Substance Use Problems

We also find it helpful to take a dimensional approach to substance use, by grouping different substances into one of three broad groups, according to their effect on the body and the brain.

• stimulants: substances that excite and stimulate mental processes
• depressants: substances that dampen and mute mental processes
• hallucinogens: substances that alter and distort perceptual and sensing processes.

The number of substances that can be placed in any of these groups is formidable. Yet, from our clinical perspective, most clients’ primary problems are with:

• alcohol
• cocaine and the amphetamines
• opioids (including heroin and pharmaceutical opioids)
• cannabis
• prescription tranquillizers.

Although, when looking at concurrent disorders, tobacco is not usually identified as the substance for which clients are seeking help, nicotine needs to be identified as problematic. Its prevalence among people who have concurrent disorders is disturbingly high, and its use will seriously affect the health and life course for many clients.

Table 1-1

Dimensional approach for grouping mental health and substance use problems
Dimension	Verbal Behaviour	Mental Health Problem		Substance use problem
		Axis I: Mental Health Disorders (example)	Axis II: Personality Disorders (example)	Substance-induced disorders (example)
Psychosis (cognitive-perceptual organization)	"weird talk"	schizophrenia, other psychotic disorders, mania	schizoid, schizotypal, paranoid	substance-induced psychotic disorder (e.g., cocaine-induced paranoia), substance-induced delirium
Impulsivity (anger/aggression)	"threat talk"	impulse control disorders, gambling, sexual paraphilias, bulimia, alcohol or other drug abuse/dependance	antisocial, borderline, narcissistic, histrionic	substance-induced impulse control disorder (e.g., amphetamine-induced sexual disorder)
Mood (depression & affective instability)	"sad" talk, laconia, "manic/grandiose" talk	depressive disorders, dysthymia, bipolar disorders	affective features often present in personality disorders	substance-induced mood disorder (e.g. heroin-induced depression)
Anxiety (inhibition)	"fear talk"	abxiety disorders, panic, disorders, phobias, obsessive-compulsive disorder	avoidant, dependent, obsessive-compulsive	substance-induced anxiety disorder (e.g., cannabis-induced anxiety disorder)

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