Emilie Vanhaecke, MA
Theresa Rutchka, MS
1
To accurately diagnose a mental disorder in the context of substance
use, the clinician must be able to distinguish between:
1. Primary disorders that are not
etiologically related to a substance use,
but may occur during substance using
periods.
 2. Substance induced syndromes, in
which symptoms exceed intoxication or
withdrawal.
 3. Intoxication and withdrawal states and
their relationship to the psychiatric
symptoms being evaluated.
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2
Substance Induced Syndromes
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Substance-induced delirium
Substance-induced persisting dementia
Substance-induced persisting amnestic
disorder
Substance-induced psychotic disorder
Substance-induced mood disorder
Substance-induced anxiety disorder
Hallucinogen persisting perceptual disorder
Substance-induced sexual dysfunction
Substance-induced sleep disorder
1
3
What constitutes a sufficient
period of abstinence?
DSM-IV-TR offers a guideline of waiting
1 month after the cessation of
withdrawal to diagnose a primary
disorder.
 While establishing a sufficient period of
abstinence may make a diagnosis
clearer, it may not be practical, feasible,
or necessary to wait for a month before
assigning a diagnosis.
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4
The Assessment Process
Top priority when differentiating between
mental health disorders and substance
abuse concerns is gathering an accurate
chronological history (ie. Periods of
sobriety, periods of decreased on
increased mental health symptoms, etc)
 Giving as much time as possible between
getting sober and making mental health
diagnoses
 Accepting that diagnosing is a process that
occurs throughout the course of treatment
and therapy
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5
Dual Diagnosis Prevalence
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In the majority of cases, substance use/abuse exacerbates
mental health symptoms and can lead to furthering the cycle of
continued substance abuse and relapse of psychological
symptoms
Approximately 1/3 of individuals with mental illness and ½ of
individuals with severe mental illness experience substance
abuse
Approximately 1/3 of alcohol abusers and more than ½ of drug
abusers report experiencing mental illness
Males are generally more likely to experience co-occurring
disorders than women
Other populations at higher risk for co-occurring disorders are
veterans, low SES individuals, individuals with physical illness
6
Signs of Mental Illness
Signs of Alcohol or Drug Abuse
Difficulties at
work or school
Neglected
appearance or
dramatic change
in appearance
Changes in
spending habits
General changes
in behavior
Changes in
physical health
7
Overlapping Symptomatology
•Amphetamine
Abuse
• Cocaine
Abuse
• Alcohol
Abuse
• Cannabis
Abuse
Euphoria
/Lack of
Inhibition
Increased
Energy
Memory
Problems
Sleep
Disturbance
Increased
Sex Drive
Insomnia
Guilt
/Shame
Appetite
Changes
• Ritalin,
• Adderall,
etc Abuse
Symptoms of Mania
• Bath Salt
Abuse
• Opiate
Abuse
• Benzo
Abuse
Symptoms of Depression
8
Overlapping Symptomatology
• Cocaine
Abuse
• Ampheta
–mine
Abuse
• Stimulant
Abuse
• Alcohol
Abuse
Poor
attention
Memory
Problems
Hyper alertness
Insomnia
Hyper
-activity
Restless
-ness
Social
Withdrawal
Poor
Concentration
• Bath Salt
Abuse
Symptoms of ADHD
• Ritalin,
Adderall,
etc. Abuse
• Opiate
Abuse
• Benzo
Abuse
Symptoms of PTSD
9
Medication-Assisted Therapies
These can complicate the picture of
assessing and diagnosing
 Medication options may be limited with
antagonist therapies are on board;
hence the importance of referring to
mental health clinicians/prescribing
psychiatrists with a working knowledge
of these therapies
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10
Major Depressive Disorder
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A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed mood
or (2) loss of interest of pleasure.
1. Depressed mood most of the day, nearly every day (subjective
reports or observations made by others)
2. Diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day
3. Significant weight loss when not dieting or weight gain, or decrease
or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly ever day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness, nearly
every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing
suicide
1
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Major Depressive Disorder
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B. The symptoms do not meet criteria for a Mixed
Episode
C. The symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
D. The symptoms are not due to the direct
physiological effects of a substance or a general
medication condition.
E. The symptoms are not better accounted for by
Bereavement, i.e. after the loss of a loved one, the
symptoms persist for longer than 2 months or are
characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor
retardation.
1
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Major Depressive Disorder:
Prevalence
Major depression is one of the most
common mental disorders in the United
States.
 In 2012, an estimated 16 million adults
aged 18 or older in the U.S. had at least
one major depressive episode in the
past year. This represented 6.9 percent
of all U.S. adults.
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2
13
Major Depressive Disorder: Treatment Options
Medications
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Selective serotonin reuptake inhibitors (SSRIs)
(Prozac, Paxil, Zoloft, Celexa, Lexapro)
Serotonin and norepinephrine reuptake
inhibitors (SNRIs) (Cymbalta, Effexor XR,
Pristiq)
Norepinephrine and dopamine reuptake
inhibitors (NDRIs) (Wellbutrin)
Atypical antidepressants (Remeron)
Tricyclic antidepressants (Tofranil)
Monoamine oxidase inhibitors (MAOIs)
(Parnate)
2
14
Major Depressive Disorder: Treatment Options
Psychotherapy
Cognitive Behavioral Therapy
 Dialectic Behavioral Therapy
 Interpersonal Therapy
 Psychodynamic Therapy
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2
15
Bipolar I Disorder
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Diagnosis characterized by the occurrence of one or more Manic Episodes or Mixed Episodes.
Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at
least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) and have been present to a significant degree:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas (racing thoughts)
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences
C. The symptoms do not meet criteria for a Mixed Episode
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others, or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance or a general medical
condition.
1
16
Bipolar I Disorder
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Criteria for Mixed Episode
A. The criteria are met both for a Manic Episode and
for a Major Depressive Episode nearly every day
during at least a 1-week period.
B. The mood disturbance is sufficiently severe to
cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or others, or
there are psychotic features.
C. The symptoms are not due to the direct
physiological effects of a substance or a general
medical condition.
1
17
Bipolar II Disorder
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Diagnosis characterized by one or more Major
Depressive Episodes accompanied by at least
one Hypomanic Episode.
Hypomanic episodes have the same
symptoms as manic episodes with two
important differences: (1) the mood usually
isn’t severe enough to cause problems with
the person working or socializing with others
(e.g., they don’t have to take time off work
during the episode), or to require
hospitalization; and (2) there are never any
psychotic features present in a hypomanic
episode.
1
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Bipolar Disorder: Prevalence
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Bipolar disorder affects approximately
5.7 million adult Americans, or about
2.6% of the U.S. population age 18 and
older every year.
3
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Bipolar Disorder: Treatment
Options
Medications
Mood stabilizers (Lithium)
 Anticonvulsants, utilized as mood
stabilizers (Depakote, Lamotrigine,
Gabapentin, Topamax, etc.)
 Atypical antipsychotics (Zyprexa, Abilify,
Seroquel, Risperdal, etc.)
 Antidepressants (Prozac, Paxil, Zoloft,
Wellbutrin, etc.)
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3
20
Bipolar Disorder: Treatment
Options
Psychotherapy
Cognitive Behavioral Therapy
 Family-focused Therapy
 Interpersonal Therapy
 Psychoeducation
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3
21
Substances of Abuse That Can
Cause Symptoms of Mood
Disorders Major
Mania/Hypomani
Depression
a
Intoxication
Withdrawal
Intoxication
Alcohol
X
X
Sedative/
hypnotics
X
X
Cocaine/crack
X
X
X
Stimulants
X
X
X
Heroin/opiates
X
Withdrawal
Cannabis
Hallucinogens
X
Phencyclydine
(PCP)
X
Inhalants
X
X
4
22
Posttraumatic Stress Disorder
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Criterion A: The person was exposed to: death, threatened death, actual or threatened
serious injury, or actual or threatened sexual violence, as follows: (one required) Direct exposure, witnessing in person OR Indirectly, by learning that a close relative or
close friend was exposed to trauma. If the event involved actual or threatened death, it
must have been violent or accidental. Repeated or extreme indirect exposure to
aversive details of the event(s), usually in the course of professional duties (e.g., first
responders, collecting body parts; professionals repeatedly exposed to details of child
abuse). This does not include indirect non-professional exposure through electronic
media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (one
required)
Recurrent, involuntary, and intrusive memories. Note: Children older than six may
express this symptom in repetitive play.
Traumatic nightmares. Note: Children may have frightening dreams without content
related to the trauma(s).
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief
episodes to complete loss of consciousness. Note: Children may reenact the event in
play.
Intense or prolonged distress after exposure to traumatic reminders.
Marked physiologic reactivity after exposure to trauma-related stimuli.
23
Posttraumatic Stress Disorder
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Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one
required)
Trauma-related thoughts or feelings.
Trauma-related external reminders (e.g., people, places, conversations, activities,
objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic
event: (two required)
Inability to recall key features of the traumatic event (usually dissociative amnesia; not
due to head injury, alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or the
world (e.g., "I am bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic event or for
resulting consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
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Posttraumatic Stress Disorder
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Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or
worsened after the traumatic event: (two required)
Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D, and E) for more than one
month.
Criterion G: functional significance
Significant symptom-related distress or functional impairment (e.g.,
social, occupational).
Criterion H: exclusion
Disturbance is not due to medication, substance use, or other illness.
25
Posttraumatic Stress Disorder:
Prevalance
7-12% of individuals will experience it at
some point in their lifetime
 Over 50% comorbidity with alcohol
abuse; Over 30% comorbidity with drug
abuse
 Women more likely to develop PTSD
 Men more likely to abuse alcohol
specifically
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PTSD and Substance Abuse: A
Vicious Cycle
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Similar endorphin rush from alcohol that comes from
the body coping with a stressful moment; Endorphin
withdrawal similar to alcohol withdrawal
Substances (often depressants) often used to
“numb” the anxiety and hypervigilance of PTSD;
however, substance use worsens the feelings of fear
and anxiety in withdrawal
Stimulants being seen as a way to cope with the
“numbing” symptoms of PTSD
Substances often used to cope with flashbacks and
nightmares
Increased risk of relapse in individuals in recovery
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PTSD: Treatment Options
Cognitive-Behavioral Therapy
Psychoeducation (for the individual, and family/support
system highly encouraged)
 Family Therapy
 EMDR (Eye Movement Desensitization and Reprocessing)
 Group psychotherapy (including models such as Seeking
Safety, support groups, etc.)
 Antagonist medications indicated as potentially helpful
 SSRI’s may be effective in treating certain symptoms such
as avoidance/numbing symptoms
 Benzodiazepines have historically been prescribed but
they are not recommended for long term treatment due to
high abuse potential
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28
Attention-Deficit/Hyperactivity
Disorder
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Inattention: Six or more symptoms of inattention for children up to
age 16, or five or more for adolescents 17 and older and adults;
symptoms of inattention have been present for at least 6 months,
and they are inappropriate for developmental level:
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Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores,
or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a
long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils,
books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted
Is often forgetful in daily activities.
29
Attention-Deficit/Hyperactivity
Disorder
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Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity
for children up to age 16, or five or more for adolescents 17 and older and adults;
symptoms of hyperactivity-impulsivity have been present for at least 6 months to
an extent that is disruptive and inappropriate for the person’s developmental
level:
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Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be
limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often "on the go" acting as if "driven by a motor".
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting his/her turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
Several inattentive or hyperactive-impulsive symptoms were present before age 12
years.
Several symptoms are present in two or more setting, (e.g., at home, school or work;
with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, school, or work functioning.
The symptoms do not happen only during the course of schizophrenia or another
psychotic disorder. The symptoms are not better explained by another mental disorder
(e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
3 Subtypes
30
ADHD: Prevalence
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Up to 5% of children in the general population
meet criteria for ADHD
Between 30% and 50% carry their symptoms
into adulthood
According to a study done by the U.S.
Department of Health and Human Services:
 Teens with ADHD are twice as likely to have gotten
drunk in the past six months.
 Teens with ADHD are more likely to try alcohol or
drugs at a younger age.
 Teens with ADHD are more likely to use multiple
illegal drugs.
 Teens with ADHD are more likely to use marijuana.
31
ADHD and Stimulant Treatment
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Recovery and ADHD treatment can be difficult due to the
fact that ADHD is commonly treated with habit-forming
medication with a high potential for abuse. However,
many individuals who are diagnosed with ADHD can be
less likely to relapse once their symptoms are being
properly medicated.
To determine effectiveness, option of a “drug holiday”
Option of looking into extended release or longer acting
stimulant medications for those individuals struggling with
substance abuse.
Research suggests medication in combination with
psychotherapy is more effective for individuals with
ADHD.
32
ADHD Treatment
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Methylphenidate (Ritalin,
Concerta, Metadate, Methylin,
etc.)
Amphetamines (Dexedrine,
Dextrostat, Adderall, etc.)
Non-stimulant medications
include Strattera
(atomoxetine, a selective
norepinephrine reuptake
inhibitor) and Vyvanse
(lisdexamfetamine dimesylate)
At times – antidepressants
Medication
Cognitive-behavioral
therapy
 Psychoeducation
 Behavioral Therapy
 Social Skills Training (in
both children, and in
adults who may have
self-medicated with other
substances

Therapy
33
Borderline Personality Disorder
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Borderline Personality Disorder is a pervasive pattern of instability of
interpersonal relationships, self-image, and affects, and marked by
impulsivity beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) or the following:
1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
3. Identity disturbance: markedly and persistently unstable self-image
or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging
(spending, sex, substance abuse, reckless driving, binge eating, etc)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms
1
34
Borderline Personality Disorder:
Prevalence

In 2008, the first-ever large-scale, community
study of personality disorders found a lifetime
prevalence of 5.9 percent (18 million people)
for BPD, with no significant difference in the
rate of prevalence in men (5.6 percent)
compared with women (6.2 percent). The
authors concluded, “BPD is much more
prevalent in the general population than
previously recognized, is equally prevalent
among men and women, and is associated
with considerable mental and physical
disability, especially among women.”
5
35
Borderline Personality Disorder:
Stigma
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Individuals with a diagnosis of BPD are subject to a great
deal of discrimination and bias, both in society at large
and within the mental health treatment community.
Paris wrote: Patients with borderline personality disorder
(BPD) …. can challenge even the most experienced
therapists. The most frightening symptoms of BPD are
chronic suicidal ideation, repeated suicide attempts, and
self-mutilation. These are the patients we worry about—
and are afraid of losing. …All too frequently, [BPD] is
diagnosed as a variant of major depression or bipolar
disorder. Moreover, patients with BPD are often
mistreated. They receive prescriptions for multiple drugs
that provide only marginal benefit. They do not always get
the evidence-based psychotherapy they need.
6
36
Borderline Personality Disorder:
Treatment Options
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SAMHSA’s National Registry of EvidenceBased Programs and Practices (NREPP) lists
two evidence-based practices for this disorder:
dialectical behavior therapy and
psychoeducational multifamily groups.
DBT is a type of cognitive-behavior therapy
pioneered by Marsha Linehan in the early
1990s. It combines weekly individual therapy
with weekly group skills training in mindfulness
(i.e., awareness of present experiences),
distress tolerance, emotion regulation, and
interpersonal effectiveness over a period of at
least 12 months.
5
37
A Note On Anxiety Disorders
Is it organic anxiety?
 Or a natural and expected adjustment
period in recovery of developing new
coping skills?
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DSM 5 Screening Tools
Psychiatry.org now offers numerous APA
approved DSM 5 screening measures for
clinicians geared towards narrowing the
scope of the assessment process
 Numerous measures offered for:
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Depression
Drug and alcohol use
Mood disorders
Anxiety disorders
Trauma screening
Suicide Risk
39
Promoting Treatment
When promoting treatment adherence
and motivation for change – important to
listen to the client’s priorities
 IE. Does the client want relief from their
depression more than they want to
acknowledge a substance use problem?
Does the client prioritize their sobriety
over exploring mental health treatment?
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40
Examples to Work Through
41
References
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1. American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
American Psychiatric Association.
2. National Institute of Mental Health. (2015). Major Depression Among
Adults. Retrieved from
http://www.nimh.nih.gov/health/statistics/prevalence/major-depressionamong-adults.shtml
3. National Institute of Mental Health. (2015). Bipolar Disorder.
Retrieved from http://www.nimh.nih.gov/health/topics/bipolardisorder/index.shtml
4. Miele, G.M., Trautman, K.D., Hasin, D.S. (1996). Assessing
Comorbid Mental and Substance-Use Disorders: A Guide for Clinical
Practice. Journal of Psychiatric Practice, 276. Retrieved from
http://www.columbia.edu/~dsh2/prism/files/miele.pdf
5. U.S. Department of Health and Human Services. Report to
Congress on Borderline Personality Disorder. Retrieved from
https://store.samhsa.gov/shin/content/SMA11-4644/SMA11-4644.pdf
42
References
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6. Paris, J. (2008). Treatment of borderline personality disorder:
A guide to evidence-based practice. New York: Guilford Press.
7. Brady, K.T., Back, S.E., & Coffey, S.F. (2004). Substance
abuse and posttraumatic stress disorder. Current Directions in
Psychological Science, 13, 206-209.
8. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., &
Nelson, C.B. (1995). Posttraumatic stress disorder in the
National Comorbidity Survey. Archives of General Psychiatry,
52, 1048-1060.
9. Tull, M.T., Baruch, D., Duplinsky, M., & Lejuez, C.W. (in
press). Illicit drug use across the anxiety disorders: Prevalence,
underlying mechanisms, and treatment. In M.J. Zvolensky &
J.A.J. Smits (Eds.), Health behaviors and physical illness in
anxiety and its disorders: Contemporary theory and research.
New York, NY: Springer.
10. Mayo Clinic. (2015). Posttraumatic Stress Disorder (PTSD).
Retrieved from http://www.mayoclinic.com/health/posttraumatic-stress-disorder/DS00246
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References
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11. Copeland, M.E., and M. Harris. (2000) Healing the trauma of
abuse; A woman’s workbook. Oakland, CA: New Harbinger.
12. Behavioral Health Evolution. (2015). Dual Diagnosis.
Retrieved from http://www.bhevolution.org/public/cooccurring_disorders.page
13. Mayo Clinic. (2015). Drug addiction symptoms. Retrieved
from http://www.mayoclinic.org/diseases-conditions/drugaddiction/basics/symptoms/con-20020970.
14. Substance Abuse and Mental Health Services
Administration. (2015). Integration of mental health. Retrieved
from http://media.samhsa.gov/co-occurring/topics/healthcareintegration/index.aspx
15. National Center for Biotechnology Information. (2015). The
assessment process. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK64196/.
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