Tag Archives: irresistible impulse

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.


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

Impulse Control Disorders NOS

Impulse Control Disorders NOS generally include intermittent explosive disorder, kleptomania, pyromania, pathological gambling, and trichotillomania.

It would appear that the concept of “irresistible impulse” is troublesome because it is inherently tied to the observable behavior, thereby making it less than scientific.  The test suggests that the ICD implementation of the word “habit” may be useful since there is some implicit or explicit reinforcement value of the behaviors themselves.  Furthermore, NHW seem to be endorsing the use of “over-control mechanisms” since they can be investigated apart from the aggressive acts themselves.

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Over and above the issues of assessment, the documentation is extremely sparse at it relates to treatment.  The text did cite one particular cognitive-behavioral treatment course that I was interested in.  “Self-talk is often used to dissipate anger; self-monitoring can be employed to engender greater awareness of cues that evoke aggression and associated thoughts and feelings.  Modeling can be used to demonstrate effective problem solving, such as generating alternative solutions.  Role playing is designed to enable the child to better empathize with others.”  (Netherton, Holmes, & Walker, 1999, p. 455)  The above is a great place to start.  There is also some suggestion that SSRIs (antidepressants) may be of some use.

It has been suggested that Trichotillomania is a variant of obsessive-compulsive disorder (OCD).  It is important to distinguish trichotillomania from other dermatological issues like alopecia araeta and tinea capitis.  It is also important to access for attendant trichophaga (i.e., chewing and/or swallowing the hair) as this can lead to trichobezoars (hair casts in the digestive system).  Aside from the attendant bald spots, trichobezoars are probably the most serious health risk that is presented.   I don’t buy the psychosexual explanations for this disorder; they seem to be way out in left field.

Pathological gambling is an intense interest of mine, primarily because I used to deal cards at the casino.  This is where I digress into a story that I can’t resist telling.  I worked the graveyard shift, 10pm-6am at The Horseshoe Casino in Council Bluffs.  On this particular night I was dealing a “pit game” called Caribbean Stud.  It’s a “progressive” game that pays progressively larger amounts for better poker hands… and has the potential to pay huge if you get a straight flush or better (very rare).  On this night, a gentleman sat down and put 4 crisp 100 dollar bills on the table.  He asked for black chips, which was unusual for his level of buy in (it was only 4 chips!).  He proceeded to tell me that this was his last 400 dollars on his last credit card, and that if he didn’t win this game he was going to go home and “end it.”  I proceeded to put my hand up in the air, and told the manager I needed to check my schedule because I thought I worked at 2 tomorrow (code for, the guy in seat 2 is off his rocker).  I proceeded to tell the shift manager what had transpired, and they advised that “we should keep an eye on him.”  That’s it; I was disappointed by the apparent lack of caring on behalf of the casino to be honest.  That was the last night I dealt cards, just thinking about that guy reminds me why I don’t gamble… makes me sick just thinking about it.

“A plethora of etiological speculations have been offered for pathological gambing, including unconscious needs for punishment, latent homosexual propensities, and intermittent reinforcement with a “big win” early in the reinforcement schedule.”  (Netherton et al., 1999, p. 446)  I was suitably surprised that adult gamblers as a group appear to be heterogeneous, with no particular personality profile found to be characteristic.  I think this is an area where there is a definite lack of data… I have a “stereotypic gambling personality profile” in my head that just screams to be researched.

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