change in weight or appetite
Difficulty concentrating or sleeping (i.e.,
sleeping too much or too little)
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Major Depressive Episode

(2)

Restlessness and agitation

Slowing down of activity
Fatigue or reduced energy levels
Feelings of worthlessness or
excessive/inappropriate guilt
Recurrent thoughts of death, suicidal
thoughts, attempts or plans
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Manic Episode
Person experiences abnormally elevated,
expansive, or irritable mood for at least 1
week characterised by:

Inflated self-esteem
Decreased need for sleep
Increased talkativeness or racing thoughts
Distractibility
Agitation or increase in goal directed activity
(e.g., at work or socially)
Excessive involvement in pleasurable activities
that have a high potential for negative
consequences.
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Hypomanic and Mixed

Episodes

Hypomanic same as manic episode but

is less severe
May only last 4 days and does not
require the episode to be severe enough
to cause impairment in social or
occupational functioning
In mixed episode, person experiences
both a manic episode and major
depressive episode for at least 1 week
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Anxiety Disorders

Many people feel anxious because they

have reason to eg: trouble with law,
homelessness
Many in AOD treatment will experience
anxiety as consequence of intoxication,
withdrawal, or living without using AOD
Usually reduces over time with period of
abstinence
Problematic when persistent, or so frequent
and intense that prevents person from living
his/her life in the way that he/she would like
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Panic Attack

Sweating
Shaking
Shortness of breath
Feeling of choking
Light headedness
Heart palpitations,
chest pain or
tightness
Numbness or tingling
sensations

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Chills or hot flushes

Nausea and/or
vomiting
Fear of losing
control, going crazy
or dying
Feelings of unreality
or being detached
from oneself

Types of Anxiety Disorders

Generalised anxiety disorder (GAD)

Obsessive compulsive disorder (OCD)
Panic disorder
Agoraphobia
Social phobia
Specific phobia
Post traumatic stress disorder (PTSD)
Acute stress disorder.
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PTSD

Can develop after traumatic event

May experience some of following:

Intrusions: re-experiencing event as

nightmares, or flashbacks
Avoidance: avoiding thoughts, feelings,
people, places or activities that remind
him/her of the event,
Hyperarousal: increased startle response,
irritability or anger, difficulty sleeping and
concentrating
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Personality Disorders

Enduring destructive patterns of thinking,

feeling, behaving, and relating to other
people across wide range of social and
personal situations
Maladaptive traits are stable and long lasting
Tend to develop in adolescence or early
adulthood and are generally lifelong
Most common in AOD context ASPD and BPD

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AOD and Personality

Disorders

AOD use disorders may cause fluctuating

symptoms that mimic symptoms of
personality disorders
Eg: impulsivity, aggressiveness, selfdestructiveness, relationship problems, work
dysfunction, engaging in illegal activity,
dysregulated emotions and behaviour
Can be difficult to determine whether a
person has a personality disorder
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Antisocial Personality
Disorder

Failure to conform to social norms with

respect to lawful behaviour
Disregard for the wishes, rights and
feelings of others
Deceptive and manipulative in order to
gain personal profit or pleasure; may
repeatedly lie or con others
Reckless disregard for own or others
safety
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Antisocial Personality
Disorder (2)

Impulsive behaviour; decisions made on

spur of the moment, without
forethought, and without consideration
of the consequences for self or others
May lead to sudden change of jobs,
residences or relationships
Irritability and aggression; repeated
involvement in physical fights or assaults
Consistent and extreme irresponsibility
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Borderline Personality
Disorder

Persistent patterns of instability in

relationships, mood, and self-image
Marked impulsivity, particularly in relation
to behaviours that are self-damaging
Extreme efforts to avoid rejection or
abandonment
Pattern of unstable and intense
relationships
Unstable self-image or sense of self
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Borderline Personality
Disorder (2)

Impulsivity
Recurrent suicidal behaviour, threats or
self-mutilating behaviour
Unstable mood
Chronic feelings of emptiness
Inappropriate, intense anger
Stress-related paranoid thoughts or
severe dissociative symptoms
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Psychotic Disorders

Loss of touch with reality

Feelings, thoughts and perceptions
severely altered
Delusions and Hallucinations
May be due to intoxication or withdrawal
from substances
If the person experiences psychotic
episodes when not intoxicated or
withdrawing, possible they may have one
of the disorders described
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Delusions

Fixed, false beliefs not consistent with

cultural context
Involve a misinterpretation of
perceptions or experiences
Eg: feel that someone is out to get
them, they have special powers, or
passages from newspaper have special
meaning for them
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Hallucinations
Disturbance of sensory perceptions
Auditory (hearing voices or sounds)
Visual (seeing things not present)
Olfactory (smelling things not present)
Tactile (feeling or sensing something)
Gustatory (taste)

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Other Symptoms of
Psychosis

Disorganised speech
Grossly disorganised behaviour
Catatonic behaviour (eg decreased
reactivity)
Affect flattening (reduced range of
emotional expressiveness)
Alogia (restricted thought and speech)
Avolition (reduced involvement with
activities)
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Schizophrenia

Most common and disabling of psychotic

disorders
Affects ability to think, feel and act
To be diagnosed symptoms must have
been continuing for a period of at least 6
months
Symptoms are grouped within 2 types:

Positive symptoms
Negative symptoms
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Positive Symptoms of
Schizophrenia

(Not as in pleasurable!)
Presence of excess or distortion of
normal functioning and include
hallucinations, delusions, disorganised
speech, grossly disorganised behaviour
and catatonia

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Negative Symptoms of
Schizophrenia

Absence of normal functioning including

affective flattening, avolition, alogia
Can cause significant impairment in a
persons functioning
Classification of types of
schizophrenia depending upon the
predominance of symptoms displayed
(paranoid, disorganised, catatonic,
undifferentiated, residual type)
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Other Psychotic Disorders

Schizophreniform disorder:
equivalent to schizophrenia except its
duration limited to less than 6 months
Schizoaffective disorder: symptoms
of schizophrenia alongside major
depressive, manic or mixed episode
2 types: i) bipolar type (if manic or
mixed); ii) depressive type (if major
depressive)
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Substance-Induced
Disorders

Occur as direct consequence of AOD

intoxication or withdrawal
Diagnosis requires symptoms only
present following intoxication or
withdrawal
If symptoms in absence of intoxication or
withdrawal, possible they have
independent mental health disorder
Symptoms tend to reduce over time with
period of abstinence
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Examples of Substance
Induced Disorders

Alcohol use/withdrawal - symptoms of

depression or anxiety
Manic symptoms induced by intoxication
with stimulants, steroids, hallucinogens
Psychotic symptoms induced by
withdrawal from alcohol, intoxication with
amphetamines, cocaine, cannabis, LSD
or PCP
Other disorders - substance-induced
delirium, amnestic disorder, dementia,
sexual dysfunction, sleep disorder
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Substance-Induced
Psychosis

Difficult to distinguish substance-induced

psychosis from other psychotic disorders
Substance-induced psychosis - symptoms
appear quickly and last relatively short
time, from hours to days until the effects
of drug wear off
Psychosis can persist for days, weeks,
months or longer
Possible individuals already at risk for
developing psychotic disorder triggered
by substance use
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Substance-Induced Psychosis
(2)

Visual hallucinations more common in

substance withdrawal and intoxication
Stimulant intoxication more commonly
associated with tactile hallucinations,
person experiences physical sensation
interpret as having bugs under skin ("ice
bugs" or "cocaine bugs)
Tactile hallucinations can occur in alcohol
withdrawal; auditory and visual
hallucinations are more common
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Substance-Induced Psychosis
(3)

Stimulant psychosis sometimes more

agitated, energetic, more difficult to
calm with sedating or psychiatric
medication compared to non-drug
induced psychosis
Difference with schizophrenia - lack of
negative and cognitive symptoms with
return to normal inter-episode
functioning during periods of abstinence
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Delirium

Disturbance of consciousness and

cognition that represents significant
change from previous level of functioning
Reduced awareness of surroundings,
difficulty concentrating, may be difficult to
engage him/her in conversation
Changes in cognition include short-term
memory impairment, disorientation (in
regards to time or place), language
disturbance (eg difficulty finding words,
naming objects, writing)
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In sum

Not all clients with symptoms of mental

illness will meet diagnostic criteria
Diagnostic labels can be very useful but
should not be limiting!
Diagnosis needs to be undertaken by
trained professionals however important
to be aware of symptoms and to be able
to communicate with other
professionals, clients and families/carers
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