Brief Answer: Detailed psychiatric evaluation Detailed Answer: Hi, Thanks for writing to us, From the account that you have given, I understand that these behaviors have been present in your son for a long time now. His persistent behavior had been one which included frequent lying, stealing, a hostile attitude towards others, getting into fights and landing himself with the legal authorities, and most importantly, being unable to learn from his mistakes or be apologetic about such behaviors. While in high school, he got hooked on to substances of potential abuse after having been advised opioids for some sports injuries. Since then he had also been admitted to rehab centers, but had reverted back to these behaviors once discharged from there. From this account, it appears that your son might be having a problem in his personality make up. This behavioral pattern is frequently seen in "cluster B" personalities. If there is a familial loading of bipolar disorder, this might increase the propensity to act impulsively and the chances of substance abuse, other self-harming and violent behaviors. Also bipolar disorder may be a possibility as you have pointed out. Classically in this disorder we see clear episodes of elevated mood/irritability or that of low mood and depressive symptoms, but it may even be at a trait level where the classical picture is not obtained and what we find is increased irritability, relationship difficulties and impulsivity leading to substance abuse. Personality disorders are hard to treat, and associated substance abuse may further complicate the condition. In most cases, personality traits are responsible for substance intake which needs addressed primarily in order to tackle the substance abuse. Your son requires an extensive assessment by a professionally qualified psychologist who could use various scales and instruments used for such measurements. In addition, he first needs to be evaluated for any medical complications that he might have incurred due to his substance taking behavior. Once these have been completed, the mainstay of treatment would be psychotherapy. It is very difficult to manage these cases clinically, since the relationship between the therapist and the person is often strained due to interference from the latter's personality make-up. However, with patience and experience, it is possible. Once a therapeutic alliance has been established, your son can benefit from cognitive therapy, interpersonal therapy, motivational enhancement therapy and relapse prevention therapy. If needed, he may also be prescribed medicines to reduce impulsive behaviors and the craving he has for substances of abuse. If bipolarity is detected during evaluation he may also be started on mood stabilizers. I appreciate your concern for your son. However, your attitudes towards him might also need some fine-tuning, guided by a professional. It needs to be understood that enabling and allowing him to procure and use substances might increase the behavior by faulty reinforcement, and thus pose hurdle towards mitigating the original problem. I am hopeful that with proper guidance, your son will be able to achieve his full potential in life; and would be a bright and successful person. Hope this helps, Dr A Rao

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