Comorbidity of Personality Disorders and Substance Abuse Disorders

There are an estimated 44%-60% of people who have been diagnosed with substance use disorder who also qualify with symptoms pertaining to a minimum of one personality disorder.  Personality disorders include antisocial personality disorder, avoidant personality disorder, borderline personality disorder, obsessive-compulsive personality disorder and schizoid personality disorder.  Each of these personality disorders have their own symptoms and characteristics, but generally speaking any personality disorder affects people cognitively, which is the way people look at themselves and the world in general, affectation, which is the level of reaction to any one thing, as well as interpersonal functioning and the level of impulse control a person has.  A person can suffer from mood swings, anger outbursts or alcohol or substance abuse.

A person who is diagnosed with a personality can also have a second diagnosis of substance abuse disorder.  This is defined as:

 

 

 

 

 

 

“A complex behavioral disorder characterized by preoccupation with obtaining                     alcohol or other drugs (AOD) and a narrowing of the behavioral repertoire towards          excessive consumption and loss of control over consumption.  It is usually also           accompanied by the development of tolerance and withdrawal and impairment in social and occupational functioning.” (www.cdad.com)

A patient must present with certain symptoms in order to be diagnosed with substance abuse disorder, the symptoms are the behaviors someone would expect from anyone with a substance abuse disorder, but they are not usually so obvious to the patient.  The symptoms include a tolerance of the substance or a need for more and more of the substance because it is harder and harder to feel the effects of the substance, withdrawal when the substance is not used on a regular basis, the substance being used for longer than the patient thought they would be using it for, the patient having a continuous desire to control the habit of using the substance but is unsuccessful at doing so, the patient spending a lot of time trying to find or use the substance or coming off of the substance, the patient giving up activities in multiple areas of their life in order to have the opportunity to use the substance, and continuing use even though it is causing health problems to the patient.

The diagnosis of substance abuse disorder comes about when the patient has become increasingly more tolerant and dependent on their chosen substance.  After the body becomes accustomed to having that substance available on a regular basis, the body will react with withdrawal symptoms which can include headaches, insomnia, and hallucinations and could include aggression, paranoia or promiscuous behavior.  Most patients live in denial when it comes to admitting they have a problem and have to get past that denial in order for any type of treatment to help them.

When a patient is diagnosed with both of these disorders at the same time it is considered co-morbidity of substance abuse disorder and personality disorder.  A little over half of patients who have been seen for substance use disorder have also been diagnosed with a minimum of one personality disorder.

There are two treatments that have been established for this type of co-morbidity.  One is called dual focus schema therapy and it combines different life skills such as functional analysis and coping skills training.  This treatment involves 24 sessions and plans for two stages.  The first of these stages is called early relapse prevention and helps the patient develop life skills that will aid the patient in dealing with temptation or actual relapses.  The second stage is called schema change therapy and coping skills work, this stage helps the patient make the changes more concrete and helps the patient develop methods for coping once abstinence is achieved.

Looking at co-morbidity of substance abuse and personality disorders has shown how difficult it can be to diagnose a patient with multiple disorders, especially when it involves substance abuse because substance use is so common and it seems there really is a fine line between the two.

References

Netherton, S.D., Holmes, D., Walker, C.E. (1999). Child and Adolescent Psychological Disorders.  New York, NY: Oxford University Press.

(Retrieved 2009, October 28). Co-occurring Mental Health and Substance Abuse Disorders. www.dshs.wa.gov.com.   http://www.dshs.wa.gov/pdf/hrsa/mh/cobestpract.pdf

(Retrieved 2009, October 28). Axis II Personality Disorders and Mental Retardation.  Psyweb.com.   http://psyweb.com/Mdisord/DSM_IV/jsp/Axis_II.jsp

(Retrieved 2009, October 28). Frequently Asked Questions (FAQ’s) About Substance Abuse Disorders.  www.cdad.org  http://www.cdad.org/FAQSubstanceUseDisorders.htm

Comparing and Contrasting Dissociative Identity Disorder (DID, Multiple Personality Disorder) with Conversion Disorder (CD)

Dissociative Identity Disorder and Conversion Disorder are similar in that they both stem from stressful events.  In Dissociative Identity Disorder a personality is formed when extreme child abuse or sexual abuse is experienced.  With Conversion Disorder it is a more recent event like a rape or physical or emotional abuse. Other than this similarity the two disorders are quite different.

Dissociative Identity Disorder is a disorder in which the person affected suffers from as little as 2 distinct personalities and can suffer from as many as 100 or more.  Each personality has a very distinct identity, and will often take control of the person and how they act.  Because of the different identities taking over the people lose time.  They don’t remember the period of time that they were not in control and then have a hard time understanding why everything is different, especially in extreme cases when the other identity takes over for years at a time.  Usually an alternate identity takes over when the primary identity experiences something overly stressful.  It is common for people with this disorder to have other disorders or to have problems with substance abuse.  While DID has been known to last a lifetime, treatment can help.  Treatment usually involves psychotherapy and helps the person to integrate the identities into one.  It can be a painful process as well as time consuming, but according to people who have been able to achieve integration, it is definitely worth it.

Alternatively Conversion Disorder affects people in their sensory areas or physically where voluntary movement is concerned.  It is known to be a somatoform disorder and is said to be a large part of why people visit their primary care physicians.  Basically when people shove their emotions and stress too far inward they turn into physical symptoms.  This is called converting.  The conversion of these symptoms can cause a patient to contact their caregiver nine times as often.  The patient does not control the symptoms and can have a surprisingly painful beginning, and diagnosis can become complicated by a true physical illness.

Conversion Disorder has specific risk factors which include the fact that someone is female, men are less likely to receive this diagnosis.  This diagnosis is more common in the teen years, if there is someone in the family who is already receiving treatment for Conversion Disorder, it is likely to continue in the family line.

Differential Diagnosis – Delusional Disorders vs Schizophrenic Disorders

Schizophrenia is characterized by two or more of the following: Bizarre delusions, hallucinations (auditory or visual), disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms like blunted affect (affective flattening) or a general lack of desire, drive, or motivation to pursue meaningful goals (avolition).  Subtypes include paranoid, disorganized, catatonic, undifferentiated, or residual types.  Compared with Delusional Disorder (DD), social and occupational dysfunction is clinically significant.  There must be continuous signs of the disturbance that persist for at least 6 months, including at least 1 month of bizarre delusions.  On the whole, schizophrenia is marked by delusions that are “not plausible,” where DD is characterized by delusions that are conceivably possible, even if unlikely.

The essential feature of Delusional Disorder (DD) is the presence of one or more “nonbizarre” delusions that persist for at least 1 month, and which have never escalated to a constellation of symptoms that typify Schizophrenia.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 323)  Subtypes include ertomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types.  DD can be distinguished from Schizophrenia by the absence active phase schizophrenia symptoms.  This would include prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 327)  In short, DD is comparatively mild in its symptoms when compared with schizophrenia.

In short, the primary differentiating factor between schizophrenia and DD is the word bizarre.  If the delusion is plausible, even if improbable, then the diagnosis is DD.  If the delusion is outlandish, or impossible, then the diagnosis is schizophrenia.  “If delusions are judged to be bizarre, only this single symptom is needed to satisfy Criterion A for Schizophrenia.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 299)

Reference

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.