History Taking

Obtaining accurate information from patients with alcohol and drug problems is often difficult because of the stigma associated with substance abuse and the fear of legal consequences. At times they want help for the medical complications of substance use (such as injuries, or depression) but are ambivalent about giving up alcohol or drug use entirely. It is often the case that these patients are evasive and attempt to conceal or minimize the extent of their alcohol or drug use. Acquiring accurate information about the presence, severity, duration and effects of alcohol and drug use therefore requires a considerable amount of clinical skill.

The medical model for history taking is the most widely used approach to diagnostic evaluation. This consists of identifying the chief complaint, evaluating the present illness, reviewing past his tory, conducting a review of biological systems (e.g., gastrointestinal, cardiovascular), asking about family history of similar disorders, and discussing the patient's psychological and social functioning. A history of the present illness begins with questions on use of alcohol, drugs, and TOBACCO. The questions should cover PRESCRIPTION DRUGS as well as illicit drugs, with additional elaboration of the kind of drugs, the amount used, and the mode of administration (e.g., smoking, injection). Questions about alcohol use should refer specifically to the amount and frequency of use of major beverage types (wine, spirits, Beer). A thorough physical examination is important because each substance has specific pathological effects on certain organs and body systems. For example, alcohol affects the liver, stomach, and cardiovascular system. Drugs often produce abnormalities in ''vital signs'' such as temperature, pulse, and blood pressure. A mental status examination frequently gives evidence of substance use disorders because of poor personal hygiene, inappropriate affect (sad, euphoric, irritable, ANXIOUS), illogical or delusional thought processes, and memory problems. The physical examination can be supplemented by laboratory tests, which sometimes aid in early diagnosis before severe or irreversible damage has taken place. Laboratory tests are useful in two ways (1) alcohol and drugs can be measured directly in blood, urine, and exhaled air; (2) biochemical and psychological functions known to be affected by substance use can be assessed. Many drugs can be detected in the urine for twelve to forty-eight hours after their consumption. An estimate of BLOOD ALCOHOL Concentration (BAC) can be made directly by blood test or indirectly by means of a breath or saliva test. Elevated gamma glutamyl transpeptidase (GGTP), a liver enzyme, is a sensitive indicator of chronic, heavy alcohol intake.

In addition to the physical examination and laboratory tests, a variety of diagnostic interview procedures have been developed to provide objective, empirically based, reliable diagnoses of substance use disorders in various clinical populations. One type, exemplified by the DIAGNOSTIC INTERVIEW Schedule (DIS; see Robins et al., 1981) and the Composite International Diagnostic Interview (CIDI; see Robins et al., 1988), is highly structured and requires a minimum of clinical judgment by the interviewer. These interviews provide information not only about substance use disorders, but also about physical conditions and psychiatric disorders that are commonly associated with substance abuse. A second type of diagnostic interview is exemplified by the STRUCTURED CLINICAL INTERVIEW for DSM-III-R (SCID), which is designed for use by mental health professionals (Spitzer et al., 1992). The SCID assesses thirty-three of the more commonly occurring psychiatric disorders described in DSM-III-R. Among these are depression, schizophrenia, and the substance use disorders. A similar clinical interview, which has been designed for international use, is the Schedules for Clinical Assessment in Neuropsychiatry (SCAN; see Wing et al., 1990). The SCID and SCAN interviews allow the experienced clinician to tailor questions to fit the patient's understanding, to ask additional questions that clarify ambiguities, to challenge inconsistencies, and to make clinical judgments about the seriousness of symptoms. They are both modeled on the standard medical history practiced by many mental health professionals. Questions about the chief complaint, past episodes of psychiatric disturbance, treatment history, and current functioning all contribute to a thorough and orderly psychiatric history that is extremely useful for diagnosing substance use disorders.

In recent years there has been interest in researching and developing a system of self-reporting to aid in the diagnosing of drug use severity. There has been resistance to this kind of diagnostic tool because of clinical suspicion that individuals with substance-use disorders often are not capable of reporting their symptoms accurately. The result of which is a reliance on clinicians or trained interviewers over self-reporting, paper/pencil measures to determine a patient's drug use severity. However, patient-reported data on outcomes and effectiveness of substance abuse treatments is becoming an increasing necessity. Additionally, according to a recent investigation of methodological studies, self-report measures appear to be neither inherently reliable nor unreliable. Certainly the information reported can be imprecise because of memory loss and under- or overreporting, among other variables. Also a variety of conditions can render self-report measurements susceptible to measurement error and systematic response bias but there is no empirical evidence to definitively show that self-reported data is more problematic than interviewer formats. Research has shown that format can create systematic bias but this can be accounted for by combining the data from alternate forms (Heithoff & Wiseman, 1996).

Alcohol No More

Alcohol No More

Do you love a drink from time to time? A lot of us do, often when socializing with acquaintances and loved ones. Drinking may be beneficial or harmful, depending upon your age and health status, and, naturally, how much you drink.

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