Tag Archives: alcoholic

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

Comorbidity: Substance Abuse Disorders (SUDs)


Comorbid, or comorbidity, is literally defined as “recurring together.”  (Shiel, Jr. & Stoppler, 2008, p. 94)  For our purposes, comorbidity will refer to cases where two or more psychiatric conditions coexist, and where one of the conditions is a substance abuse disorder (SUD).  “There are 11 groups of substances specifically discussed in the DSM-IV: alcohol; amphetamines and related sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; phencyclidine and related drugs (PCP); and sedatives, hypnotics, and anxiolytics.”  (Colman, 2009, p. 741)  Any one of the above substances, or combination of the above substances, can contribute to and be related this discussion of comorbidity with SUDs.

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Although this list is by no means exhaustive, “long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders (ED), and personality disorders (PD).”  (Netherton, Holmes, & Walker, 1999, p. 248)  Increased risk of mood disorders has been documented across all substance categories and across all mood related diagnoses.  (Blaney & Millon, 2009, p. 287)  Substance-Related Disorders are commonly comorbid with many mental disorders, including Conduct Disorder in adolescents; Antisocial and Borderline Personality Disorders, Schizophrenia, Bipolar Disorder.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 204)   Schneier et al. (2010) also concluded that alcohol use disorders and social anxiety disorder (SAD) is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity.

ADHD represents a risk factor for substance abuse.  ADHD patients with a high degree of nicotine consumption may be consuming large quantities as a form of self-medication.  Nicotine and alcohol, when combined, pose a markedly greater risk for the development of other addictions.  (Ohlmeier et al., 2007, p. 542)  There is “high comorbidity between heavy drinking and heavy smoking.”  (Blaney & Millon, 2009, p. 266)  These admissions seem to support the premise that alcohol and nicotine continue to serve as “gateway drugs” for people whom suffer from ADHD.

“In terms of clinical presentation, a concurrent Personality Disorder (PD) diagnosis is associated with an earlier age of onset of alcohol-related problems, increased addiction severity, more secondary drug use, more psychological distress, and greater impairment in social functioning.  As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, earlier relapse, poorer treatment response, and worse long-term outcome.”  (Zikos, Gill, & Charney, 2010, p. 66)  Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Personality Disorders (PDs) appear to be particularly prevalent, perhaps because the link between substance dependency and antisocial behavior can be found genetically.  (Blaney & Millon, 2009, p. 263)

“Among individuals with schizophrenia, between 40% and 50% also meet criteria for one or more substance use disorders.”  (Blaney & Millon, 2009, p. 288)  Comorbid substance use complicates adherence to sometimes complex schizophrenia treatment regimens.  Poor adherence to treatment results in worsening of schizophrenia symptoms, relapse, worsening of overall condition, increased utilization of health care facilities, re-hospitalization, reduced quality of life, social alienation, increased substance abuse, unemployment, violence, high rates of victimization, incarceration, and death.  (Hardeman, Harding, & Narasimhan, 2010, p. 405-406)  The compounding effect of substance abuse on the quality of life for individuals with schizophrenia can’t be understated.  Substance abuse is particularly common and also worsens the course of schizophrenia.  (Buckley, Miller, Lehrer, & Castle, 2009, p. 396)

Differential diagnosis and treatment can sometimes be a troublesome proposition.  Comorbidity complicates the diagnosis, treatment, and clinical course of Substance Abuse Disorders (SUDs).  (Blaney & Millon, 2009, p. 287)  “If symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 210)  Carbaugh and Sias (2010) concluded that successful outcomes can be increased through proper diagnosis and early intervention, at least in the case of comorbid Bulimia Nervosa and substance abuse.  Prevention of substance use disorders can help alleviate or decrease much impairment in psychiatric patients in particular.  (Powers, 2007, p. 357)  Furthermore, a review of treatments for patients with severe mental illness and comorbid substance use disorders concluded that mental health treatment combined with substance abuse treatment is more effective than treatment occurring alone for either disorder or occurring concurrently without articulation between treatments.  (Hoblyn, Balt, Woodard, & Brooks, 2009, p. 54)

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References

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

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009, Mar). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35(2), 383-402. doi: 10.1093/schbul/sbn135

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Hardeman, S. M., Harding, R. K., & Narasimhan, M. (2010, Apr). Simplifying adherence in schizophrenia. Psychiatric Services, 61(4), 405-408. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2006767471&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Hoblyn, J. C., Balt, S. L., Woodard, S. A., & Brooks, J. O. (2009, Jan). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric Services, 60(1), 50-55. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1654365811&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Ohlmeier, M. D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Weise, B., … Schneider, U. (2007, Aug). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism : International Journal of the Medical Council on Alcoholism, 42(6), 539-543. doi: 10.1093/alcalc/agm069

Powers, R. A. (2007, May). Alcohol and drug abuse prevention. Psychiatric Annals, 37(5), 349-358. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282831&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schneier, F. R., Foose, T. E., Hasin, D. S., & Heimberg, R. G. (2010, Jun). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40(6), 977-988. doi: 10.1017/S0033291709991231

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world  medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Zikos, E., Gill, K. J., & Charney, D. A. (2010, Feb). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1986429431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Substance Abuse Grab-bag


On the subject of terminology, I thought it was rather odd that NHW made the statement that “the phrases ‘chemical dependency, addiction, and habit’ are still in use but less so than ‘substance abuse, use, or misuse;’” and then later citing “changes in the thinking in the field of chemical dependency.”  (Netherton, Holmes, & Walker, 1999, p. 241)  Perhaps that’s an indication that old habits are not easily broken.

The text again acknowledges that “the use of substances to cope, alter moods, or reach another level of consciousness has been an acceptable form of communication and expression for most of humankind.”  (Netherton et al., 1999, p. 242)  This statement alone suffices to encapsulate the difficulty of the task at hand.  Quite simply, there is a significant portion of the population that doesn’t recognize there is a problem.  “Substance use has become less stigmatizing among adolescents and is fiend less as a problem among their peers.”  (Netherton et al., 1999, p. 242)  Check and checkmate.

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I have trouble “getting behind” the disease model for substance use and abuse.  To my eyes, substance use appears more like a behavior than a disease.  In my experience, alcoholism is typically a secondary symptom stemming from another underlying physical cause or emotional disorder.  The degree and the prevalence of comorbidity would appear to support this position.  While I don’t disagree that the behavior needs to be recognized and addressed, I believe that addressing the underlying emotional disorder is critical to the long term success of these individuals.

Other substance-related models include the developmental model, the gateway model, problem behavior theory, cognitive models, the social learning model, and finally… the addictive behavior model.  I believe that social learning weighs heavily on the adolescent mind, and I wholly support the statement that “adolescents place great value on peer opinions and struggle to fit in.”  (Netherton et al., 1999, p. 247)  This serves as an entry point for the behavior, which then sets the tone for the addictive behavior model, which subsequently suggests that behaviors are a series of bad habits that have been over-conditioned to the extent that they become detrimental.

“Long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders, and personality disorders.”  (Netherton et al., 1999, p. 248)  This is only the second time in this class where we have listed entire categories as being comorbid with a specific disorder.  Is this the first mention of dual diagnosis in this class, or have we previously addressed that?

Addressing treatment, the treatment options range from pretreatment services, through outpatient treatment, to intensive inpatient treatment and/or residential care.  “Some of the fundamental treatment services include structure, dual diagnosis capabilities, pharmacological interventions, arrangements with medical care, role modeling, client participation in the therapeutic milieu, family groups, individual and group therapy, school/vocational training, recreational programs, relapse prevention, and 12-step support.”  (Netherton et al., 1999, p. 255)

Of the specific treatment approaches and interventions, I most identified with the harm reduction approach.  “Harm reduction, harm minimization, and risk reduction are terms that describe methods based on the assumption that habits can be placed along a continuum ranging from lowest risk to highest amount of risk.”  (Netherton et al., 1999, p. 258)  The object, or the goal, is the transition the individual along the continuum to a behavior that is less harmful.  It seems to be more progressive in its approach, with its intent to “normalize rather than marginalize substance abusers.”  I don’t think this is necessarily the ideal treatment for all people who suffer from alcohol-related problems, but I think it would be a less invasive and potentially better received option than some of the more stringent measures.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Substance Abuse: Etiological Considerations


Historically speaking, I was intrigued by the suggestion that discovery of the New World opened up new vistas of experience alteration.  (Blaney & Millon, 2009, p. 254)  I was surprised that caffeine (specifically, coffee) was not addressed in more detail.  Overall, the historical precedent is clear… substance use and abuse has been prevalent for most of recorded human history.

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I would not have considered alcoholism to be under-diagnosed until reading this chapter.  I knew the efficacy of treatment was modest, but the distinct absence of evidence-based practices was rather disturbing.  I was under the impression that we were more knowledgeable regarding the etiological foundation of substance abuse.  Although it is difficult to refute, I am starting to equate words like multifactor, interactional, and interdependent as “we don’t really know.”

“Drug abuse begins with drug use, and one can neither try nor abuse that which is unavailable or unaffordable.”  (Blaney & Millon, 2009, p. 255)  Consumption is inexorably tied to availability.  Despite that admonition, societal control is easier said than done.

The statement “economic success stories (hence models for youths) are often individuals engaged in illegal activities, including the selling of drugs” is both true and unfortunate.  (Blaney & Millon, 2009, p. 256)  The media increasingly glamorizes the use, abuse, and sale of drugs.  While teaching in the public school system, I once made the statement “who’s a kid going to listen to, me (24k a year) or Notorious BIG (24k a day).”  “The current mass marketing of prescription, over-the-counter, and social libations all promote the theme that drugs solve problems and improve quality of life.”  (Blaney & Millon, 2009, p. 257)  I couldn’t have said it better myself.

I have issues with the gateway model whereby use and abuse of drugs is seen sequentially.  “Cigarettes, alcohol, marijuana, stimulants, depressants, hallucinogens, cocaine, and heroin are seen hierarchically.”  (Blaney & Millon, 2009, p. 258)  Without, peer groups play a major role in the introduction of substances into people’s lives… however; those same peers can have a reinforcing effect when it comes to the negative consequences of progression.  I think eventually everyone reaches a threshold of risk they are willing to assume when it comes to mind altering substances… everyone just has a different threshold or process of risk assessment.

Sexual abuse rears its ugly head, again.  “In any treatment population of alcoholic women, the rates of a history of sexual abuse range from 24% to 85%.”  (Blaney & Millon, 2009, p. 260)  By now it is self evident that if we could limit exposure to that single environmental factor we could have a tremendous impact on the mental health status of society as a whole.

The concept of assortative mating, or the tendency for alcoholics to marry alcoholics, is an interesting concept.  Perhaps we could conclude that “social drugs” like alcohol (and to a lesser extent, cigarettes) are going to continue to be serious social issues that continue to plague an increasingly distinct segment of the total population.

The biochemical level seems to be the most logical and most effective way to determine etiological foundations of substance abuse.  Dopamine, Serotonin, GABA, glutamate, opioid, cannaboid, and nicotine systems are all implicated in the development of recurrent substance abuse.  Differential dopamine release, for example, represents a “positive reinforcing situation” which may explain the increased risk of abuse.  (Blaney & Millon, 2009, p. 265)

“The decline in marijuana and cocaine use in the United States during the 1980s resulted from an increased perception of danger.”  (Blaney & Millon, 2009, p. 268)  There has to be a more effective way to combat drug use than with general educational drug prevention programs?

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.