Distinguishing Substance Induced Mood Disorders
Patrick J. Hart Psy.D.
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Psychologists and psychotherapists frequently do not have specialized training in the identification and treatment of substance related disorders. It has been reported that 90% of graduate psychology students have had no formal course work in the area of substance abuse (Margolis & Zweben, 1998).
It is so very noteworthy that::
“Many therapists today find themselves in the remarkable position of having no systematic understanding of how to identify, treat, or appropriately refer alcohol and drug problems, despite the fact that we are in the middle of an epidemic of chemical use of unprecedented proportions.” (p.19).
And it is extremely important to acknowledge that:
“Substance abuse disorders can and do mimic virtually every other psychiatric diagnosis.” (p.10).
Very few therapists, psychologists, or psychiatrists have undertaken rigorous formal training to prepare them to treat clients with problems of addiction. Conducting psychotherapy with people who suffer from chemical, drug, or alcohol abuse is inherently difficult, and many professionals lack the clinical discernment (or willingness) to work with such populations.
The stigma and shame that surround problems of addiction routinely produces clients who are secretive and entirely evasive about the true form and frequency of their use of prescription or recreational drugs and alcohol. Opening up to such difficulties is problematic for therapist and clients alike! The fact is, terms like “addict” and “alcoholic” still carry a life-stultifying stigma and put one at risk from immensely unfortunate prejudices.
Mood disorders may be brought about by alcohol and various other “recreational” drugs. Mood disorders can also be associated with prescribed medications or a person’s exposure to a broad range of environmental toxins and allergins.
Bipolar Spectrum Disorder symptoms (Bipolar I and Bipolar II distinctions) are associated with a wide range of impulsive and self-destructive behaviors. Substance use and similar stressors frequently result in symptoms that mimic depressive affects (anhedonia) and manic / hypomanic behavior patterns. Psychologists and other clinicians are advised to remain vigilant to the presence of substance abuse patterns in caring adequately for bipolar patients.
For a more comprehensive exploration of the distinctions in Bipolar Spectrum Disorders, please see the attached article that compares and critically reviews Diagnostic Criterion and Indications for Therapy.
Differential Diagnosis:
Substance Induced Mood Disorder and Personality Disorders
One of the primary debates surrounding the diagnosis of Bipolar II Disorder (BII) concerns its comorbidity with personality disorders, which has . been reported at varying rates. Ucok, et al, (1998) indicate that epidemilological surveys using DSM-III criteria have estimated the prevalence of overall personality disorders from 10% to 13% in outpatient clinical populations. In the 1980’s comorbidity rates between Bipolar I (BI) and personality disorders were reported at 4% to 12%, yet more recently such rates have been reported to be significantly higher at 47.7% (Ucok, 1998).
One reason for such differences in reports of comorbidity rates may be due to the varying methodologies used for assessment and to changes in DSM-IV diagnostic nomenclature. Assessment methods vary from self-report measures to structured interviews, and the need for more definitive research is apparent.
One recent study indicates that: “It has been found that the majority of personality disorders associated with Bipolar II Disorder are from clusters B (histrionic, borderline, narcissistic, antisocial) in bipolars, and cluster C (avoidant, dependent, passive-aggressive, obsessive-compulsive) in unipolars” (Ucok, et al., 1998, p. 72). These authors report that 47.5% of BI subjects in this study were noted for at least one personality disorder, as compared to a 15.5% in control subjects.
Although the authors provide no statistic, it is noteworthy that suicide attempts were more frequent in patients with a history of Personality Disorder diagnoses. The authors also indicate that patients with BI in remission have traits that differ from those of normal controls. Unfortunately, the authors do not elaborate upon these differences; yet they conclude that: “These results suggest that the comorbidity of personality disorders with Bipolar Disorder predicts a poor treatment outcome.” (p. 74).
Differential Diagnosis: Bipolar II Disorder and Personality Disorders
The discerning clinician will make clinical judgments carefully when diagnosis involves closely associated and potentially “comorbid” clinical pictures. This is especially true in differentiating diagnoses of personality disorders and Bipolar Disorders. The General Diagnostic Criteria for Assessing Personality Disorders (APA, 1994, p. 633) specifically emphasizes “enduring patterns of behavior” as the definitive aspect of diagnostic decisions. Just the opposite is true in BII.
Vigilant assessors are aware that the “enduring patterns” associated with personality disorders may contradict the diagnosis of BII. Recall that “hypomania,” the essential feature of BII, must be associated with an “… unequivocal change in functioning that is uncharacteristic of the person when not symptomatic (APA, 1994, p. 338). This nuance, alone, provides evaluating psychologists a critical and important clinical discernment.
Having had person-to-person contact with the euphoric, grandiose, over enthusiastic, and “expansive quality of mood disturbance” described here as hypomanic, I will assure you this:given the above descriptors,you (the astute psychologist) will recognize a hypomanic episode when you see it!
Recent research has revealed that only 5% to 15% of patients noted for Bipolar II Disorder develop a full-blown manic episode that ultimately warrants a diagnosis of BI (Vieta, et al, 1997). These authors indicate remarkable differences exist between BI and BII patients. Their research showed that BII tended to be more severe in terms of episode frequency, however, symptom severity was found to be clearly greater in BI. The authors conclude: “Bipolar II Disorder could be described as a milder form of manic-depressive illness regarding symptom severity, but as a more malignant form concerning episode frequency” (p. 99).
Psychologists and substance abuse counselors must also have the ability to skillfully distinguish BI and BII from episodes of Substance Induced Mood Disorder, Mood Disorder Due to a General Medical Condition, Dysthymic Disorder, Cyclothymic Disorder, and Psychotic Disorder (APA, 1994, pp. 361-362). The essential features of manic and hypomanic episodes define the distinguishing attributes of Bipolar Disorders in all considerations of differential diagnosis.
Useful Links to Educate Yourself about Bipolar Disorder:
- Depression and Mania in Substance Induced Mood Disorders
- Diagnosis of Substance Induced Mood Disorder
- Diagnostic Criteria for Substance Induced Mood Disorder
- Substance Abuse Treatment for Co-Occurring Disorders