Decisions to change often follow a process known as the
decisional balance, where a user considers the pros and
cons for change. Ambivalence is quite normal for some-
one contemplating change. If a user decides that the pros
for change outweigh the cons, then she or he likely will
be more committed to changing behavior and seeking
help. Self-efficacy also has been found to predict sub-
stance abuse. Self-efficacyis a term from social learning
theory that describes, in the case of substance abuse,
whether a person has competence and confidence to
negotiate a specific situation without use of substances.
Lower self-efficacy in a situation predicts poorer sub-
stance use outcomes in that situation.
Cognitive impairment is of concern when a user has
engaged in extreme or chronic substance abuse.
Perceptual problems result from acute intoxication.
One phenomenon, substance use myopia, refers to how
cognitive processes become impaired as intoxication
increases, literally narrowing a person’s ability to see or
accurately perceive events occurring around him or her.
During substance use myopia, clients are vulnerable to
impulsive, disinhibited, and risky behavior because per-
ception of risk is impaired. As an example, substance-
induced myopia leads to poor judgment, such as
believing that it is safe to drive under the influence of
substances.
Emotions and moods also have been associated
with substance abuse. Many users report links
between emotional events and substance use behavior,
and relapses have been linked to extreme emotions
(positive or negative). Users often use substances to
manage emotions and moods but also report that sub-
stance use contributes to loss of emotional control.
Research has established that chronic substance use
may disrupt emotional expression and contribute to
substance induced dysphoria.
Social and environmental factors linked to addictive
processes may include relationship stressors and envi-
ronmental stressors such as unemployment and poverty.
Some researchers believe that a major function of sub-
stance misuse is in tension reduction. Changes in rela-
tionship interactions and environmental conditions have
been linked to changes in substance use. Youths are espe-
cially vulnerable to changes in the environment and sub-
stance abuse in that age group can be influenced heavily
(both positively and negatively) by such changes.Diagnosis of Substance Use Disorders
Misuse of substances can be diagnosed by means of
structured clinical interviews that assess for criteriaspecified by the American Psychiatric Association in
the Diagnostic and Statistical Manual of Mental
Disorders,fourth edition (DSM-IV). The most com-
monly used interviews are the Structured Clinical
Interview for DSM-IV (SCID) and the Diagnostic
Interview Schedule (DIS). Substance misuse is classi-
fied as either substance abuse or dependence for a sin-
gle substance or for multiple substances. DSM-IV
diagnostic categories also include “specifiers” that
denote abuse with or without physiological depen-
dence and “course specifiers” that define the course of
the disorder, including early full remission, early par-
tial remission, sustained full remission, sustained par-
tial remission, on agonist therapy (such as
methadone), or in a controlled environment (where
access is restricted).
DSM-IVdiagnoses conceptualize substance abuse
as a chronic condition subject to periods of remission.
However, researchers have found evidence that a sub-
group of people diagnosed with alcohol dependence,
for example, show evidence of controlled moderate
drinking without problems later in life. In addition,
other research shows that the course of substance
abuse does not necessarily worsen with time nor do
users need to hit the bottom to want help. Substance
use diagnoses for adolescents have been found to be
very unstable. Many adolescents meeting DSM-IVcri-
teria for substance abuse or dependence experience a
“maturing out” process as they age and go on to adult
lives free of substance-related problems. Therefore,
substance use diagnoses for adolescents should be
interpreted with caution.Arthur W. BlumeSee alsoSubstance Abuse Treatment; Therapeutic
Communities for Treatment of Substance AbuseFurther Readings
DiClemente, C. C. (2003). Addiction and change: How
addictions develop and addicted people recover.New
York: Guilford Press.
Donovan, D. M., & Alan Marlatt, G. (Eds.). (2005).
Assessment of addictive behaviors(2nd ed.). New York:
Guilford Press.
McCrady, B. S., & Epstein, E. E. (Eds.). (1999). Addictions:
A comprehensive guidebook.New York: Oxford
University Press.
Miller, W. R., & Carroll, K. M. (2006). Rethinking substance
abuse: What the science shows, and what we should do
about it.New York: Guilford Press.780 ———Substance Use DisordersS-Cutler (Encyc)-45463.qxd 11/18/2007 12:44 PM Page 780