Psychiatrie Issues of Adolescent Chemical Dependence

Chemical Dependency

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Psychiatric Issues of Adolescent Chemical Dependence Martha A. Morrison, MD, * and Quentin Ted Smith, MDt

HISTORICAL APPROACH

Nineteenth century studies of alcoholism approached the subject from a descriptive behavioral and statistical point of view, whereas studies in the twentieth century focused on the physiologic effects of alcohol. Two of the earliest psychoanalytic papers on addictive disorders were written in the early 1930s by Glove~5 and Rado. 70 Glover described the addict as a person who sought the effects of a drug that would gratifY sexual longings as well as the need for security and self-esteem. Rado emphasized the importance of the psychological structure of the patient as the most Significant factor that determined the origin and nature of addiction. Hendin's44 study of marijuana abuse among college students supported the importance of underlying psychodynamics in the selection of a particular drug. Wieder and Kaplan's85 analytic case reports of drug-using adolescents and Brull'sl5 discussion of the psychodynamics of drug use also pointed out the importance of the interaction between unconscious needs and conflicts and the choice of a particular drug of abuse. Although it may be true that a person takes a certain drug because of intrapsychic reason, it may also be true that availability may playa part in the drug selection. Prior to the 1960s, the popular notion of an addict was of a black, urban ghetto dweller. Efforts to treat the heroin addict ranged mainly from attempts to cure the addiction in the 1920s to long-term treatment at one

*Director,

Adolescent Chemical Dependence Program and ACTION Adolescent Outpatient Program, Ridgeview Institute; Private Practice, Georgia Alcohol and Drug Associates, Executive Medical Consultant, Alcohol and Drug Resource Center Impaired Professionals Program-Medical Association of Georgia, Smyrna, Georgia tAssociate Professor Psychiatry, Emory University School of Medicine; Associate Cinical Professor of Psychiatry, Morehouse College of Medicine; Private Practice, Child, Adolescent and Adult Psychiatry; Associate Director, Adolescent Services, Ridgeview Institute; Smyrna, Georgia

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of two government hospitals in the 1930s, 1940s, and 1950s. The latter programs had hospital relapse rates as high as 90 per cent. 51 Treatment of the alcoholic patient prior to the 1970s was characterized by rapid detoxification and brief hospital stays. This ineffective approach has been superceded by contemporary treatment that is more comprehensive in scope. Psychological treatments alone proved unsuccessful in the treatment of addictive disorders. The labeling of persons as alcoholic54 or addictive 46 personalities51 . 54 did little to stem the tide of pessimism regarding psychological treatment of addictive disorders. Brill l2 concluded that traditional voluntary approaches with drug abusers were ineffectual. Accompanying the information and population explosion of the 1960s was an explosion of drug usage. Never before were so many drugs available with the potential for abuse. 34 No longer was drug abuse and addiction confined to the poor, central city user. Large numbers of college students were involved in regular use. Over the past 25 years, addictive disorders have touched many lives, disregarding age, race, creed, color, or geographic location. The escalating use of drugs by adolescents in the 1970s has been accompanied by growing literature addressing the problem of adolescent substance abuse disorders. I, 41. 60, 63 Alcohol continues to be the most commonly used drug in this country.39. 56. 62 Although adolescents (ages 16-24) account for approximately 18 per cent of the population, they were involved in 48 per cent of highway deaths; 50 per cent of accidents are related to drugs or alcohol. Alcohol and drugs are present in 50 per cent of adolescent suicides. Alcohol and drugs are also factors in homiciderelated deaths. l l Money and mortality underscore the impact of substance abuse in this country.

CHARACTERISTICS OF ADOLESCENCE Adolescence is a time of change, stress, and growth. Many hormonal, behavioral, and emotional changes occur. These changes significantly affect the entire family, not just the growing adolescent. During this time, when teenagers are no longer children but not yet adults, adult demands begin to be placed on them before they have developed the appropriate maturity level. The peak incidence of manifestations of stress in young adults occurs during the prepubertal years (ages 11-13) and in late adolescence (ages 18-19). Peak delinquent behavior tends to occur during the last 6 months of high school, yet peak psychiatric referrals tend to occur during the first 6 months of college. 63 What brings these problems to the attention of others? They are often expressed through difficulties in communication, hostile behavior, tendencies for isolation, or complete personality change. When adolescents begin to experience difficulties, parents are almost always perceived by the teenager as the culprits. The adolescents, teachers, and even the parents themselves tend to place the blame on parental deficiencies. All of this may lead to family breakdown and complete family disruption and dis or-

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ganization. Some of the behaviors cited above are merely components of normal adolescence and must be handled as such, but some are at the other end of the spectrum of behavior. They are definitely abnormal and produce destructive results. Attention is not generally focused on adolescents until someone has become aware of their involvement with drugs and (subsequent) sexual promiscuity or legal difficulties.

COURSE OF THE DISEASE OF CHEMICAL DEPENDENCE Alcoholism and drug addiction are variations of the disease of chemical dependence. 36. 77 In the adolescent, this disease may produce extremely serious consequences (subsequently detailed), owing in part to the characteristics of this developmental stage. With certain variations persons predisposed to chemical dependence follow a fairly well-marked path to addiction, that is, they spend time using and abusing mood-altering chemicals before they cross the biochemical-genetic line into addiction. 33, 61, 76, 77 After crossing this line, the addicted person progressively exhibits the characteristics of full-blown addictive disease until death, if untreated. This journey is considerably more rapid in adolescents than in adults. Its progression seems to be related to age, sex, ethnic origin, and drug of choice. 63,78 This process of "telescoping," or more rapid progression, has been clinically demonstrated in chemically dependent adolescents. 64 Malignancy of pathology, increased progression and rapidity of the disease process, and increased morbidity with regard to juvenile or adolescent chemical dependence appears similar in these respects to other adolescent illnesses (i.e., juvenile diabetes mellitus or juvenile rheumatoid arthritis).

CHARACTERISTICS OF CHEMICAL DEPENDENCE Chemical dependence is a primary, unique, and individualized disease. It is not the result of a bad habit, mental illness, lack of willpower or stupidity. Rather, it is a primary disease entity in itself, and developing the disease is not dependent on long length of usage, which chemical is used, or what dose is used. One may become "just as addicted" with low doses as with high doses. The basic causal agent is a biochemical and genetic defect. 9. 36, 45. 53, 61, 64, 74, 76, 77 Abnormal chemical and metabolic changes occur in the addict to cause him or her to have the irrational, illogical compulsion to use chemicals. Chemical dependence becomes a family disease since family members become as compulsively concerned with the addicted member as he or she is with the chemical. The chief symptom of the disease is the compulsion (or repeated, irresistible urge) to use the chemical, despite the negative consequences experienced in major areas of life. 64, 77 It is a progressive, chronic, and multidimensional disease with the potential for relapse, which will result in death if allowed to progress. 64, 77 Symptoms seen in adolescent chemical dependence are similar to those seen in adults in some respects. Because of their age, incomplete personality

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development, and dependent family role, however, symptoms specific to this population occur. These more specific symptoms (subsequently detailed) may become exacerbated and tend to shorten and intensify the progression of the disease. In addition, lack of job skills, independence, or income coupled with acting out age-related behavioral tendencies may lead chemically dependent adolescents to tum to illegal activities or even suicide. A simple definition of alcoholism or drug addiction is the continued use of chemicals even as it causes major interference in one, two, or all three spheres (physical, emotional, or sociospiritual-cultural) of one's life. Chemically dependent adolescents continue to use chemicals despite the consequences they experience. They do not see the connection between the chemical and the negative consequences because of the phenomenon of denial. Consequences may be medical or physical, psychological, emotional, or sociospiritual-cultural. Consequences may be related to their church or community activities, their positions at work or school, or to their family or peer relationships. As the disease progresses, chemically dependent adolescents become isolated from everything and everyone except the chemical, leading to pronounced feelings of aloneness, depression, decreased self-esteem, confusion, insecurity, and tremendous inner turmoil.

UNDERLYING EMOTIONAL ISSUES Peer affiliation and peer acceptance are the hallmarks of this developmental stage and are crucial for the adolescent's development of a good sense of self. There is an intense need for acceptance, praise, and approval, a need that is more profound during adolescence than at any other time in life. The ability to set one's own limits and to influence others is being developed; therefore, testing limits and manipulating others are a normal part of adolescence. As adolescents test limits of the family and community values and rules, they experiment with extremes in values and behavior. They are likely to adopt idealism at one time, taking vows of poverty and chastity, and then switch almost overnight to hedonism and a determination to satisfy all their physical appetites for food, sex, and material goods to the fullest. 29 With these extreme changes in ideals, goals, and behavior come extreme swings in moods. Adolescents are confused and scared. One minute they are demanding total independence, and the next they are crying out emotionally for protection from themselves and the world they find themselves in. Autonomy is both sought and feared,7 and a sense of free-floating anxiety often is experienced by adolescents. What happens to the adolescent during this stage? Typically, an identity crisis occurs. Teenagers don't know who they are, what they are doing, where they are going, or why. Acting out behavior (Le., behavior that expresses the internal conflicts experienced but not directly acknowledged) occurs generally in one of three areas: substance abuse, sexual promiscuity, or criminal behavior. Tendencies for impulsiveness, destructiveness, mistrustful behavior, and irresponsibility are common. Because of this confusion and turmoil, the self-administration of psychoactive substances {Le., drug

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taking) often is perceived by teenagers as one of their few pleasurable options. Initially, the chemical can raise self-esteem and relieve tension and is one reason teenagers begin to use. The drug effect intensifies alreadyoccurring mood swings, however, and "bad trips" may be reported from experimentation during this stage. Why do adolescents use drugs? They use because of peer pressure, family conflicts or neglect, and personal frustrations and disappointments. In other words, they use (1) to "have a good time," (2) to be part of the group, and (3) to get their minds off their problems or escape. Typically, adolescents begin using out of curiosity and for experimental purposes with peers or friends. They continue to use and progress to abuse to escape painful feelings, conflicts, and low self-esteem, and often merely because "everyone else is doing it." Adolescents may exhibit an increased vulnerability to substance abuse and addiction problems not only because of hormonal and physiologic growth and stress, but also as a result of certain psychodynamics. Because of intense inner change, perceived stress, and emotional turmoil, the seeking of psychoactive substances to alter mood, coupled with peer pressure, may be more likely to occur during the teenage years. 63 What may initially provide a pleasurable sensation also may mistakenly contribute to the adolescent's sense of independence, grandiosity, and invulnerability. Erroneously, they may subsequently assume that willpower will prevent future problems from arising. Their crucial need to strive for independence and growth may preclude attaining a realistic ability to assess the substance abuse situation. When adolescents begin significantly abusing substances, an arrest in emotional maturation occurS.64 They begin to cope with normal emotional stresses by means of abnormal coping mechanisms (i. e., chemicals). Regression to a more immature state appears to occur, despite chronological age. Attainment of "nonchemical" coping skills, that is, normal emotional developmental growth, does not appear to occur. Adolescents therefore react in a more impulsive, irresponsible, and immature fashion because of this emotional lag in development secondary to substance abuse or dependence. 64 This is a highly significant issue with regard to both identification of adolescent substance abuse or dependence and therapeutic approach. DENIAL

Denial is a remarkable and unique phenomenon seen in chemically dependent persons, particularly in the adolescent population. (The phenomenon of addictive disease denial must be clearly differentiated from the traditional psychiatric defense mechanism of denial seen in psychotic illness. ) The denial seen in chemical dependence is specific and secondary to this condition and causes adolescents to be unable to perceive themselves or other people, places, and things as they really are. The two mechanisms involved in addictive denial are (1) an altered perception of reality and (2) pain repression. 77, 80 The keys to successfully combating this type of denial

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are confrontation and rigorous self-honesty, so that reality perceptions are no longer impaired because of the active disease process and repression of pain is no longer necessary. Adolescents feel the need to try harder when it comes to power and control. They desire control over their own lives and world. The negative and destructive message of the "dragon" of drug denial says, "Leave me alone; I can do it myself." This is a comment adolescents frequently make about many things, and in some cases is appropriate but not with chemical dependence. The intensity of this denial of addiction seems to give the message of the second dragon an added seductive quality for adolescents. The second "dragon" says, "I can quit anytime I want to," and many chemically dependent adolescents truly believe that they can. They may have stopped on previous occasions but can rarely "stay stopped" without resorting once again to chemicals to cope with everyday stress. Adolescents have limited experience because of their age and emotional immaturity, and are still developing abilities to cope with life events and a value system on which to base life-style and philosophy. When they begin to use and abuse mood-altering chemicals, they stop acquiring other coping skills and begin limiting their exposure to new experiences. They substitute the feeling of well-being from the chemical for positive feelings for achievements and relationships. Their selection of experiences is based on the relevance of each experience to using the chemical(s). Because of this self-deception, adolescents begin to practice deceit with others, lying about their behaviors and feelings and hiding from those who would confront them. They avoid people who would make them aware of their fear of loss of control over the chemical, that is, avoid confrontation and self-honesty. Adolescent behaviors indicative of denial are lying regarding substance use, guarding supply of chemicals, thinking about the drug inappropriately, using inappropriately (before parties, alone, etc.), appearing in public in altered state of consciousness, hiding chemicals, preoccupation with chemicals, continuing use despite warnings or advice, self-prescribing, inability to "stay stopped," frequent visits to emegency rooms (clinics or physicians), inappropriate dependence on another person (dysfunctional emotional involvements), anger, hostility, rage and defensiveness regarding chemical use, taking care of everyone else, blaming other people, places and things, self-pity, attempting to control other people, places and things, intellectualizing or philosophizing, withdrawing or isolating, and chronic irresponsibility. Denial therefore serves the purpose of altering one's perception of reality, repressing the pain of consequences that occur, and allowing the disease process to progress. Progression then becomes a vicious circle, thoroughly enhanced by this mechanism of denial (Fig. 1).

OTHER DEFENSE MECHANISMS Although denial is a major defense mechanism of adolescents with chemical dependence, it is by no means the only defense used. Anna Freud29 in her classic work Ego and the Mechanisms of Defense listed the

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following mechanisms: regression, repression, reaction-formation, isolation, undoing, projection, introjection, turning against the self, reversal, and sublimation. In addition to the above, Feniche}28 included denial, postponement of affects, affect equivalents, and change in the quality of affects. Among the 16 mental mechanisms listed by Hinse 47 were rationalization, transference, condensation, symbolization and transposition, conversion, and fantasy and daydreaming. Some of the more commonly noted defenses seen in chemically dependent adolescents are listed below. Projection, attributing one's own ideas or impulses to another,48 is a familiar defense seen in chemically dependent adolescents. This defense usually is over-used during the initial contacts with the adolescent. Chemically dependent adolescents who successfully move through treatment show a reduction in the extent that projection is used. Rationalization, a term first introduced into psychoanalysis by Ernest Jones, means justifying, by plausible means, feelings, behavior, and motives that would otherwise be intolerable. 5 Rationalization is a frequent companion of denial and projection. For example, Keith was a 15-year-old teenager and a heavy abuser of a variety of drugs, who relied heavily on the use of rationalization to cover massive feelings of low self-esteem and inadequacy. Isolation, the separation of memory from its affective component, may be present in adolescents with severe and prolonged substance abuse. Mike, a bright, compulsive 15-year-old teenager who used a wide variety of drugs and alcohol over 3 years, had experienced several drug overdoses as well as numerous accidents. Mike complained about being unable to feel any emotion, which in a "normal" adolescent would be emotionally charged material. "I know I should feel something about beating up on my mom last year, but I don't feel nothing. It's frustrating as [profanity] not to be able to feel stuff like other people." Sublimation is a healthy defense mechanism discussed in the writings of Hartmann. 40 It is characterized by the displacement of sexual and aggressive drives into socially valued behavior. Sublimation frequently is not apparent in the chemically dependent adolescent prior to treatment. The adolescent who is dysfunctional secondary to dependence on alcohol or drugs is one whose capacity to delay gratification is impaired. Channeling primitive impulses into socially acceptable behavior is of little interest to the substance abuser. The playing of a musical instrument may on the surface appear to be channeling energy into a socially acceptable activity. However, the musical instrument is often an ornament which the chemically dependent adolescent identifies as part of his drug and alcohol image. The impairment of sublimation often results in a youngster who is bored and unmotivated. The chemically dependent adolescent who is successfully treated will often show the development of sublimation. As sucessful recovery takes place, one sees the development of new leisure skills and other prosocial activities. Jennifer, a beautiful and articulate 16 year old, had been using a variety of drugs for 3 years prior to entering treatment. Marijuana was her drug of choice. Jennifer's mother was depressed, alcoholic, and emotionally unstable. Jennifer's father was too busy amassing wealth to spend the necessary time with her. The father gave many gifts but nothing of himself.

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Jennifer felt rejected and unloved by her parents, and concluded that the parental inattention was due to some defect in herself. Jennifer did not feel that she was the bright, pretty, talented person people outside the family told her she was. For the first 13 years of her life, Jennifer tried to overcome feelings of inadequacy by excelling in school and at the piano. She quickly learned that use of marijuana significantly eased her feelings of rejection and inadequacy. With escalating use over the next 3 years, Jennifer's school performance plummeted, her relationship with her parents worsened, and she was arrested on three occasions for possession of drugs and shoplifting. "I knew I was really messed up when d wake up in the morning and would get high instead of feeding my dog which I loved. I wasn't interested in [profanity] and didn't care about nothing but getting high." Jennifer's last arrest resulted in her hospitalization for the treatment of chemical dependence. Her hospital course showed the gradual redirection of sexual and aggressive impulses into socially acceptable behavior, that is, improved school performance, completion of several crafts projects, and an intense interest in photography.

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EMOTIONAL AND BEHAVIORAL SYMPTOMS OF CHEMICAL DEPENDENCE Emotional and behavioral manifestations of substance abuse and dependence in adolescents are varied and correspond to the stage of progression. Clinical experience has demonstrated that different patterns of drug usage occur when adolescents socially or recreationally use a chemical, abuse the chemical, begin to experience early signs of dependence (crossing a line), and exhibit full-blown dependent or addictive disease characteristics. Characteristics seen during the social or experimental using stage in adolescence include the following: In this country, the average age of first use for boys is 11.9 years; for girls, 12.7 years. 52 Adolescents use drugs for the first time almost always because of peer pressure: to be a part of the group and for acceptance. Most drug use initiated between ages 15 and 24 (the period of greatest risk for initiation) appears to be related to peer and social influences rather than an underlying psychiatric disorder. 56 The first episode of intoxication or hangover may occur during this stage. Because of this negative consequence of drinking, adolescents often promise themselves not to use so much next time. In this period, occasional supervised drinking may occur because drinking generally is socially acceptable in the United States, and parents serve as the most significant role models for adolescents. Adolescents are likely to emulate their parents' drinking patterns. Children with alcoholic parents, particularly alcoholic fathers, are much more likely to become alcoholic themselves. 74 This fact probably has more to do with a genetic factor than with the role modeling previously dscribed. Alcohol or drug use frequently occurs independently of the family, but teens rarely use alone during this early stage. Most adolescents today appear not just involved in substance use but in substance abuse. Symptoms seen during this stage include the following: Use is more regular than in the early experimental stage. Weekend

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drinking occurs, and a regular pattern of use evolves. Adolescents report drinking and using drugs to communicate, to relate, to belong, and to be a part of the group. Abuse continues in an attempt to increase self-esteem and to increase feelings of adequacy and security. Legal problems may begin to occur, such as driving under the influence and possession charges. Hiding and lying about drugs may occur. Adolescents become more suspicious, vague, and secretive about what they are consuming and how much they are taking. Tolerance levels begin to change. Tolerance to the chemical rises, leading to the need for larger doses to obtain the same subjective effect, or "high." Emotional changes are noticed, for example, increased irritability, mood swings, and a lack of caring for oneself and others. Confrontation by parents because of repercussions of observed emotional and behavioral changes may occur. Polarization of parents and children may begin to take place with subsequent further strain on communication channels. Careful distinction must be made between abuse and addiction for the adolescent. During the abusing stage, the behavior controls the chemicals. Once the biochemical-genetic line is crossed, the chemicals control the behavior. The addict can no longer guarantee his or her behavior when using chemicals. Abuse is a cortical (rational and logical) process; addiction acts as an instinctual urge. Addiction is controlled by deeper, more primitive (i. e., lower) centers of the brain. 76 The addict's compulsion to use the chemical arises from more primitive central nervous system instinctual centers,76. 77 where imbalances or deficiencies in central neurotransmitters, that is, naturally occurring brain chemicals, occur that may contribute to addiction. 9. 13, 77 This therefore implies that for the addict, the choice to ingest the drug no longer exists and continued chemical use precludes logical and rational thought processes. 76, 77 Crossing this biochemical-genetic line is essentially analogous to early addiction and is therefore symptomatic of the disease process. Characteristics seen in this early period of chemical dependence are: Teenagers drink and use to get "high." They drink to escape and no longer use simply for slight elation or the euphoric effect. They drink and use drugs to block pain and discomfort. Chemically dependent adolescents gradually change friends to include only drinking and drug-oriented peers (i.e., negative peer pressure), often those who use more than they do. They may appear in inappropriate altered states of consciousness at school and work, or in public. The time spent using and abusing is increased, with evidence of preoccupation with regard to chemical use. Blackouts (temporary periods of drug or alcohol amnesia but not passing out) may begin to occur. Blackouts are one symptom of addiction that are almost pathognomonic by themselves. Withdrawal symptoms may occur when chemical use is decreased or discontinued and may masquerade as other symptoms-a GI virus or flu, mood swings, irritability, or anxiety. With the progression of dependence more difficulties begin to occur at home, and family conflict increases. Increasingly, problems appear at home, with subsequent adolescent reactions such as running away, acting

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out behavior, or generally a progressive isolation and withdrawal from the family and from involvement in family activities. Suspensions at school may occur and grades become affected. A decrease in community and school activities and a decrease in motivation occur. There is a very high correlation between poor academic performance and teen substance abuse. 19. 23 The number and intensity of negative behaviors in major areas of life increase and are evident from verbal abusiveness, rebelliousness, fighting behavior, and sexual promiscuity. Typically, there is a loss of coping skills (i.e., regression to a state of emotional immaturity). Guilt and anxiety may be experienced because of the loss of control of drug use. More serious legal problems then arise. In response to all these conditions, adolescents promise repeatedly to stop using, and denial surfaces, leading them to believe that they can stop any time, and they can stop by themselves. 77 Manifestations of full-blown addictive disease or chemical dependence in the adolescent represent the final and most progressive stage of the journey. These symptoms are as follows: For addicted adolescents, life becomes centered around alcohol and drugs. Peer groups change dramatically. Friends are now almost exclusively alcohol and drug users. At this stage, adolescents are drinking and using to "maintain"; they are not drinking for euphoria but for freedom from the emotional pain and the hurt they experience almost continually. Repeated attempts to "stay stopped" are made, yet such attempts are unsucessful. This ability to stop chemical use for a limited period of time leads adolescents mistakenly to believe they can control chemical use. Physical deterioration may begin to occur in either appearance or physical health. Weight loss and dental, gum, and complexion problems also tend to occur during the course of the disease, as well as a general lethargy translated as being "burned out" or "spaced out." There also may be serious physical withdrawal symptoms when one tries to stop using drugs, and gastrointestinal, nervous, cardiac, or liver complications may result. Hiding and lying about drug usage is common. Using drugs and alcohol alone occurs. At this stage, use is no longer simply a matter of peer acceptance or peer affiliation. Guarding one's supply becomes important, emphasizing the need for continual chemical availability. Increased feelings of aloneness and isolation occur, which are both profound and dramatic. Concern is now expressed by parents, teachers, and significant others, even peers. Frequent visits to psychiatrists or other physicians or emergency rooms, or continued need for medications may occur. Psychosomatic complaints may be present, as well as an increased number of accidents and traumas (particularly burns and falls). 6, 66 Gradually, a loss of self-esteem occurs, with an increase in denial and accompanying anger and depression. These emotional symptoms are generally secondary to the disease of chemical dependence, not necessarily evidence of primary psychopathology. In this case, when the drugs are removed and a period of chemical abstinence occurs, the psychiatric manifestations generally disappear. 77, 80 Serious family conflicts, with increasing fragmentation, disorganization, and eventual chaos, may occur. Con-

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frontation within the family can be seen, with fighting among brothers and sisters, running-away behavior, and isolation from family activities. All of these characteristics are progressive and are examples of manifestations of the chief symptom of chemical dependence-loss of control. Chemical use persists despite consequences suffered. Persistent chemical use in addicted or dependent adolescents eventually may result in repeated institutionalization, incarceration, or even death. DUAL DIAGNOSES The literature on dual disorders (substance abuse disorders and psychiatric disorders) has increased steadily since the early 1970s. 2. 4, 32, 65 Despite the growing literature, McDonald60 points out that adolescent substance abuse is probably the most commonly missed pediatric diagnosis. It is important to note that the physician's denial may interfere with making the proper diagnosis. A high index of suspicion and a realization that even adolescents who wear nice clothes use alcohol and drugs will help to make a correct diagnosis. The interview of all adolescents should include a thorough inquiry into alcohol and drug use. A review of the differential diagnoses of substance-induced organic mental disorders includes a variety of disorders22; these include schizophrenia, temporal lobe epilepsy, malingering, delirium, influenza, manic episodes, affctive disorders, nonorganic psychotic disorders, panic disorders, and generalized anxiety disorders. Other disorders that could be included are mental retardation, specific developmental disorders, attention deficit disorders, conduct disorder, personality disorder, and oppositional disorder. This list of differential diagnostic possibilities indicates that if anyone of them is diagnosed, alcohol and drug abuse should be included in the differential diagnosis. Failure to ask about alcohol and drug abuse could result in delayed or even missed diagnosis. Alterman's3 discussion of substance abuse in psychiatric patients indicated few programs that addressed the existence of dual disorders. In most existing programs, psychiatrists emphasize the treatment of the psychiatric disorder, whereas chemical dependence programs place the emphasis on treating alcohol and drug problems. Each approach is too narrow to address the needs of patients with dual diagnoses. Recent approaches in a few programs include an addictionologist and a psychiatrist working in concert to treat the patient with dual disease. Udel 81 discusses the importance of separating out characterologic symptoms that were present prior to the drug use from psychopathologic changes associated with intoxication and use. Failure to recognize transitory psychopathy secondary to intoxication may result in inappropriate treatment for a disorder that will clear as the intoxication subsides. Numerous studies have documented the frequency of depression with substance use disorders. 25, 27, 59, 67, 75 There is a stronger relationship between affective disorder and alcohol than there is between affective disorder and drugs. The affective disorder may be primary (occurs in absence of preexisting psychiatric disorders) or secondary to alcohol. Famularo et al. reported 10 cases of preadolescent alcohol abuse and dependence. 27 The

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prevalence of affective disorder among the ten children and their families was impressive. Additionally, many of the children had other DSM-III diagnoses on axis I or II. Some of the children responded well to lithium or an antidepressant. The importance of differentiating between primary affective disorders and disorders secondary to alcohol cannot be overemphasized. Medication seems of little benefit if alcohol is the primary problem. 73 Numerous studies have linked antisocial personality disorder to alcohol and drug disorders. 37, 72, 71 Hartocollis studied the personality characteristics of adolescent problem drinkers. The results of the MMPI showed elevation of the hypomanic, psychopathic deviation, and schizophrenic scores. Those studied tended to act out and to ignore social customs and mores. A review of the hospital records of 100 adolescents between the ages of 13 and 18 admitted to an adolescent unit in a private hospital designed specifically for treatment of chemical dependence showed that when a dual diagnosis (substance abuse and psychiatric diagnosis) was made, conduct disorder was the secondary diagnosis nearly 50 per cent of the time. The links that tie together antisocial personality disorders and alcohol and drug abuse, and the knowledge that conduct disorders are precursors of antisocial personality would suggest that identification of specific subtypes of conduct disorders that lead to alcoholism and drug addiction may lead to prevention and early intervention. Borderline Personality Disorder One of the diagnostic criteria for borderline personality is impulsivity or unpredictability in at least two areas that are potentially self-damaging (e. g., spending, sex, gambling, substance use, shoplifting, overeating, physically self-damaging acts).22 Masterson58 gives many case examples of the use of a variety of substances (e.g., alcohol, amphetamines, barbiturates, DMT, heroin, LSD, mescaline, marijuana) by borderline adolescents. These substances are used to discharge anger, overcome boredom, and ward off painful affects. Loranger and Tullis 55 point out the high rate of alcoholism found in the families of 83 women with a DSM-III diagnosis of borderline personality. Alcoholism was more prevalent in first-degree relatives of borderline patients than in relatives of bipolar or schizophrenic patients. Hellman 43 stresses the importance of understanding the value of drinking to the patient, and not attacking the narcissistic defenses of alcoholic patients with a borderline personality. He sees no inherent incompatibility between psychoanalytically oriented psychotherapy and the approach of Alcoholics Anonymous. Borderline adolescents who are chemically dependent frequently enter treatment with feelings of intense depression, rage, and emptiness. Psychiatrists and chemical dependence staff may use different treatment models in their approach with the borderline adolescent. The psychiatrists may encourage regression in intense individual therapy, whereas the chemical dependence staff may attempt to reverse the patient's regression as quickly as possible. Gordon and Beresin38 point out that borderline patients may become significantly worse when the above approaches conflict. Whichever treatment approach is chosen, the importance of a consistent treatment

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model for a patient who manifests splitting as a major defense cannot be overemphasized. Psychotic Disorders There is an increased frequency of a history of substance abuse in patients with schizophrenic disorders.3, 4 Evaluation of the adolescent patient who has a history of alcohol or drug abuse should include a determination of whether the substance abuse is the primary disorder and the psychosis secondary, or whether the reverse is true. A variety of substances such as marijuana, LSD, PCP, and amphetamines may produce psychotic symptoms. 21 Some adolescents will have no history of psychotic symptoms before or after the effects of the alcohol or drug wear off. Other adolescents with a presumed underlying borderline or psychotic substrate may display psychotic symptoms resembling schizophrenia after the effects of the drug wear off. Still other adolescents with a clear history of schizophrenia prior to alcohol or drug abuse may aggravate their symptoms by abusing drugs or alcohol. Tsuang et aI., 79 in their review of 72 drug abusers with psychotic symptoms, noted that drug abusers with psychoses of longer duration were likely to have schizoid or paranoid premorbid personalities, poor insight, and disorganized thoughts. These patients' symptoms most closely resembled those of atypical schizophrenia. If toxicity and medical problems are eliminated as causes of psychotic symptoms, the actively psychotic adolescent should be managed by a psychiatrist even if that adolescent has a history of drug or alcohol abuse. The actively psychotic adolescent is usually too disruptive to the milieu of an inpatient unit primarily set up for chemical dependence treatment of adolescents. Although there may be controversy over the use of other drugs in the chemically dependent adolescent, it is clear that antipsychotic medication should be a part of the treatment of the functionally psychotic adolescent. Mter the adolescent with psychotic symptoms that are functional recovers from the acute psychotic symptoms, he should be encouraged to participate in the Narcotics or Alcoholics Anonymous program to address his or her alcohol or drug issues. These twelve-step self-help groups may serve as both a support and resource to the patient and parents. Attention Deficit Disorder (ADD) The attention deficit disorders (ADDs) are characterized by developmentally inappropriate inattention and impulsivity. Subtypes include ADD with hyperactivity, ADD without hyperactivity, and ADD, residual type. Persons with the residual type were once diagnosed as having ADD with hyperactivity; they now retain the impulsivity and inattention, but lose the hyperactivity. 22 Assessment of the adolescent with ADD should include questions regarding alcohol and drug use. Inquiry into the alcohol and drug-using behavior of the ADD adolescent seems logical given the fact that some studies 16 showed an association between ADD and conduct and antisocial disorders. Alcohol and drug abuse are not uncommonly one of the components of conduct and antisocial disorders.

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The adolescent who presents with both chemical dependence and ADD may pose a dilemma for treatment providers. Some questions raised might include: Should the adolescent receive stimulant medication for ADD if one of the aims of treatment is to live chemically free? What is the effect on the milieu of an inpatient adolescent chemical dependence unit if one of its members is regularly taking stimulants for ADD? How does the adolescent in such a milieu feel about being singled out as different or special? What are staff and parental attitudes about using stimulants in a chemically dependent adolescent with ADD? The adolescent's teachers and other educational experts may be helpful in exploring nonchemical methods of managing the adolescent in the classroom. Anorexia Anorexia and bulimia are subtypes of eating disorders.22 Both disorders have received growing attention in both the scientific and popular literature. Maloney and Klykylo's57 overview of anorexia nervosa, bulimia, and obesity in children and adolescents suggested that these disorders appear to be reaching epidemic proportions (prevalence of 25 per cent in the general population). The increase in both public and professional awareness of anorexia and bulimia has most likely contributed to increased case findings. Anorexia is a disorder mostly of young female subjects characterized by intense fear of becoming obese, disturbance of body image, weight loss of at least 25 per cent of original body weight, and refusal to maintain body weight over a minimal normal weight for age and weight. 22 Genetic factors may play. a role in this disorder.30. 31, 49 Because of the small number of patient studies, the authors urge caution in drawing any firm conclusions about genetic predisposition. Sociocultural and family factors that emphasize thinness may also playa part in the development of this disorder.1O The reader is referred to the work of Bruch for a detailed description of the psychodynamics of this disorder.14 Data from a number of studies indicate early-onset anorexia nervosa has a better long-term outlook than does lateonset anorexia nervosa. Treatment of anorexia includes a variety of modalities, including psychoanalysis, psychoanalytically oriented psychotherapy, behavioral modification, family therapy, and pharmacotherapy. Whether any of these methods is superior to the others has not yet been conclusively demonstrated. A few reports appeared in the latter half of the 1970s, which emphasized the frequency of occurrence of anorexia nervosa and alcoholism. 17, 24 It is doubtful that physicians who treat anorexic adolescents routinely inquire into the possibility of alcohol or drug use. Bulimia

The main features of bulimia include recurrent binge episodes, awareness that the eating pattern is abnormal and fear of being unable to stop voluntarily, depressed mood following the eating binges, use of diets, cathartics, diuretics and self-induced vomiting, inconspicuous eating during a binge, and consumption of high-calorie, easily digested foods during a binge. 22 Several surveys explore the frequency of bulimia irr high school

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and college students. 18, 20, 69 These studies indicated up to 14 per cent of young women met the DSM-III criteria. In the past, psychodynamic and behavioral approaches were the major approaches to the understanding and treatment of bulimia. A recent view of bulimia is to conceptualize this disorder as an addictive disorder in much the same way that one views chemical dependence. Treatment approaches that view bulimia as an addictive disorder use techniques borrowed from the Alcoholics Anonymous program. 50 Programs using the AA aproach in treating bulimia are too new to evaluate long-term efficacy. Bulimic patients may have both bulimia and substance abuse disorders.68 It is not uncommon to find that bulimic patients have a positive family history for alcoholism. Since substance abuse disorders are frequently found in adolescents, a thorough alcohol and drug history should be taken routinely in bulimic adolecents. The reverse is also true. Children of Alcoholics The disease of chemical dependence may severely impact all family members. 8, 83 Frequently, chemically dependent adolescents have been raised in an alcoholic or addicted home, thereby further compounding the problem because of the addictive behavior patterns that are bred in this environment. Children of alcoholics (COAs) are those who have been affected by the alcoholism of a parent or other adult who fills that role. Consequently, COAs develop common characteristics secondary to having been raised in a chemically dependent environment, that is, an adjustment reaction to family alcoholism. 42 COAs therefore are vulnerable to many destructive patterns of physical and emotional problems. These problems can impact the child of the alcoholic so severely that lifetime emotional scars may result if these problems go. unrecognized or untreated. 42 Many of these people are not even aware that they need help, and help must be made available to them for their own well-being, not just as a part of an effort to aid the recovering alcoholic in the family. 83 In essence, COAs and other family members of the alcoholic appear to take on the characteristics of the disease without necessarily taking drugs or drinking. One third of COAs become chemically dependent, whereas one third marry others who are chemically dependent and one fourth do both. 84 COAs are therefore the highest-risk group for developing chemical dependence themselves because of both genetic and environmental factors. The addicted adolescent who is also a COA represents a dual diagnosis. All of the disease characteristics are further exacerbated and are more pronounced and intensified. Ability to communicate, share feelings, and trust others is even more dramatically impaired than with just addiction. If these COA issues remain unidentified or untreated, prognosis for recovery from chemical dependence for the adolescent is significantly more guarded. THE USE OF MEDICATION IN CHEMICALLY DEPENDENT ADOLESCENTS The primary care physician who evaluates the adolescent patient for fatigue, ongoing anxiety, depression, insomnia, or upper respiratory symp-

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toms should consider alcohol and drug abuse in the differential diagnosis. Those adolescents who come to the office or the emergency room and appear "crazy" may be adolescents experiencing the effects of drug or alcohol. Adolescents who are toxic from alcohol or drugs should not receive a psychiatric diagnosis until the toxic state subsides. The judicious use of medication in the chemically dependent adolescent may be appropriate for a number of conditions. For example, a short course of a benzodiazepine may be part of the overall approach to the adolescent experiencing significant withdrawal symptoms from alcohol. Lithium, antidepressants, antipsychotic, and stimulant medications may be of benefit to the chemically dependent adolescent who also suffers from a bipolar, major depressive, schizophrenic disorder or ADD, respectively. Patients with a psychiatric disorder and chemical dependence should be managed by a psychiatrist in concert with an addictionologist. The physician should inquire into any sensations of euphoria produced by medication taken by the chemically dependent adolescent to weigh the risk of potential abuse. The routine prescribing of sleeping pills, minor tranquilizers, or other mood-altering drugs for the chemically dependent adolescent must be discouraged.

CONCLUSION A plan to solve the problem of adolescent substance abuse and addiction needs to focus on several areas: education, demonstration, cooperation, prevention, intervention, habilitation, treatment, and recovery. Possibly the most important aspect of solving the problem of chemical abuse is related to widespread change in attitudes and perceptions, and increased awareness of chemical dependence. Programs to inform the community, school, students, parents, and health professionals provide the means of such change. Facts about alcohol and drug abuse can be taught so that substance abuse can be clearly perceived as an unacceptable means of coping with life. It is crucial that health professionals, parents, and adolescents understand chemical dependence not only as a chronic and progressive disease, but more importantly as a treatable disease. Early and accurate diagnosis lead to increased success of intervention and treatment. Many symptoms of certain drugs in adolescents can be easily misdiagnosed for psychiatric illness. Treating the observed symptom may be quite different from treating the drug abuse. Polydrug abuse in the adolescent further complicates the clinical picture, especially when the treating physician is unaware of the drug abuse habit of the patient. In addition, the younger the age that a person is exposed to the chemical, the more susceptible that person is to a psychiatric reaction. 26 The early stages of adolesent drug abuse also may be missed because behavioral changes may be attributed incorrectly to the normal maturation process that occurs during adolescence. 56 For these reasons, drug abuse testing (i. e., urine drug screening) is essential to provide the proper treatment for the diagnosed condition. 82 Pediatricians particularly are in a position to address substance abuse/dependence prevention from a developmental perspective. Pediatri-

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cians and other primary health care providers can playa significant role in informing and educating the family and community about alcohol and drug problems. Parents, students, schools, law enforcement officials, and others may turn to physicians for assistance. Physicians must be aware of community resources such as substance abuse prevention and treatment programs, parent action groups, self-help groups, and community mobilized efforts to combat chemical abuse and dependence. 56 Pediatricians, as well as other health care professionals, must always consider psychoactive drug use by adolescents as possible causes of general health or emotional problems, such as poor appetite, insomnia, problem behavior, academic underachievement, and loss of energy and motivation. Early diagnosis and intervention with youth can result in enormous benefits for the lives of the youth, families, and society. 56 REFERENCES 1. Alibrandi T: Young Alcoholics. CompCare Publications, 1978 2. Alterman AI, Erdlen F, Murphy E: Alcohol abuse in the psychiatric hospital population. Addictive Behaviors 6:69-73, 1981 3. Alterman AI, Erdlen FR, La Porte DJ, et al: Effects of illicit drug use in an inpatient psychiatric population. Addictive Behaviors 7:231-242, 1982 4. Alterman AI: Substance Abuse and Psychopathology. New York, Plenum Press, 1985, pp 367-390 5. American Psychiatric Association Glossary. Washington, D.C., 1975 6. America's Alcohol Scoreboard. In Research and Education on Alcohol and Drugs. ILLCAAP. Third and Fourth Special Reports to the U.S. Congress on Alcohol and Health, National Institute on Alcohol Abuse and Addiction, 1982 7. Bettelheim B: Surviving and Other Essays. New York, Alfred A. Knopf, 1979 8. Black C: It Will Never Happen to Me. Denver, Colorado, MAC Book, 1982 9. Bloom F, Bayon A, Battenberg E et al: Endorphins: Developmental, cellular, and behavioral aspects. In Costa E, Trabucchi M (eds): Neuronal Peptides and Neuronal Communication. New York, Raven Press, 1980 10. Boskind-Lodahl M: Cinderella's stepsisters: A feminist perspective on anorexia nervosa and bulimia. J Women Cult Soc 2:342-356, 1976 11. Brenner B: Alcoholism and fatal accidents. Quart J Stud Alcohol 28:517-528, 1967 12. Brill L: Three approaches to the casework treatment of narcotics addicts. Social Work 13:25-35, 1968 13. Brown MR, Fisher LA: Brain peptides as intercellular messengers: implications for medicine. JAM A 251:1310--1315, 1984 14. Bruch H: Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. New York, Basic Books, 1973 15. Brull HF: The psychodynamics of drug use: A social work perspective. Adolesc Psychiatry 4:309-317, 1975 16. Cantwell DP: Hyperactivity and antisocial behavior. J Am Acad Child Psychiatry 17:252-262, 1978 17. Cantwell DP, Sturzenberger S, Borroughts J et al: Anorexia nervosa: An affective disorder? Arch Gen Psychiatry 34:1087-1093, 1977 18. Clarke MG, Palmer RL: Eating attitudes and neurotic symptoms in university students. Br J Psychiatry 142:399-404, 1983 19. Colleges try to combat rampant alcohol use, but with little effect. Wall Street Journal Feb 8, 1983 20. Cooper PI. Fairburn CG: Binge eating and self-induced vomiting in the community: A preliminary study. Br J Psychiatry 142:139-144, 1983 21. Davison K: Drug-induced psychoses and their relationship to schizophrenia. In Kali D et al (eds): Schizophrenia Today. Oxford, Pergamon Press, 1976, pp 105-133

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58. Masterson JF: Treatment of the Borderline Adolescent: A Developmental Approach. Wiley Interscience, 1972 59. McDonald DI: Drugs, Drinking and Adolescents. Chicago, Year Book Medical Publishers, 1984 60. Mayfield DG, Cdeman LL: Alcohol use and affective disorders. J Dis Nerv System 29:467-474, 1968 61. Mendelson JH, Mello NK (eds): Idem: Genetic Determinants of Alcoholism The Diagnosis and Treatment of Alcoholism. New York, McGraw-Hill, 1979 62. Metropolitan Life Insurance Statistical Bulletin: Jan/Mar. 1984. Alcohol and other drug abuse among adolescents, pp 4-13, 1984 63. Millman, R, Khuri E: Substance abuse: Clinical problems and perspectives. In Lowinson, Ruiz (eds): Adolescence and Substance Abuse, 1981, pp 739--751 64. Morrison MA: Substance Abuse and Addiction in Adolescents. In Press 65. Murin SM: Substance Abuse and Psychopathology. New York, American Psychiatric Association Press, 1984 66. National Council on Alcoholism: 1984 Facts on Alcoholism 67. Paton S, Kessler R, Kandel D: Depressive mood and adolescent illicit drug use. A longitudinal analysis. J Gen PsychoI131-267, 1977 68. Pyle RL, Mitchell JE, Eckert ED: Bulimia: A report of 34 cases. J Clin Psychiatry 42:60, 1981 69. Pyle RL, Mitchell JE, Eckert ED, et al: The incidence of bulimia in freshman college students. Internat J Eating Disorders 2:75-85, 1983 70. Rado S: Psychoanalysis of pharmacothymia. Psychoanalysis 2, pp. 1-23, 1933 71. Robins LN: Sturdy childhood predictors of adult antisocial behavior: Replications from longitudinal studies. Psychological Medicine 8:611-622, 1978 72. Schuckit MA: Alcoholism and other psychiatric disorders. Hosp Commun Psychiatry 34:1022-1027, 1983 73. Schuckit MA: A study of alcoholics with secondary depression. Am J Psychiatry 140:711-714, 1983 74. Spalt L: Evidence of an x-linked recessive genetic characteristic in alcoholism. JAM A 241:1979 75. Spensley J: Doxepin: A useful adjunct in the treatment of heroin addicts in a methadone program. Internat J Addiction 11:191, 1976 76. Suojanen WW: Addiction and the minds of mind. In Bersinger RC, Suojanen WW (eds): Management and the Brain: An Integrative Approach to Organization Behavior. Atlanta, Georgia, Georgia State University, 1983, pp 77-92 77. Talbott GD: Substance abuse and the professional provider. Ala J Med Sci 21:150--155, 1984 78. Teenagers' Drug Scoreboard: Research and Education on Alcohol and Drugs. ILLCAAP. From third and fourth Special Reports to the U.S. Congress on Alcohol and Health, National Institute on Alcohol Abuse and Addiction, 1982 79. Tsuang MT, Simpson JC, Kronfol Z: Subtypes of drug abuse with psychosis: Demographic characteristics, clinical features, and family history. Arch Gen Psychiatry 39:141-147, 1982 80. Udel M: Chemical abuse/dependence: Physician's occupational hazard. J Med Assoc Georgia 73:775-778, 1984 81. Udel M: Highs and lows of substance abuse. Aud Dig Psychiatry 4: Nov 1985 82. Verebey K, Gold MS, Mule J: Laboratory testing in the diagnosis of marijuana intoxication and withdrawal. Psychiatr Ann 16: Apr 1986 83. Wegscheider-Cruse, S: Another Chance: Hope and Help for the Alcoholic Family. Palo Alto, California, Science and Behavior Books, 1980 84. Wegscheider-Cruse S: Personal communication, 1985 85. Wieder H, Kaplan E: Drug use in adolescents. Psychoanal Stud Child 24:399--431, 1969 Ridgeview Institute 3995 South Cobb Drive Smyrna, Georgia 30080