Special Issues in the Psychiatric Examination
Two special issues in the psychiatric examination of substance dependence include 1) the source of information when obtain-ing the history of the substance abuse, and 2) the management of aberrant behaviors. Information about a patient’s substance abuse history can be provided not only by the patient but also by employers, family members and school officials. When patients self-report the amount of substance abused, there is a tendency to underreport the severity and duration of abuse, particularly if the patient is being referred to treatment by an outside source such as the family, the employer, or the legal system. Objective veri-fication of the exact amount of substance use is sometimes dif-ficult but the critical issues in arriving at a diagnosis of substance dependence do not depend on the precise amount of substance abused. Tolerance and withdrawal can be assessed independently by using tests such as the naloxone challenge and the barbitu-rate tolerance test. In general, significant others’ estimates of the amount of drug use by the patient can be a good source of data. Thus, the initial evaluation of substance abuse and dependence may involve a wider range of interviews than would occur with many other types of psychiatric patients.
Aberrant behaviors potentially requiring management include intoxication, violence, suicide, impaired cognitive func-tioning and uncontrolled affective displays. The evaluation of an intoxicated substance abuser can address only a limited number of issues. These issues are primarily related to the safety of the substance abuser and other individuals who may be affected by his or her actions. Thus, a medical evaluation for signs of over-dose or major cognitive impairment is critical, with consideration of detaining the patient for several hours or even days if severe complications are evident. Intoxication with sedating drugs such as alcohol can lead to significant motor and cognitive impairment, which would have an impact on a patient’s capacity to drive a mo-tor vehicle. When a patient drives a car to an evaluation and is ob-viously intoxicated, the psychiatrist has an obligation to prevent the patient from getting back into the driver’s seat of that vehicle until the effects of that drug intoxication have worn off. This may involve contacting the police to restrain the patient from driving at least temporarily. Similar issues of police restraint can arise when an intoxicated patient becomes violent and has threatened to harm his or her employers or family members. Judgment and impulse control may be substantially affected by abused drugs, but these effects may be temporary, and a short-term preventive intervention may be sufficient to avert substantial harm to the pa-tient or others.
Temporary suicidal behavior may be encountered in a va-riety of substance addictions, particularly those with alcohol and stimulants. Suicidal ideation may be intense but may clear within hours. During the evaluation session, it is important to elicit the precipitants that led the patient to seek treatment at this time and to keep the evaluation focused on specific data needed for the evaluation of substance dependence, its medical complications and any comorbid psychiatric disorders. Many patients spend a great deal of time detailing their drug-abusing careers, but in gen-eral these stories do not provide useful material for the evaluation or for future psychotherapeutic interventions. Similarly, the eval-uation should not become focused on the affective aspects of a patient’s recent life because affect is frequently used as a defense to avoid discussing issues of more immediate relevance such as precipitants or to act as a pretext for obtaining benzodiazepines or other anti-anxiety agents from the physician. Abused substances have generally been a way of managing affect and these patients need to develop alternative coping strategies