Tag Archives: Substance Abuse

What Effect Does Violence have on Kids? – Practical Application of Stanley Greenspan’s Theory of Emotional Development to Violent Behavior

I have chosen to apply the Theory of Emotional Development as seen by Stanley Greenspan to violent behavior.  I can see where this theory can explain how violent behavior gets embedded into a person, especially when the behavior is experienced from birth or from a young age, either by witnessing or by being victimized by violence.

Greenspan’s Theory assumes that children learn behavior by experiencing it.  The behavior would then continue into adulthood unless something drastic affects them.  It would have to be to the point that they feel they need to change the behavior.  In the case of violence, this drastic happening could be, going to jail or prison, going too far with the violence, or even being injured bad enough to be hospitalized for a while.  This of course depends on the person.

There are several assumptions from the theory that I will compare to the affects of violence on children.  I will also compare the milestones within the stages of emotional development to the stages the children go through when submerged in a violent environment.

There are also several reasons why violence would be someone’s first reaction to any situation.  There are many signs that a child could have violent tendencies, we could see these as they grow older.  Some children show behavioral problems at very young ages, their mental health status could grow worse and there are often problems academically and behaviorally throughout adolescence.

It seems that how often someone is exposed to violent behavior and the age at which they are first exposed determines the severity of the violent actions the child may eventually commit.

If a child is exposed to violence through a victim standpoint, it is most likely that as parents, the violence will be committed against their immediate family, but it is also likely that violence will be committed against outsiders as well.

If a child is exposed to violence through a witness standpoint, negative results could include becoming aggressive and having developmental challenges. Also, some criminal behavior could be seen.

There are many long-term effects that can take hold of a person when they are exposed to violence, especially if it was for a very long period of time.   These effects include depression, antisocial behavior, and substance abuse.  The child also learns to associate a positive attitude to violent behavior, if they are continually exposed.  They end up feeling as if the perpetrator is rewarded for the behavior.

In the Theory of Emotional Development one assumption is, “the capacity to organize experiences is present early in life”.  When violence is present in a person’s life, it is generally something that has been experienced from a very early time in their life.  Generally it is in the form of domestic violence toward a parent or themselves.

The violence that is experienced through the child’s life is organized when the child either accepts this behavior as normal or decides that the behavior is wrong and then fights against it.

This theory, “Assumes that initially organization is emotion based rather than cognition based”.  The research associated with violent behavior shows the learning of violence is cognition based.  It is a learned behavior in that, the more a child is exposed to various types of violence, the more likely they are to become offenders and the worse the offences become.

It also says, “Infants organize their emotions differently at different stages of ego development”.  Infants who emerge into life where violence is prevalent will organize their emotions accordingly.  These babies will startle easily, as loud noise and yelling does anyway, but then will grow into toddlers who may sense something is wrong, but will also be desensitized to the violent behavior around them.  Also, because of the actions that are prevalent in the home, they will see the violence as normal because they have no ability to compare it to others’ behavior.

This theory says, “With the maturation of the brain, interpreting progresses to higher levels of organization”.  As the child progresses into elementary school age, and they are exposed to other children’s life styles, they will begin to understand, maybe truly for the first time, that the behavior they are experiencing is wrong.

At this point, and as they grow, they will start to compare their own home life to their friends’ and then start to really organize how they feel as to whether the behavior is normal in other peoples lives.  Because they are starting to comprehend what’s happening in their household, they will generally devise a way to hide what’s happening to them in order to appear normal to everyone else.

This theory also states, “Emotional organization is acquired through relationships with those who care for the child”.  The child’s primary caretaker is generally their abuser.  Because of this, the emotions acquired in this relationship are generally those of confusion.  This is because the parent usually tells them that they are loved, but then the actions of that parent don’t agree with the words.  The child unknowingly learns to develop hate; sometimes toward the abuser and sometimes toward themselves because they feel they can never do what it takes to feel the love promised them so often.  These emotions carry through to adulthood and usually affect their own relationships, even as early as Jr. High or High School relationships.

Another assumption from this theory is, “Socialplay is the vehicle for promoting emotional organization”.  Children who live with violence in the home are more likely to try to stay away from the home as much as possible.  As soon as they realize they have an escape at a friend’s house they will make any excuse to try to go there in order to get away from either viewing the violence or becoming a victim of it.

Socialplay then becomes more and more about what their friends have access to that the child doesn’t feel they have.  These things do not necessarily have a monetary value, but emotional value.  Affection, courteousness, and other familial values are not found at home, so they take comfort in finding them in other people’s homes.

Greenspan also says, “Experiences must be age appropriate; have range, depth, and stability; and be personally unique.”  Unfortunately for children who experience violence on a daily basis there are not many age appropriate experiences.  These children quickly learn the keys to survival and how to fend for themselves.  These methods become intertwined into daily life and as the child grows, it becomes a way of life.  This is usually the start of the person committing violent acts when they are older.  It is not generally something they see as being a chosen action, but more something that just happens.

Greenspan has defined six milestones within the stages of emotional development. These milestones are self regulation, intimacy, two-way communication, complex communication, emotional ideas, and, emotional thinking.  Each of these milestones represents a phase or stage of a child’s life, and what they should accomplish during that phase where emotional development is concerned.

The first stage of emotional development is engagement.  This stage usually lasts from about three weeks of age until about eight months of age.

During this stage the “infants learn to share attention, relate to others with warmth, positive emotion, and expectation of pleasant interactions, and trust they are secure”.  This is the stage in which self regulation and intimacy are learned.  During these crucial early weeks and months of a child’s life, if they are involved in a violent environment, they would learn the opposite of what is involved in engagement.  They would eventually learn there are not many, if any, pleasant interactions and would not feel secure in their own actions.  In fact their first reaction to attention would come to be the flight reaction and then when older the fight reaction.

Two-way communication is the second stage of emotional development.  This stage usually lasts from about six months of age until about 18 months of age.  During this stage “infants learn to signal needs and intentions, comprehend others’ intentions, communicate information (motorically and verbally), make assumptions about safety, and have reciprocal interactions”.  This is the stage in which two-way communication is learned.  The children in this age group are still too young to recognize that the violence in their environment is not normal; yet, they are learning skills to survive there.  The two-way communication they are learning is how to signal their needs in the least threatening way.  Whether they are experiencing violence by witnessing it or are being abused, they learn the other person’s intentions could be painful and their safety could be compromised if not handled with care.  They carry this skill into later life when dealing with others.

The third stage of emotional development is shared meanings.  This stage usually lasts from about 18 months of age until about 36 months of age.  During this stage “children learn to relate their behaviors, sensations, and gestures to the world of ideas, engage in pretend play, intentionally use language to communicate, and begin to understand cognitive concepts”.  There are two milestones associated with this stage, complex communication and emotional ideas.  A lot of children who are exposed to violence from an early age end up learning things like complex communication at a later time than other children.  Because of this, these children sometimes develop learning disabilities which eventually become a sore spot for these children.  When other children don’t understand what is happening in that child’s life and choose to use that child’s slower development as something hurtful, the violent feelings tend to erupt as this is what that child has been taught at home.

The fourth and final stage in Greenspan’s theory is emotional thinking.  This stage usually lasts from about three years of age to about six years of age.  During this stage, “children can organize experiences and ideas, make connections among ideas, begin reality testing, gain a sense of themselves and their emotions, see themselves in space and time, and develop categories of experience”.  Emotional thinking is developed in this stage.  This is the age when children start to recognize that things in their home environment are not quite right.  They start to put together the fact that other children’s home lives do not involve violence on a regular basis.  At this point the child is still unsure of what, if anything, they can do about the violence in their own home.  This can be the turning point in a child’s life.

It can be when they subconsciously decide if they will incorporate the violence their caregiver has unknowingly taught them into their own lives and become violent with other people, or if they will become more docile and turn inward.

I feel that this theory, if taken further into research about violent behavior, would be a good one to look at in order to help predict violent tendencies in children.  If we do this we can try to incorporate treatment earlier and possibly cut out a lot of the violence we are seeing today.  The assumptions and the stages of the theory for emotional development are very helpful when looking at violence from an outside perspective.


Cullen, P.  (2009, May 21). Physical, emotional and sexual abuse was widespread in State institutions. The Irish Times p. 9.

Fagan, J.  (1996). The Criminalization of Domestic Violence: Promises and Limits
National Institute of Justice. Retrieved from LexisNexis database.

Nader, C. (2008, December 3). Death often tragic end to history of domestic violence.  The Age p. 11.

Murrell, A.R., Christoff, K.A., Henning, K.R. (2007, July 17).  Characteristics of Domestic Violence Offenders: Associations with Childhood Exposure to Violence.                                  J Fam Viol, 22:523-532

Appleyard, K., Egeland, B., van Dulmen, M.H.M., Sroufe, L.A. (2004. February 2). When more is not better: the role of cumulative risk in child behavior outcomes. Journal of Child Psychology and Psychiatry, 46:3, 235-245

Bergen, D. (2008). Human Development Traditional and Contemporary Theories. Pearson Prentice Hall.

Comparing PTSD and Somatization Disorder

Comparing PTSD and Somatization Disorder shows that there are some similarities in the symptoms but for the most part they are different.  Somatization Disorder has a lot more physical symptoms while PTSD has more symptoms leaning toward emotional.  The symptoms the two disorders have in common are headaches and stomachaches.  In both cases symptoms can be so severe and last so long that it completely disrupts the person’s life.

Do you have medically unexplained physical, or somatic, symptoms?

Somatization disorder can cause a person towards an emotional reaction such as depression or even suicide because they feel so much pain and can never get a diagnosis for it.  The symptoms often lead to substance abuse.  Thereby leaving them to feel hopeless, as if they will never get the help they need.  Somatization disorder has a wide range of physical symptoms.  A person with this disorder will report many different symptoms over a period of time with no real medical explanation.  These symptoms are often pain throughout the body, but not usually all at the same time.  Pain in the form of headaches, stomach ache, joint or muscle pain.  It could also be internal, such as vomiting, or it could come about as a sexual or menstrual problem.  Neurological symptoms are also common, often occurring as problems with balance or vision and even paralysis.

Generally for a patient to be diagnosed they will have experienced a minimum of eight symptoms.  There will be a minimum number of symptoms from a given category.  An example of this is that a patient will experience four or more symptoms from the pain category, two or more symptoms from the gastrointestinal category, one or more symptoms from the sexual symptoms category, and one or more symptoms from the pseudoneurological symptoms.  When a person is showing signs of these symptoms they will be unexplainable and a medical diagnosis is not usually possible.  Generally the person will explain the pain they are having in a fashion that makes it seem as if they are in more pain than you think they should be in, as if they are over exaggerating the symptoms.

Somatization Disorder lasts for a very long time which is one thing this disorder has in common with PTSD.  PTSD symptoms can last anywhere from months to years.   Most PTSD symptoms are different from Somatization Disorder because they come from more of a psychological background than a physical background.  PTSD symptoms are generally geared more towards an emotional aspect, some examples are worry over dying, acting younger than the chronological age, having an impaired memory or obsessiveness.  It seems that PTSD actually transforms a person’s behavior instead of changing them physically.  This is because when traumatic experiences occur, the feelings they experience, such as shock, nervousness or fear continue on for a length of time and gradually get stronger.  The stronger they get the less of a normal life the person is able to lead.

These increased symptoms can include nightmares or night terrors, hypervigilance, panic attacks, hypersensitivity, low self-esteem and shattered self-confidence or a physical or mental paralysis.  There are three categories often used by clinicians in order to type or group people who are diagnosed with PTSD.  The categories used are re-living, avoiding, and increased arousal.  The people in the re-living group are people who suffer from living through the trauma they have been through over and over again.  This can happen through a flashback or a hallucination or just by being reminded even in small ways.  The people in the avoiding group tend to try to stay away from people, places or things that can remind them of the event.  Unfortunately the person can start to isolate themselves and eventually can turn completely inward from detachment.  The people in the increased arousal group lean towards either having difficulty showing their emotions or on the other end of the spectrum showing overly exaggerated emotions.  This group is also the group who has some physical symptoms such as higher blood pressure, muscle tension and nausea.

In conclusion, it has become very apparent to me that while there are some similarities between PTSD and Somatization Disorder, there are a lot more differences.  It has also become very apparent to me that the people who suffer from these disorders are dealing with a lot of pain, and whether it is physical or emotional, this pain can cause the person suffering from it to shut down and disable them from enjoying the life they were meant to lead.


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

Blaney, P.H., Millon, T. (2009). Oxford Textbook of Psychopathology.

New York, NY: Oxford University Press.

(2009, February 9). Anxiety & Panic Disorders Guide. WebMD.com. Retrieved October 5, 2009, from http://www.webmd.com/anxiety-panic/guide/post-traumatic-stress-disorder

(Retrieved 2009, October 5). Somatization Disorder. Intelihealth.com.  http://www.intelihealth.com/IH/ihtPrint/W/8271/25759/187986.html?d=dmtHealthAZ&hide=t&k=base

(Retrieved 2009, October 5). Posttraumatic Stress Disorder. American Academy of Child & Adolescent Psychiatry. AACAP.org


(Retrieved 2009, October 5). Somatization Disorder. PsychNet-UK.


Kinchin, D. (2005). Post Traumatic Stress Disorder The Invisible Injury.

Didcot, Oxfordshire OX11 9YS, UK.  Retrieved October 5, 2009, from http://www.successunlimited.co.uk/books/ptsympt.htm


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

Eating Disorders (EDs) and Substance Use Disorders (SUDs): Shared and Causal Etiology

The etiologies of both Eating Disorders (EDs) and Substance Use Disorders (SUDs) are perceived to be complex and multidimensional in nature.  No simple etiological path is indicated in either category.  Many contemporary theories “implicate a ‘collision’ among biological factors (e.g., genetic influences on neurotransmitter and hormonal function), psychological tendencies (problems with mood, temperament, and impulse controls), and social pressures (promoting body consciousness or generalized self-definition problems, and developmental processes (conducive to self-image or adjustment problems).”  (Blaney & Millon, 2009, p. 436)  The current model of SUD risk factors would not be complete without all of the above, perhaps with a few minor modifications.  This essay will attempt to address and discuss the common etiological factors between EDs and SUDs, as well an explore concepts of causal etiology that suggest that having one disorder predispositions an individual to succumb to another.

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Causal etiology has suggested that having one disorder (an eating disorder, for example) may put an individual at risk for developing another disorder (like substance abuse, or vice versa).  The statistics surrounding the comorbidity of substance abuse and eating disorders is considerable.  “Substance abuse and eating disorders have the highest mortality risks of all mental disorders and half of all clients with eating disorders abuse alcohol or illicit drugs.”  (Carbaugh & Sias, 2010, p. 125)  Shared or causal etiological factors between the substance abuse and eating disorders include psychological, environmental, and biological antecedents.  Both disorders are influenced by specific personality type (lack of control, craving, denial, impulsiveness), similar developmental issues (societal and familial pressures), as well as common family history (genetic predisposition) and specific biological vulnerability.  (Carbaugh & Sias, 2010)  Whether causal or shared, it is increasingly evident that SUDs and EDs share common etiological pathways, even to the extent that they may be causal in their relationship.

Common personality factors play a significant role in the onset and maintenance of both eating disorders and their comorbid conditions.  However, the personality of people whom suffer from AN tend to qualitatively different from the personalities of people whom suffer from BN.  Individuals whom suffer from AN have been found to be approval seeking, self-doubting, conflict-avoidant, excessively dependent, socially anxious, and have a tendency to be described as “perfectionists.”  Individuals whom suffer from bulimia often experience significant affective instability including highly variable mood states, impulsive behavior, low frustration tolerance, and high anxiety.  (Netherton, Holmes, & Walker, 1999, p. 401)  Differences in the underlying personality deficiencies can account for differences in comorbidity when comparing EDs among themselves, although EDs and SUDs generally continue to demonstrate remarkable comorbidity regardless of the type of ED we examine.

The news media frames obesity as a “moral problem.”  Obese populations are condemned by the media as engaging in gluttony and sloth while society overwhelmingly blames “bad individual choices” (despite increasing discussion of social-structural factors over time).  (Saguy & Gruys, 2010, p. 247)  The above statements easily could have been rewritten to drive home a different message.  The news media frames drug abuse as a “moral problem.”  Drug abusers are condemned by the media as engaging in greed and apathy (synonyms for gluttony and sloth) while society overwhelming blames “bad individual choices” (despite increasing discussing of social structural factors over time).  Obesity and drug abuse are 21st Century witches.  Will you join the hunt?

The contribution of the family only begins with biological disturbances in the serotonin, dopamine, gamma-aminobutyric acid and endogenous opioid peptide systems that may underlie both disorders.  (Pearlstein, 2002, p. 70)  Despite the fact that The Academy for Eating Disorders (AED) has specifically condemned statements that implicate family influences “as the primary cause of AN or BN,” they have acknowledged that particular styles of family behavior and biological vulnerability may increase risk for psychopathology in general, including eating disorders.  (“Role of Family in EDs”, 2009)  Dieting is one example of a behavior that is frequently encouraged by well intentioned families.  Research supports the positive association between the dieting behaviors (not just eating disorders themselves) and increased risk for alcohol use problems.  (Heidelberg & Correia, 2009)  Families who promote dieting in their children may inadvertently be promoting substance abuse.  Add latent genetic influence (like a parent with an eating disorder or who abuses substances) to that encouragement we may have a ‘perfect storm’ of predispositions that could potentially result in a full blown eating disorder comorbid with a substance abuse problem.  Be it through the environmental impact of familial behavior, or by latent genetic influence, family plays a significant role in the development of both disorders.

EDs and SUDs can be viewed through the same lens.  Shared etiology, including familial contributions, media influences, and personality factors; all play a role in the perpetuation of the stereotype.  If we perpetuated the image of common people drinking wate,r instead of hard bodies drinking alcohol, perhaps the association between substance abuse and eating disorders could be severed.

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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.

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=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Heidelberg, N. F., & Correia, C. J. (2009, Dec). Dieting behavior and alcohol use behaviors among national eating disorders screening program participants. Journal of Alcohol and Drug Education, 53(3), 53-64. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1959547071&sid=9&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.

Paper stresses important role of family in eating disorders. (2009, Nov). Journal of Psychosocial Nursing & Mental Health Services, 47(11), 11. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1908060671&sid=9&Fmt=3&clientId=4683&RQT=309&VName=PQD

Pearlstein, T. (2002, Mar). Eating disorders and comorbidity. Archives of Women’s Mental Health, 4(3), 67-78. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=24&did=687270031&SrchMode=2&sid=11&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1274809726&clientId=4683

Saguy, A. C., & Gruys, K. (2010, May). Morality and health: News media constructions of overweight and eating disorders. Social Problems, 57(2), 231-250. doi: 10.1525/sp.2010.57.2.231

Substance Abuse: Etiological Considerations

Over the course of the last few decades prevalence of substance abuse has increased on a global scale.  The lifetime prevalence of a substance use disorder in the general population is approximately 24%.  The lifetime prevalence of any mental disorder (excluding substance abuse/dependence) is approximately 22.5%.  (McDowell & Clodfelter Jr., 2001)  Despite the increase, no single etiological path has been identified as a precipitating cause.  “Many interrelated factors influence a person’s decision to use substances.  These include psychological (intrapersonal and interpersonal), biological, environmental, and cultural factors.”  (Netherton, Holmes, & Walker, 1999, p. 245)  This essay will attempt to address some of the more predominant etiologies as related to substance abuse, with the express understanding that no single explanation is solely plausible due to the interactional and interdependent natures of the etiologies themselves.

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Individualized personality traits have been inexorably linked to problem drug behavior.  The “addictive personality” has come to represent individuals whom demonstrate significant levels of neuroticism; disinhibitory tendencies; anti-sociality; novelty seeking; negative affect; low self-esteem; anxiety sensitivity; hopelessness; sensation seeking; and impulsivity.  All of these individualized variables and personality traits can be employed to predict both nature and course of substance use.  (Blaney & Millon, 2009, p. 271, p. 260)  “Drug abusers show deficits in impulsive choice and inhibition, although it is impossible to know whether difference in impulsivity caused or were caused by drug abuse.”  (Perry & Carroll, 2008, p. 19)  Reyno and associates (2006) found that anxiety sensitivity was strongly related to alcohol consumption in certain high risk situations.

Genetically speaking, “having a biological parent who was or is alcoholic increases one’s risk for alcoholism about 2.5 times, regardless of whether one was raised by that parent.”  (Blaney & Millon, 2009, p. 261)  Drug availability, when coupled with permission parental attitudes (up to and including parental drug use), has been shown to facilitate adolescent initiation and use of substances.  (Blaney & Millon, 2009, p. 258)  Parental smoking has been shown to increase risk for substance use in adolescent offspring.  (Keyes, Legrand, Iacono, & McGue, 2008)  As severity of substance abuse in the family increases, the negative consequences on adolescent development increase and are manifested in physical symptoms and negative mood.  (Gance-Cleveland, Mays, & Steffen, 2008)  It has been suggested that removal of the child from the substance abusing household can result in significant gains in child cognitive functioning.  McNichol & Tash (2001) found that children placed in forster care presented with low to average cognitive skills, but that they made disproportionate and significant improvement during placement.  Furthermore, they found that children with prenatal exposure to drugs scored significantly lower at the beginning of the placement, but made significantly more progress than the other children during placement.  This research seems to suggest that prenatal exposure to drugs, while regrettable, is not a “life sentence” for children.

Since adolescents place great value on peer opinions and struggle to fit in, peers contribute to the onset of drug use first by providing access to the substance by contributing to developing attitudes regarding expectancy.  (Blaney & Millon, 2009, p. 258; Netherton et al., 1999, p. 247)  Early expectancies of personal response to drug use have been shown to predict later use.  (Blaney & Millon, 2009, p. 268)  Research suggests that doing things in order to be popular with others is strongly related to feeling pressured by others, and that peer pressure is a far stronger predictor of risk behaviors and potential psychosocial difficulties than popularity.  (Santor, Messervey, & Kusumakar, 2000)

There is considerable evidence that severe trauma (e.g., disaster, assault, combat) greatly increase the risk for drug use and abuse.  (Blaney & Millon, 2009, p. 260)  In an exemplary study, Brave Heart (2003) leveraged the Lacota population to demonstrate that historical trauma (HT) has substance abuse ramifications, deemed to be a historical trauma response (HTR).  HT represents the cumulative emotional and psychological wounding over the lifespan and across generations.  HTR manifests in traumatized populations as depression, self-destructive behavior, suicidal thoughts and gestures, anxiety, low self-esteem, anger, difficulty recognizing and expressing emotions, and substance abuse.  (Brave Heart, 2003)  There is also evidence to the contrary, with research that suggests that among homeless men, trauma experiences are strong indicators of mental health problems, but are not indicators of either physical health or substance abuse problems.  (Kim, Ford, Howard, & Bradford, 2010)

The weight of cultural influences is colossal, as demonstrated by relative conformity of subcultures within a specific society, and by the wide comparative variability between and among cultures and subcultures.  (Blaney & Millon, 2009, p. 255)  For example, “the holocaust experienced by American Indian and Alaska Native (AI/AN) peoples during the past five centuries includes ravaged communities, destroyed families, the brutal murder of hundreds of thousands of AI/AN people, organized attempts to erase rich cultures and beautiful languages, and trans-generational scars that affect AI/ANs to this day.”  The subsequent introduction of alcohol and other substances have resulted in high rates of sexual and physical trauma, high death rates from physical complications of substance abuse, suicide, homicide, depression, grief, poor school performance, and low employment rates.  (Gray & Nye, 2001)

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

Brave Heart, M. Y. (2003, Jan-Mar). The historical trauma response among natives and its relationship with substance abuse: A Lakota illustration. Journal of Psychoactive Drugs, 35(1), 7-13. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=338232111&sid=18&Fmt=3&clientId=4683&RQT=309&VName=PQD

Gance-Cleveland, B., Mays, M. Z., & Steffen, A. (2008, Jan). Association of adolescent physical and emotional health with perceived severity of parental substance abuse. Journal for Specialists in Pediatric Nursing, 13(1), 15-25. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1418986821&sid=20&Fmt=3&clientId=4683&RQT=309&VName=PQD

Gray, N., & Nye, P. S. (2001). American indian and alaska native substance abuse: Co-morbidity and cultural issues. American Indian and Alaska Native Mental Health Research (Online), 10(2), 67-84. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1077011111&sid=19&Fmt=3&clientId=4683&RQT=309&VName=PQD

Keyes, M., Legrand, L. N., Iacono, W. G., & McGue, M. (2008, Oct). Parental smoking and adolescent problem behavior: An adoption study of general and specific effects. The American Journal of Psychiatry, 165(10), 1338-1344. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1567487491&sid=7&Fmt=4&clientId=4683&RQT=309&VName=PQD

Kim, M. M., Ford, J. D., Howard, D. L., & Bradford, D. W. (2010, Feb). Assessing trauma, substance abuse, and mental health in a sample of homeless men. Health & Social Work, 35(1), 39-48. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1969768361&sid=18&Fmt=3&clientId=4683&RQT=309&VName=PQD

McDowell, D. M., & Clodfelter Jr., R. C. (2001, Apr). Depression and substance abuse: Considerations of etiology, comorbidity, evaluation, and treatment. Psychiatric Annals, 31(4), 244-251. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=71687723&sid=22&Fmt=4&clientId=4683&RQT=309&VName=PQD

McNichol, T., & Tash, C. (2001, Mar/Apr). Parental substance abuse and the development of children in family foster care. Child Welfare, 80(2), 239-256. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=70552258&sid=20&Fmt=4&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.

Perry, J. L., & Carroll, M. E. (2008, Sep). The role of impulsive behavior in drug abuse. Psychopharmacology, 200(1), 1-26. doi: 10.1007/s00213-008-1173-0

Reyno, S. M., Stewart, S. H., Brown, C. G., Horvath, P., & Wiens, J. (2006, Aug). Anxiety sensitivity and situation-specific drinking in women with alcohol problems. Brief Treatment and Crisis Intervention, 6(3), 268-282. doi: 10.1093/brief-treatment/mhl007

Santor, D. A., Messervey, D., & Kusumakar, V. (2000, Apr). Measuring peer pressure, popularity, and conformity in adolescent boys and girls: Predicting school performance, sexual attitudes, and substance abuse. Journal of Youth and Adolescence, 29(2), 163-182. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=53959633&sid=17&Fmt=4&clientId=4683&RQT=309&VName=PQD

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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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