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Separating Symptom from Disorder
in Screening for Co-occurring Disorders

Every patient has feelings, many have symptoms, and some have disorders. Learning to differentiate among these is essential in the assessment process. For the patient, learning the difference is essential to the treatment and recovery process.

Traditional psychoanalytic approaches to addiction often viewed the patient's difficulty in managing painful emotions as the key to the treatment approach. These approaches never fully appreciated either the physical or social aspects to addictive disease, but they did underscore the role of emotion in the process of addiction and recovery. Slogans like "Life on life's terms," "Get real, feel, and deal," and "Stark raving sobriety" captured the new or recovering experience of an intense emotional life.

Feelings are normal affective responses to life. A full range can be expected. Symptoms including depression, anxiety, guilt, shame, irritability, sadness, distractibility, and sleeplessness may all occur, particularly after a change in substance use.
Edward Khantzian, one of the first and foremost addiction psychiatrists, once said that "alcoholics either feel too much or nothing at all." A person in early recovery experiences emotions that are, perhaps for the first time since childhood, unadulterated by substances. Some of these re-emerging feelings are experienced as positive; others are very uncomfortable, such as sadness and loss, fear and anxiety, guilt and shame, or anger.

Many patients will fear these feelings, and with growing discomfort seek immediate relief. In some cases, for patients without new coping skills, this search for relief may lead to relapse. In other cases, it may involve trying to self-diagnose and seek a prescribed "medication" that will make the feelings stop.

Having these feelings, learning to label them, and managing them are principal challenges in the early recovery process, and perhaps for life. Many addiction treatment providers hang a poster in the treatment setting that illustrates emotions and facial expressions. A mood poster or handout can help facilitate the clinical interaction and the development of affect management skills.

Feelings are normal affective responses to life. A full range can be expected. Symptoms including depression, anxiety, guilt, shame, irritability, sadness, distractibility, and sleeplessness may all occur, particularly after a change in substance use. As mentioned previously, these symptoms are often associated with withdrawal, intoxication, and the newfound experience of life without chemicals. Symptoms will likely occur in response to stimuli and will pass. Symptoms may also be isolated and not cluster into a series of criteria, as outlined in the DSM-IV, to constitute a diagnosis.

If a person does have DSM-IV symptoms and they are of sufficient duration, causing significant functional impairment then, he or she may meet criteria for a disorder. Feelings and symptoms pass in minutes, hours, or days. Disorders persist for weeks, months, or even years.

Feelings will need to be processed, symptoms will need to be managed, and disorders will need to be treated.

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This is an excerpt from the Hazelden Co-occurring Disorders Program, Screening and Assessment curriculum.

 
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