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Diagnosis of Substance Related Disorders

November 1, 2010
by John M. Ellis, LISW, LICDC, ICCS
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Complicating Factors Within the Continuum of Mental Health Disorders

Complications in obtaining differential or co-morbid diagnosis

Multiple clinical licenses allow for diagnostic authority on a vast array of DSM categories (LISW, LCSW, LPCC, LPC, licensed psychologist or other professionals). Many of these professionals carry expertise within sub-diagnostic categories (for example, mood, psychosis or anxiety). Clinicians tend to hone in on specific sub-populations, illnesses or scopes. In fact, disclosure statements are required by many state licensure authorities to ensure professionals are transparent with their areas of expertise. I, for instance, have not made a diagnosis of schizophrenia over the last decade. Not because I'm license prohibited but in recognition of a self-acknowledged lack of expertise on this complicated malady. When suspecting psychosis, I refer to a practitioner best equipped to diagnose and offer service recommendations. In short, I believe clinicians tend to diagnose within their own area of expertise. Abraham Maslow once stated, “When all you have is a hammer, you see every problem as a nail.” This begs the question: How many clients are “under diagnosed” due to the limited scope of their provider?

Systemic barriers to accurate diagnosis

Keeping with the belief that clinicians are more likely to diagnose within their area of expertise, the disproportionate emphasis on mental illness versus substance related disorders in higher education curricula is cause for alarm. In Ohio, for example, state standards recognize Physicians, Psychologists, Professional Counselors (LPCC), Independent Social Workers (LISW) and Independent Chemical Dependency Counselors (LICDC) as being experts capable of delivering substance treatment services, as well as having full diagnostic authority for substance disorders. Of those listed, it is only the Chemical Dependency Counselor who may have less than a master's degree. (Since 2002, new LICDC applicants are required to have a master's in a behavioral health field, and 270 chemical dependency specific training hours. The grand-parenting widow allowed for many existing non-degreed individuals to inherit this independent license). These rules carry the bold assumption that all these disciplines are infused with core knowledge of addictions. This is not true.

Requirements for the Ohio Psychology license examination require no course work relative to addictions studies (OAC, 2010); nor does the Ohio Social Work, Counselor, and Family/Marital Therapist Board. One can become a Licensed Psychologist, Licensed Independent Social Worker or Licensed Professional Counselor, all with full diagnostic authority, without having a single addictions course in his/her entire academic career. Though some universities may have addictions specific courses, these are classified as electives.

Physicians may be viewed as the ultimate authority on addictions related issues, yet medical schools do not “prioritize” addictions education. Rather than having stand-alone courses, addictions topics are often infused into behavioral medicine-otherwise known as psychiatry. Although addiction related issues are certainly mentioned by all specialties (cocaine causing heart attacks, alcohol culpable in some liver disease, for example), the main focus of medical school is on medical disease, as opposed to primary cause. Typically general practitioners may encounter their most substantial learning as an intern or resident. Per Dr. Chris Delos-Reyes, MD, Chief Clinical Officer of the Cuyahoga Alcohol and Drug Addictions and Mental Health Services Board in Cleveland:

“The lack of training leads to a vicious cycle of misunderstanding and mistrust of alcoholics and addicts and an unwillingness to deal with ‘those people.’ So they treat the symptoms (read: cirrhosis, ulcers, heart attacks, etc.) but fail to mention alcohol/drugs as the primary cause … it's 2010. Definitely better than the 70s and 80s, but still not great.”

It is my fear that addictions treatment may become mental health treatment by default in 15 years unless we aggressively address curricula and licensure.

Worthy of mention is the current argument related to diagnosis of addictive disorders even as the DSM-5 language is being drafted. Historically, the DSM has had clear distinction between what is dependence vs. what is abuse. Leading national expert Carlton Erickson, PhD, explains this as “one's a brain disease and the other is not” (Enos, 2010). The new version (still in comment stage) looks to eliminate the distinction between abuse and dependence altogether. I fret we're moving away from diagnostic clarity and demarcation into more ambiguous territory.

This brings us all back to our diagnostic realities:

  • A diagnosis is usually made at the first clinical contact (which lasts from 30-120 minutes).

  • There is insufficient time to use all resources at our disposal toward ensuring accurate diagnosis.

  • Clients may be motivated to filter information and present themselves in the most amiable of lights.