Chapter 14: Abnormal Psychology (pages 265-296)
The term “dual diagnosis” is one you will frequently hear discussed in the field of
addictions work. While dual diagnosis will not be covered in depth by this course, this
chapter on abnormal psychology provides the opportunity to introduce this concept. Dual
diagnosis can be identified when there is at least one mental health disorder, such as
depression, present with and underlying a substance abuse disorder. The disorders are
said to co-exist and thus a person is dually diagnosed—diagnosed with both issues to be
addressed in counseling and overall treatment. Be sure to read this chapter carefully; in
this course we will highlight the mental health issues most commonly associated with
substance abuse: psychotic, affective or mood, anxiety, and personality disorders.
Be aware that the standard guide used by psychologists and therapists is the Diagnostic
and Statistical Manual of Mental Disorders, which is now in a revised fourth edition—no
longer “revised third” as to which the book refers. Currently, you will hear the DSM IVR discussed in professional circles. The DSM IV and DSM IV-R do reflect some
changes in diagnoses; for example, there is no longer passive-aggressive personality
disorder. We will focus on commonly seen disorders in dual diagnosis, which have
remained the same.
Multiaxial Assessment Based on the DSM-IV-TR
Diagnosing mental health and substance abuse disorders is both a science and an art.
There are more than 300 different diagnoses in the DSM so many disorders have signs
and symptoms in common with each other. A DSM diagnosis is made based upon
information gathered during the biopsychosocial interview and upon the professional’s
knowledge of mental health and substance abuse disorders. Please note that only trained
and licensed professional counselors are able to diagnose an individual with a mental
health or substance use disorder.
A diagnosis is written out in the format of a Multiaxial Assessment that is common
among mental health and substance abuse treatment professionals. The system involves
assessment on multiple axes where each axis refers to a different domain of information.
The Multiaxial Assessment format allows for information to be clearly disseminated and
understood amongst the treatment team and any other medical personnel.

Axis I is where clinical disorders and other conditions that may be of focus of
clinical attention are recorded. Examples of disorders recorded on Axis I include
Substance Dependence or Abuse, Depression, Anxiety, Bipolar, and Dysthymic
disorder and is often the reason the client seeks treatment.

Axis II is where Personality Disorders and Mental Retardation diagnoses are
recorded.

Axis III is where General Medical Conditions are indicated. Medical conditions
are potentially relevant to the understanding or management of the individual's
mental disorder. Examples of Axis III disorders could be Cardiac Arrest, Asthma,
Diabetes, or even Obesity.

Axis IV is where Psychosocial and Environmental problems are recorded.
Problems with primary support group, problems related to the social environment,
educational problems, occupational problems, housing problems, economic
problems, problems with access to health care services, problems related to
interaction with the legal system/crime, and other psychosocial and environmental
problems are examples that would be recorded on Axis IV (American Psychiatric
Association, 2000).

Axis V is the Global Assessment of Functioning or GAF. A GAF score ranges
from 1 to 100 (where one is the lowest score and 100 is the highest score) and is
based on the clinician’s judgment of the individual's overall level of functioning.
This information is useful in planning treatment and measuring its impact, and in
predicting outcome.
1. List the four perspectives one can take regarding a person who has psychological
problems.
2. Briefly discuss how Christians may be considered “abnormal” but “functional”.
3. The DSM is careful to emphasize that people are not disordered but _____________.
4. It suggests a person is not an alcoholic but rather has an _______________________.
5. The first step toward ultimate normality—normality as God intended it from the
beginning—is ____________________________.
6. Total health in a whole person demands healthy relationships in three directions.
These are:
7. List twelve characteristics identified as found in a person who is mentally healthy.
8. List the three factors that appear to contribute to psychological problems.
Anxiety Disorders
A number of anxiety disorders are often found to co-exist with substance abuse. The
defining characteristics of these disorders are people exhibit anxious arousal and
avoidance of the anxiety-provoking situation. The anxiety disorders typically seen with
substance abuse include obsessive-compulsive disorder, posttraumatic stress disorder,
and generalized anxiety disorder. Other possibilities are phobic disorders such as
agoraphobia, social phobia or specific phobias such as those listed on page 276. Anxiety
disorders are common both in the general population and among substance abusers.
9. What percent of children have experiences that create anxiety? _______________
10. Problems begin when much of the anxiety is not dealt with at the time of the
experiences but is _______________________.
11. Match the following disorders with their descriptions.
____ 1. Posttraumatic stress disorder
____ 5. Generalized anxiety disorder
____ 2. Obsessive-compulsive disorder
____ 6. Social phobia
____ 3. Panic disorder
____ 7. Simple phobia
____ 4. Agoraphobia
a. Characterized by re-experiencing (i.e. through a flashback) a traumatic event such as
rape or a war experience.
b. Fear of a specific object or situation.
c. Characterized by intense anxiety attacks during which a person may feel dizzy and
have fear of dying.
d. An irrational fear of leaving the home setting.
e. Recurrent irrational thoughts and irrational actions interfere with daily functioning, and
the person is aware they are a problem.
f. The source of this anxiety is unknown but it is chronic, generalized and persistent.
g. There is a fear of social situations in which the individual fears embarrassment or
humiliation.
12. List the four classifications of mood disorders.
These disorders are frequently seen with substance abuse.
13. Increases in mood, speech and motor ability characterize the _____________ phase
of bipolar disorder. The euphoric mood resembles the “high” of an _____________.
14. Psychiatrists treat more cases of ___________________ than any other emotional
disturbance.
15. Distinguish between cyclothymia and dysthymia.
Refer back to Chapter 4 on emotion and feelings for more on depression and suicide.
16. A major cause of discouragement among dedicated Christians is ________________.
17. The best known of the psychotic disorders is _________________________. It
begins is ____________________ or early ___________________.
18. List and briefly define the four classical symptoms of schizophrenia.
19. The maladaptive behavior pattern associated with the use of psychoactive drugs is
reflected in what three characteristics?
20. Distinguish between substance abuse and substance dependency.
21. Depressive symptoms common in alcohol dependency may partially account for the
high rate of ______________ among alcohol-dependent persons.
22. Define personality disorders.
23. Personality disorders can be understood on a continuum where a spectrum of
behavior is involved ranging from the full-blown personality ______________ ,which
is rare in the population, to the presentation of personality _____________, which are
common.
Antisocial Personality Disorder and Borderline Personality Disorder are commonly
diagnosed with substance abuse disorders. The former is discussed in the book.
24. Another term used for the antisocial personality is _______________________.
25. Such individuals engage in repeated ________________ with other members of
society. The most prominent characteristic of this disorder may be the relative
absence of ____________________.
26. Apart from salvation, what is the likelihood of significant improvement in this
disorder?
Although not discussed in detail in this book, borderline personality disorders are a great
challenge for the treatment provider. People with this disorder may be considered semipermanently unstable—in their affect, relationships, self-image, and marked impulsivity.
Females make up the majority of theses diagnosed cases. Indicators of this disorder
include five or more of the following: (1) frantic efforts to avoid real or imagined
abandonment; (2) a pattern of unstable and intense interpersonal relationships, sometimes
extremely idealizing, sometimes devaluing the other person involved; (3) identity
disturbance; (4) impulsivity; (5) recurrent suicidal or self-mutilating behavior or threats;
(6) marked mood reactions; (7) feelings of emptiness; (8) intense inappropriate anger or
difficulty controlling anger; and (9) transient stress-related paranoid ideation or severe
dissociative symptoms. Substance use is associated with increased symptoms among
borderline clients.