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Assessing Alcohol and Substance Use Disorders & Comorbid Conditions

Treatment for Alcohol & Substance Use Disorders A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

Link to Alcohol and Substance Use Disorders Assessments

On Coping.US under the Clinical Treatment Tools Section you will find Clincial Assessment Tools and on that page you will find assessments used to identify Alcohol and/or Sustance Use Disorders. Have a look at:
Insight into the Addiction to Alcohol and/or Other Substances

Ways People use Alcohol and Substances 


  • Experimentation
  • Social/Recreational
  • As a stress reliever


  • Illegal
  • Harmful to self or others


Potential Consequences of Abuse of Alcohol or Substances
  • Accidents or injuries
  • Blackouts
  • Legal problems
  • Poor job performance
  • Family Problems
  • Sexual behavior that increases the risk of HIV infections or Sexually Transmitted Diseases (STD’s)

Addiction to Alcohol or Substances
Addiction is the irresistible compulsion to use alcohol or drugs despite negative consequences

Characterized by

  • Repeated failures to control use
  • Increased tolerance
  • Increased disruption in the family

Understanding Addiction
  • For 1 in 10 people substance abuse leads to Addiction
  • Chronic – once a person develops it, the person will always have to deal with it
  • Progressive – gets worse over time
  • Primary – not just symptom but a primary illness of the person
  • Terminal - can lead to death of person
  • Characterized by Denial – a defense mechanism – user denies that his/her life is out of control

Risk of Addiction
  • Addiction is a family disease – children of alcoholic have 3x’s chance and if both parents then 5x’s chance of becoming an addict – both genetic and learned behavior
  • Prior abuse of alcohol and other substances
  • Other contributing factors-seek release from depression or self-destructive lifestyle

Impact of Alcohol and/or Substance Use Disorders on the Abuser
  • Health - neglect nutrition, sleep and basic health needs
  • Productivity - interferes with job and work
  • Decision making - poor decisions due to distorted perceptions
  • Safety - impaired vision, hearing and muscle coordination with low levels of attention, alertness & mental acuity
  • Security - financial difficulties leads to risk of engaging in illegal activities in community

Emotional Effects of Alcohol and/or Substance Use Disorders
  • Aggression
  • Burnout
  • Anxiety
  • Depression
  • Paranoia
  • Denial

Behavioral Effects of Alcohol and/or Substance Use Disorders
  • Slow reaction time
  • Impaired coordination
  • Slowed or slurred speech
  • Irritability
  • Excessive Talking
  • Inability to sit still
  • Limited attention span
  • Poor motivation and lack of energy

Physical Effects of Alcohol and Substance Use Disorders
  • Weight loss
  • Sweating
  • Chills
  • Smell of alcohol or pot

Enabling behaviors in Families Common to Alcohol and/or Substance Use Disorders
Enabling is action that someone takes to protect person with problem from consequences of his/her actions. Unfortunately, enabling actually helps person to NOT deal with problem by:
  • Covering up
  • Rationalizing
  • Withdrawing/Avoiding
  • Blaming
  • Controlling
  • Threatening

Behavioral Traps Families fall into when a Member is has Alcohol and/or Sustance Use Disoerders
  • Sympathy
  • Excuses
  • Apology
  • Diversions
  • Innocence
  • Anger
  • Pity
  • Tears
Functional Analysis of Alcohol and/or Substance Use
Functional Analysis Identifies:
  • Triggers which set a person up to use
  • Thoughts and emotions which are connected to a person's alcohol and/or substance use
  • What actions and behaviors a person engaged in to set self up for alcohol and/or substance use
  • Positive consequences of the use
  • Negative consequences of the use

What were Triggers of for a person's Use or Abuse of Alcohol and/or Substances
  • Who was with the person when the person used
  • What the person was doing before person used
  • What the person did to set up person's use
  • Where the person was before person used
  • How was person feeling prior to person's use
  • What had happened prior to person's use which might have set up this use

What thoughts and feelings led to person's alcohol and/or substance use or abuse
  • What feelings trigger the person's desire to use or abuse alcohol and/or substances
  • What thoughts trigger the peron's desire to use or abuse alcohol and/or substances
  • What makes the person aware of person's desire to use or abuse alcohol and/or substances
  • What feelings dooe the person have as the person sets self up to use or abuse alcohol and/or substances

What behaviors or actions does a person take to use or abuse alcohol and/or substance
  • What does the person do to set up self to use or abuse
  • What does the person do to people around that person prior to going out to use
  • What does the person do to hide personal use and abuse fromt the person's family, work or authorities
  • What does the person do to clean up the messes, the person makes as a result of the person's use and abuse of alcohol and/or substances

What positive consequences did the person experience in the person's use of alcohol and/or substance
Ask the person:
  • What was the high like when you starting using
  • What was the positive energy like with the people you with whom you were using
  • How much stress was relieved by your use
  • How much of your depression was lessened by your use

What negative consequences came from the person's use of alcohol and/or substance
Ask the person:
  • What happened after you came down from your high from your use
  • What happened to the other people you were using with when they came down from their highs
  • What legal issues arose as a result of your use
  • What family problems were worsened by your use
  • What school or work problems were worsened by your use

Goals of functional analysis
  • To get the person to find an alternative activity to do if the person falls into same old emotional and thinking triggers which lead to use
  • To encourage the person to find different people to hang out with so as not to have those who lead the person into the person's use
  • To encourage the person to find alternative activities and places to engage in which are not prone to trigger the person's use

Functional Analysis Helps People Identify
  • Their unhealthy thoughts, emotions and actions which lead to their alcohol and/or substance use and abuse
  • Their lifestyle activities which lead to their alcohol and/or substance use and abuse
  • What new people, places, and situations theyneed to get in their lives which will lessen their chances of going back into their old pattern of alcohol and/or substance use and abuse
Problem Solving for Avoiding Abusing Alcohol and/or Substances

Steps in Problem Solving

Step 1: Recognize the Problem
Recognize the problem (“Is there a problem?”)
Recognition of problems may come from several clues, including
  • Worry, anger & depression
  • Having problems pointed out by others
  • Being preoccupied
  • Always feeling like one is in crisis.

Step 2- Clarify what the problem is

  • Identify and specify the problem (“What is the problem?”)
  • It is easier to solve problems that are concrete and well defined than those that are global or vague
  • For large problems that seem over whelming, it is important to try to break them down into smaller, more manageable steps.

Step 3-Brainstorm alternative solutions

  • Consider various approaches to solving the problem (“What can I do to solve the problem?”)
  • Brainstorm-generate as many solutions as possible without considering, at first, which are good or bad ideas
  • It is important for quantity, rather than quality, in the beginning
  • Writing these ideas down is very helpful-the person may want to return to the list in the future
  • It is also important to recognize that not doing anything immediately is an option

Step 4- Select most promising solution

  • Select the most promising approach (“What will happen if . . . ?”)
  • This step involves thinking ahead
  • Review each approach, considering both positive and negative consequences of all solutions
  • This step may also involve collecting more information and assessing whether some solutions are feasible (e.g., “Can I borrow Tom’s car to take the driving test?”)

Step 5-Assess Effectiveness

  • Assess the effectiveness of the selected approach (“What did happen when I . . . ?”)
  • While some problems are easy to solve, others are more difficult

Problem Solving Journal 
It is helpful for a person dealing with an alcohol and/or substance use disorder to keep a journal in which problems as the arise are problem solved. In keep the journal people are encouraged to fill in the following points:
1.Identify the problem
2.Brainstorm alternative solutions
3.Rate the possibility of the alternatives as solutions
4.Order alternatives in priority of being most likely to successfully solve the problem one is working on
Comorbidity of Substance Use Disorder and Mental Health Disorders

Comorbidity of Bipolar, Alcohol Use Disorder and other conditions 

The frequency with which individuals who have bipolar disorder also suffer from substance abuse is very high. In fact, it leaves little doubt that there is a link between the two although it is not yet known which condition leads to the other. It is estimated that approximately 60% of all individuals with bipolar disorder also abuse substances.

When both conditions are seen in an individual it can lead to three different types of complications. These include:

1.Problems in diagnosing the bipolar disorder

2.The substance mimics the symptoms of bipolar disorder (e.g. severe mood swings) leading to a misdiagnosis

3.The substance has adverse effects on the treatment for the bipolar disorder

Carmiol et al (2014) looked into Bipolar disorder and alcohol use disorder (AUD) due to their high rate of comorbidity, more than 50% of individuals with bipolar disorder also receive a diagnosis of AUD in their lifetimes. Although both disorders are heritable, it is unclear if the same genetic factors mediate risk for bipolar disorder and AUD

They examined 733 Costa Rican individuals from 61 bipolar pedigrees. Based on a best estimate process:

  • 32% of the sample met criteria for bipolar disorder
  • 17% had a lifetime AUD diagnosis
  • 32% met criteria for lifetime nicotine dependence
  • 21% had an anxiety disorder
  • AUD, nicotine dependence and anxiety disorders were relatively more common among individuals with bipolar disorder than in their non-bipolar relatives
All illnesses were shown to be heritable and bipolar disorder was genetically correlated with AUD, nicotine dependence and anxiety disorders. The genetic correlation between bipolar and AUD remained when controlling for anxiety, suggesting that unique genetic factors influence the risk for comorbid bipolar and AUD independent of anxiety. Their findings provide evidence for shared genetic effects on bipolar disorder and AUD risk. Demonstrating that common genetic factors influence these independent diagnostic constructs could help to refine our diagnostic nosology. (Carmiol, N. N., Peralta, J. M., Almasy, L. L., Contreras, J. J., Pacheco, A. A., Escamilla, M. A., & ... Glahn, D. C. (2014). Shared genetic factors influence risk for bipolar disorder and alcohol use disorders.European Psychiatry, 29(5), 282-287. doi:10.1016/j.eurpsy.2013.10.001)

Increase of Impulsivity with comorbid Bipolar and Substance Use Disorder
Trait impulsivity is increased additively in bipolar disorder and substance abuse. Performance impulsivity is increased in Interepisode bipolar disorder only if a history of substance abuse is present. This increased predisposition to impulsivity when not manic may contribute to the decrement in treatment outcome and compliance and increased risk for suicide and aggression, in bipolar disorder with substance abuse. (Swann, A.C., Dougherty, D.M., Pazzaglia, P.J., Pham, M. & Moeller, F.G.(2004). Impulsivity: A link between bipolar disorder and substance abuse. Bipolar Disorders, 6, 204–212.).

Likelihood of Substance Use Disorders in people with Mental Health Disorder


Odds Ratio

Bipolar Disorder




Panic Disorder


Major Depression


Anxiety Disorder


Weiss, R.D. & Smith-Connery, H. (2011). Integrated Group Therapy for Bipolar Disorder and Substance Abuse. New York: Guilford Press.

Significant Symptoms of Substance use Disorders in patients with Mental Health Disorder
  • Enhanced reinforcement
  • Mood Change
  • Escape
  • Hopelessness
  • Poor Judgment
  • Inability to appreciate consequences

Results of Substance Use Disorder with Mental Health Disorder
  • Lower medication adherence
  • Greater chance relapses
  • Increased hospitalizations
  • Homelessness
  • Suicide

Models of Comorbid SUDs & Mental Health Disorder Treatment
  1. Sequential – Treat SUD first then Mental Health Disorder
  2. Parallel – Treat both at same time but within different treatment modalities
  3. Integrated – Treat both at same time within the same treatment modality

Focus of Integrated Model
  • Dealing with the Mental Health Disorder without use of Alcohol &/or Drugs
  • Confronting denial, ambivalence, acceptance
  • Monitoring overall mood during each week
  • Emphasis on compliance in taking psychiatric medications
  • Identifying & fighting triggers
  • Emphasis on “wellness” model of good night’s sleep, balance nutritional intake & exercise

Parallels in Recovery & Relapse thinking between Comorbid Disorders
  • “May as well thinking” vs. “It matters what you do”
  • Abstinence violation effect vs. stopping taking psychiatric meds when anxious or depressed
  • Recovery thinking vs. relapse thinking & acting out
  • Remember: you’re always on the road to getting better or getting worse: “It matters what you do!”