Tag Archives: risk reduction

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

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.