Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits

Chapter 6 -- Anxiety Disorders

Definitions and Diagnoses

The anxiety disorders are the most common group of psychiatric disorders. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of anxiety, panic, and phobias.

A panic attack is a distinct period of intense fear or discomfort that develops abruptly, usually reaching a crescendo within a few minutes or less. Physical symptoms may include hyperventilation, palpitations, trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea or choking. Psychologic symptoms may include depersonalization and derealization and fear of fainting, dying, doing something uncontrolled, or losing one's mind. A panic disorder consists of episodes of panic attacks followed by a period of persistent fear of the recurrence of more panic attacks.

When the focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably avoided, the anxiety disorder is called a phobia.Phobia-inspired avoidance behavior as well as travel and activity restrictions may become intense and incapacitating. The phobias include agoraphobia, social phobia, and simple or specific phobia; panic attacks and panic disorders are often but not necessarily involved.

Specific phobia, also called single or simple phobia, describes the onset of intense, excessive, or unreasonable fear, stimulated by the presence or anticipation of a specific object or situation.The causes may be naturally occurring (for example, animals, insects, thunder, water), situational (such as heights or riding in elevators), or related to receiving injections or giving blood. Social phobia describes the persistent and recognizably irrational fear of embarrassment and humiliation in social situations. The social phobia may be quite specific (for example, public speaking) or may become generalized to all social situations. Agoraphobiais the fear of being caught in a situation from which a graceful and speedy escape would be impossible, difficult, or embarrassing. Examples of feared situations include attendance in an auditorium, being stuck in traffic, and being outside the house.

In generalized anxiety disorder, there is no specific focus to the anxiety; symptoms are free-floating. Generalized anxiety disorder involves excessive anxiety, worry, and apprehensive expectations focused on many life circumstances, more days than not, for a period of at least 6 months. The intensity, duration, and frequency of symptoms are out of proportion to the probability or consequences of the feared event. Somatic symptom clusters often involve: 1) motor tension (such as trembling, restlessness, and fatigue), 2) autonomic hyperactivity (for example, shortness of breath, palpitations, sweating, dry mouth, dizziness, and abdominal distress), and 3) hyperarousal (such as exaggerated startle response, irritability, insomnia, and poor concentration).

Obsessive-compulsive disorder (OCD) is an anxiety disorder involving obsessions or compulsive rituals or both. Obsessions are repetitive and intrusive thoughts, impulses, or images that cause marked anxiety. They often involve transgressing social norms, harming others, and becoming contaminated, but they are more intense than excessive worries about real problems. Compulsions are repetitive rituals and acts that people are driven to perform and which they perform reluctantly to prevent or reduce distress. The frequency and duration of their repetition make them inconvenient and often incapacitating. Examples include ritualistic behaviors (such as hand-washing and rechecking) and mental acts (for example, counting and repeating words silently); they are time-consuming and interfere significantly with daily functioning.

Post-traumatic stress disorder (PTSD) involves an individual's experiencing a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressor event, the individual experiences intense fear, helplessness, or horror. PTSD entails a persistent reexperiencing of the trauma in the form of recurrent and intrusive images and thoughts, or recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations).People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response.They persistently avoid stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event.

Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has increased. Clinicians note that long-term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD disorders. Many such problems are addressed in treatment efforts popular in adult children of alcoholic (ACOA) programs, some of which are controversial and unsubstantiated by research or long-term observation. Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible dissociated states. Such differentiation can be extremely complicated. While a clinician's immediate response may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric phenomena.

Prevalence

Prevalence rates for anxiety disorders in the general population can be estimated from the Epidemiologic Catchment Area (ECA) studies. According to the ECA studies, anxiety disorders affect more than 7 percent of adults (Regier et al., 1988).(In the general population, the lifetime prevalence rate of anxiety disorders is 14.6 percent.) Women, individuals under age 45, those who are separated or divorced, and those in low socioeconomic groups all have a higher rate of anxiety disorders than individuals in other groups.

The ECA studies indicate that in the general population:

  • The 1-month prevalence rate for any anxiety disorder is 7.3 percent (4.7 percent for males and 9.7 percent for females), and the 6-month rate is 8.9 percent.
  • The 1-month prevalence rate for phobia is about 6.2 percent (3.8 percent for males and 8.4 percent for females).
  • The 1-month prevalence rate for panic disorder is about 0.5 percent (0.3 percent for males and 0.7 percent for females).
  • The 1-month prevalence rate for obsessive-compulsive disorder is 1.3 percent (1.1 percent for males and 1.5 percent for females).
  • Lifetime prevalence of post-traumatic stress syndrome in the general population is estimated to be less than 1 percent.The prevalence among individuals who have experienced a psychologically traumatic stressor and then developed psychiatric symptoms is poorly understood.

Among patients with AOD problems, there is a significant likelihood for having a coexisting anxiety disorder. One study noted that more than 60 percent of patients being treated for AOD disorders had a lifetime diagnosis of an anxiety disorder, and about 45 percent experienced an anxiety disorder within the past month (Ross et al., 1988). Other studies have demonstrated that most anxiety disorders among patients in addiction treatment are AOD induced (Anthenelli and Schuckit, 1993).

Differential Diagnosis

Anxiety sometimes has value as a signal of danger. In the same way that being sad is an appropriate response to some situations, experiencing anxiety can be an appropriate response. When manifestations of anxiety occur without apparent triggers or are out of proportion to the situation, they can be considered anxiety symptoms. If the symptoms are persisting, maladaptive, and meet certain diagnostic criteria, then the symptoms can be described as a syndrome. Further, if specific criteria are met in terms of consistency, repetitiveness, and duration, then the symptoms can be considered an anxiety disorder.

Anxiety symptoms are the most common psychiatric symptoms seen in AOD abusers. AOD-induced or withdrawal-related anxiety symptoms usually resolve within a few days or weeks. Most anxiety symptoms seen in AOD abusers resolve with AOD treatment; such conditions would be diagnosed according to the DSM-IV draft as substance-induced anxiety disorders. However, some people with AOD disorders have coexisting anxiety disorders that can be mildly to seriously debilitating.

Medical problems that may produce symptoms of anxiety include those affecting the cardiovascular and respiratory symptoms; neurological, hematological, and immunological disorders;and endocrine dysfunction. Several disease states can resemble generalized anxiety or panic, including acute cardiac disorders, cardiac arrhythmia, hyperthyroid conditions, brain disease, and HIV infection and AIDS. However, the most frequent imitator is addiction.

Medications that can cause anxiety symptoms include antispasmodics, cold medicines, thyroid supplements, digitalis, prescribed or over-the-counter diet medications, antidepressant medications, and, paradoxically, some antianxiety drugs such as benzodiazepines. Methylphenidate (Ritalin) and neuroleptic drugs can also cause anxiety. Withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms. Steroids can make people hyperactive and anxious. Idiosyncratic reactions to medications, caffeine use, and nicotine withdrawal all can cause states similar to panic. Similarly, some medications cause acathisia, which is a feeling of restlessness and the urgent need to move about. Acathisia can be confused with anxiety.

The differential diagnosis of agoraphobia and social phobia includes avoidance behaviors that occur as a part of depression, schizophrenia, paranoia, other anxiety disorders, and some organic mental disorders. Many features of OCD can emerge as secondary complications of major depression, and obsessions may appear in the context of either depression or schizophrenia; distinctions between delusions and obsessions can be difficult to make. Like PTSD, adjustment disorder is a maladaptive reaction to a psychosocial stressor but involves a broader range of less extreme experiences. Adjustment disorder may result in a few of the symptoms seen in PTSD, but intense reexperiencing is less common.

PTSD and dissociative disorders such as multiple personality disorder (MPD) are often diagnosed among individuals with AOD disorders. Although the relationship has not been systematically examined, it is one to consider in differential diagnosis. MPD is receiving renewed attention and may occur frequently with AOD use disorders. Addiction treatment personnel should be trained that patients in a blackout or altered state may appear to be sober, and may in fact be sober. Recent studies indicate evidence of overdiagnosis of MPD. It is not necessary to assess all AOD patients for this disorder. Rather, training clinical staff to be alert for the signs and symptoms of MPD is a worthwhile goal. Mental health staff who treat patients with MPD should be alert for the signs and symptoms of AOD use disorders.

Many of these individuals need treatment provided by professionals who have specialized training in trauma resolution. Such patients need stability in their primary therapeutic relationship; hence, this work should not be undertaken in settings with high staff turnover. In most settings, the AOD abuse counselor should not try to treat patients who have experienced trauma.

Traditional long-term psychotherapy can cause patients anxiety, especially patients who were traumatized during some part of their lives. During acute treatment it may be best to teach patients the skills to express conflicts in socially appropriate ways, such as in self-help and therapeutic groups. Later, psychotherapy can help patients to resolve the underlying conflicts.

AODs and Anxiety Disorders

Psychoactive drugs can markedly arouse intense psychomotor stimulation and numerous manifestations of anxiety, including generalized anxiety and panic attacks. Stimulant and marijuana use and depressant withdrawal can prompt the emergence of anxiety symptoms. Hallucinogenic drugs can cause intense emotional excitement and subsequent anxiety.

Stimulants

Stimulants, such as cocaine and the amphetamines, cause potent psychomotor stimulation.Stimulant intoxication, including caffeine intoxication, can cause motor tension, autonomic hyperactivity, hyperarousal, and panic attacks. Chronic and high-dose stimulant use can provoke the onset of obsessions and compulsive behaviors.Acute stimulant withdrawal typically involves an agitated depression, often with anxiety and sometimes with panic attacks. Subacute stimulant withdrawal, although characterized by sustained episodes of anhedonia and lethargy, frequently involves intense ruminations and dreams about stimulant use. These may prompt symptoms of anxiety and panic.

Depressants

Cessation of chronic use of sedative-hypnotics, such as alcohol and the benzodiazepines, can cause an acute sedative-hypnotic withdrawal. Cessation of chronic use of opioids, such as heroin and methadone, can cause an acute opioid withdrawal. Acute withdrawal from depressants can include intense anxiety symptoms, including motor tension, autonomic hyperactivity, and hyperarousal, depending on the degree of tolerance. Panic attacks are common. Anxiety symptoms are often self-medicated with depressants.

Following acute withdrawal, some patients experience a subacute withdrawal syndrome, also called "prolonged" or "protracted" withdrawal. Subacute withdrawal may begin shortly after acute withdrawal or may emerge weeks or months later, often in discrete episodes that last one or more days.Subacute withdrawal syndromes have been identified for alcohol, benzodiazepines, opioids, and stimulants. For example, sedative-hypnotic subacute withdrawal often includes such symptoms as bursts of anxiety, insomnia, and irritability. Benzodiazepine-related subacute withdrawal may also cause muscle spasm, tinnitus (ringing in the ear), and parasthesias (unusual physical sensations often described as burning, pricking, tickling, or tingling).

Hallucinogens

Most hallucinogenic drugs exert stimulant effects in addition to causing perceptual and sensory alterations. Some drugs, such as MDMA (Ecstasy), MDA, and mescaline are related to the amphetamines. At low doses, perceptual and sensory distortions predominate; at high doses, stimulant effects prevail. Thus, high doses of hallucinogens can prompt symptoms of anxiety and panic much like other stimulants.

While the effects of hallucinogens are pleasant at times to many users, some individuals may respond with intense anxiety and panic. Some may fear the sensory distortions and others may fear that the experiences will be permanent. In such cases, a soothing interaction in a quiet, comfortable room with minimal distractions can often allay distress. In these circumstances, individuals are often suggestible and respond well to a calm discussion that includes reassurance that the experience is drug induced, time limited, and not likely to result in permanent damage.

Marijuana, which has sedative and hallucinogenic properties, can cause a variety of mood-related effects. Acute marijuana intoxicationcan include periods of anxiety and panic, usually seen in persons who have not acquired a tolerance to the effects of the drug.

Case Example

While Molly and a group of her friends were preparing to attend a rock concert, they each consumed a tablet that was described as Ecstasy (methylenedioxymethamphetamine or MDMA). About an hour later, Molly began to experience potent emotional sensations, and felt an internal pressure to talk about her feelings. Once inside the coliseum, Molly gravitated toward the stage. At some point, she became increasingly aware of the loudness of the music, the brightness of the stage lights, and the intense crowding of concert attendees. Molly began to sweat heavily, tremble, and feel dizzy. She turned to escape the overstimulation, but the crowd of people made her passage difficult. She became fearful and nauseous, and her hands and feet tingled and became somewhat numb. By the time she reached the first-aid tent, she felt that she was losing her mind.

By taking a history from Molly and speaking with her friends, the emergency medical technician determined that she had taken MDMA, which along with the explosion of sight, sound, and crowding, prompted a severe panic attack. Molly was treated by moving her to a quiet room without bright lights, letting her walk off some of the nervousness, and using "talkdown" techniques. The acute panic symptoms resolved within minutes, although she was anxious for the next hour. About 3 hours after taking the MDMA, the stimulant effects diminished, and Molly felt only a sense of mild anxiety and frustration for having missed much of the concert.

AOD-Induced Conditions

The addiction counselor should not assume that anxiety symptoms, especially those emerging or persisting after 30 days in treatment, or depersonalization are related to AOD abuse. Staff in mental health programs, on the other hand, may fail to recognize that the symptoms of anxiety, caused by AOD use, may resemble a psychiatric disorder. Addiction counselors have historically been encouraged more than psychiatric personnel to seek referrals for the patient who requires treatment beyond their clinical skills. Both groups should view increased cross-referral and consultation as beneficial.

Panic.

Panic attacks can occur in individuals who are chronic users of alcohol, cannabis, inhalants, hallucinogens, organic solvents, and especially stimulants such as cocaine and the amphetamines. Use or withdrawal from these drugs can produce panic effects. For example, panic attacks can occur during acute and subacute withdrawal from sedative-hypnotics and opioids.

Phobias.

What appears to be a phobia may be the result of the chronic use of alcohol, benzodiazepines, or hallucinogens. For example, patients may avoid leaving the house not because of agoraphobia but because of the desire to have ready access to an AOD supply.Apparent phobias are not likely to occur following the acute use of these drugs.

Post-traumatic stress disorder.

Some effects of hallucinogens, marijuana, PCP, alcohol, and benzodiazepines may be dissociative. However, PTSD, MPD, and dissociative disorders seem to cluster with chemical dependency. PTSD is difficult to accurately diagnose and is often misdiagnosed. It is necessary to differentiate between PTSD and acute dissociative states due to drug use.

Dissociative disorders.

Some drugs, including hallucinogens, phencyclidine (PCP), and marijuana, can cause dissociation while they are being used. People who are experiencing withdrawal from alcohol, benzodiazepines, barbiturates, and opiates can manifest symptoms of dissociation. The differentiation between blackouts and dissociation can be extremely complicated. The initial response may be to describe dissociated people as inebriated, often because they are glassy eyed and poorly responsive.In response to questions about situations or events that are not recalled because of memory impairment, some people will fabricate facts or events. This process is called confabulation. It differs from lying in that the person is not consciously attempting to deceive.

Acute withdrawal and dissociative disorder often appear similar. Dissociated people require an immediate toxicological screen and should be admitted for continued observation. Attempts to establish reality-based grounding are necessary with these patients before medications are given or other interventions are attempted. The clinician should establish a soothing atmosphere, establish eye contact with the patient, and keep the patient grounded. It is often helpful to encourage agitated patients to focus externally on things they can see and describe, instead of focusing on their internal states. This shift in attention is often effective in allaying distress.

People in outpatient treatment may be verifiably abstinent and participating in recovery but may be experiencing dissociative symptoms. Patients with these disorders may have great difficulty in establishing and maintaining abstinence. Thus, integrated (rather than parallel) treatment is especially important for this group.

The evaluation of anxiety disorders and dissociative disorders, including PTSD and MPD, should include a careful history of recent and remote traumas. An assessment of trauma should include physical, sexual, and psychological abuse, and catastrophic stresses such as combat or hostage situations. For example, a rape experience within the last year and early childhood incest both could lead to the development of anxiety disorders. People living in violent situations, such as prostitutes who have been raped, can manifest anxiety symptoms. It is a mistake to ignore violence such as rape and look solely at early traumas. Recent traumas can be the trigger for PTSD or an MPD event. Early childhood abuse of males as well as females must be considered.

Obsessive-compulsive disorder.

With chronic use, several types of drugs (alcohol, benzodiazepines, and stimulants) can produce signs and symptoms similar to those of obsessive-compulsive disorder.

Assessment of the Anxious Person

Anxiety is one of the most common symptoms of people with AOD disorders. During acute assessments, many patients who are anxious and/or depressed are experiencing the effects of AOD use. As is the case with depression, time must pass before it is possible to make a definitive differential diagnosis of either AOD abuse, anxiety, depression, or a combination thereof. Most symptoms related to AOD use usually clear within 2-4 weeks, although the generally less severe subacute withdrawal symptoms may emerge after this time.

Patients with panic disorder are more likely to give a better history and description of panic attacks than the depressed patient can give regarding episodes of depression. Many people with a history of panic or anxiety disorders will be able to describe them with impressive accuracy. Also, patients with anxiety disorders are more likely to perceive them as abnormal conditions or "illnesses" that they don't deserve, compared with depressed patients who often feel that they deserve to be depressed or may feel that being depressed is a normal condition. Both depressed and anxious patients tend to ignore the connection with AOD use.

Various states may be mistakenly called anxiety, and people often use terms such as "panic attack" to describe nonpsychiatric states. Thus, clinicians should clarify the nature of the experience described by the patient. For example, many people consider any fear as anxiety or panic: "You really scared me. I almost had a panic attack." Careful inquiry along the lines of DSM-III-R criteria will distinguish definitive characteristics of anxiety disorders from commonplace distress described with popular terms.

Anxiety can be dangerous. In combination with depression (which is frequent), the risk for suicide is markedly increased. In the emergency room or clinic, people may exhibit panic, dissociation, or PTSD; they can be very difficult to handle. Anxiety can mimic signs of heart disease such as angina, arrhythmias, heart attacks, cardiac ischemia, and congestive heart failure; it can also accompany these conditions.

In the medical examination of the anxious person, there should be a high index of suspicion of AOD use, especially withdrawal from depressants and intoxication with stimulants and hallucinogens. The seemingly dissociated individual should receive immediate toxicologic screens. AOD-induced anxiety symptoms can signal serious medical crises; for example, benzodiazepine withdrawal can cause seizures.

In cases where medications cause depression, caretakers have time to deal with them. In contrast, anxiety caused by drug use may signal a medical emergency. Nonmedical people should be familiar with warning signs and have rapid access to medical screening.

Acute Assessment Issues

The medical management of withdrawal is driven by the drug(s) to which a patient has developed tolerance; it does not vary significantly if the patient is anxious or depressed. Whatever the drug involved, the management of withdrawal-related anxiety involves issues similar to those associated with depression. Psychiatric support, confinement, and medication may all be needed.

People with simple anxiety are less likely to need to be hospitalized involuntarily. Since coexisting anxiety and depression constitute a greater risk factor for suicidal behaviors than depression alone, individuals with combined anxiety, depression, acute AOD use, and suicidal thoughts should be assessed for possible hospitalization, including involuntary commitment. Similarly, people who have uncontrollable agitation or who experience depersonalization may need to be confined. However, if tension is the main manifestation, there is less need for protection.

If the patient describes acute anxiety secondary to hallucinogen or marijuana use, the first line of treatment is "talking the patient down." If this does not calm down the patient, pharmacologic treatments can be used in some situations where the anxiety symptoms remain overwhelming and dangerous. Benzodiazepines may be indicated over the short term. Sedating antidepressants may be used during the subacute phase.

Phencyclidine-induced states can be extremely variable; they can be brief and mild or long-lasting and associated with significant danger and seizures. PCP can induce vertical nystagmus (involuntary motion of the eyeball), which is otherwise rare. Glutethimide causes agitated intoxication alternating with severe sleepiness and depression.

Agitated patients who do not have parasites (scabies, lice, and crabs) but complain of the sensation of insects crawling on or under their skin have probably used stimulants. Tactile hallucinations are hallucinations that involve the sense of touch. Formications are a type of tactile hallucination that involves the sensation of something creeping or crawling on or under the skin. Formication is seen in patients with alcohol withdrawal delirium and during the withdrawal phase of stimulant intoxication.Bilateral (affecting both sides of the body) and symmetrical symptoms (itching, scratching, and redness) are indicative of formications rather than of parasites. Manifestations of parasite infestations are not symmetrical but have asymmetrical patterns on each side of the body.

Subacute Assessment Issues

While danger to self and others is not a hallmark of anxiety disorders, people in dissociated states may put themselves in great danger and require involuntary commitment. The relationship between anxiety, depression, and suicide has been noted.Thus the potential for harm to self and others should be considered. The possibility of medical disturbance and psychological and AOD issues must be considered. Consider the example of a patient who is treated in the emergency room for a panic attack. Once the patient is transferred to treatment in an outpatient mental health clinic, a plan should be developed that includes assessing AOD use, functional level (liabilities and strengths), and physical status, including cardiac and endocrine tests as indicated. Specifically, patients should be assessed for hyperthyroidism; this is especially true for women, who are four times as likely as men to have this disorder. Anxious people should also be evaluated for early stages of HIV infection and transient ischemic attacks.Neurological status should be carefully evaluated.

A psychosocial assessment is needed. If AOD use has been ruled out, it should be determined if an overwhelming stressor has provoked the anxiety response, such as grief or psychosocial stressors. For example, confusion about sexual orientation can be a potent source of stress that can lead to anxiety symptoms. Anxiety can also have cultural influences. For example, there is a subgroup of addicted people who have lost the majority of their friends to AIDS. When an individual has a pervasive anxiety disorder, develops AOD problems, and lives in a dismal social situation, a thorough biopsychosocial assessment is needed.

Grounding people in the here and now is most important.This should be accompanied by providing education about addiction to the patient and family. There are several self-help and support groups for people with anxiety and phobias. People with phobias are often treated in specialized treatment programs that utilize desensitization techniques, biofeedback, and behavioral and cognitive therapies. These specialized treatment strategies have been shown to be effective by empirical research.

Long-Term Assessment Issues

In long-term treatment, dissociative states may occasionally emerge in patients, and counselors should have the skills for handling these patients. In people who appear to be in a glassy-eyed dissociative state, the interviewer should evaluate AOD use, and if this is ruled out, consider dissociation. If the patient appears to be in a dissociative state, the clinician should ground the patient in time and place, and focus on here-and-now issues. Focusing on external events and processes rather than the patient's internal processes or history is helpful. These methods will be effective whether the patient proves to be in a drug-induced state or is manifesting a frank dissociative disorder. Both AOD and mental health counselors need to evaluate these patients.

Some people who experience anxiety are in fact experiencing an anxious depression, but the diagnosis must be reevaluated over a 30-day period. This is sufficient time for observation except in the case of subacute withdrawal from benzodiazepines. After 30 days, all traces of AODs will be gone, most neurochemical disturbances will disappear, and acute withdrawal symptoms should be over. By this time, a depression can be seen with some clarity.

Once patients have established and somewhat consolidated abstinence in their lives, they should be provided with educational and vocational testing and given support to help plan short-term and long-term goals. Patients with dual disorders may experience setbacks during overall periods of improvement. Thus, concrete planning efforts for future goals often occur over a long period of time. Although generalized anxiety disorder may severely restrict day-to-day functioning of some patients, most respond well to treatment.

Acute Treatment Strategies

Some very anxious patients misinterpret their symptoms of chronic anxiety as symptoms of an acute anxiety episode.Their misinterpretation may prompt the therapist to make the same misinterpretation.Two of the acute anxiety conditions most commonly encountered in emergency room settings are panic attacks and dissociative states -- which may resemble psychosis.

Acute interventions include calming reassurance, reality orientations, breathing management, and when needed, sedative medications such as benzodiazepines. These interventions are nearly identical to those used for the two most common AOD-related anxiety emergencies: withdrawal from sedative-hypnotics (including alcohol) and intoxication from stimulants (including cocaine). While the use of benzodiazepines is generally not problematic during acute withdrawal, their use may be problematic for abstinent recovering people who experience panic attacks. Indeed, such people may have abused benzodiazepines before they became abstinent. Acute interventions should include behavioral, cognitive, and relaxation therapies, often in combination with long-term serotonergic and depressant medications. Cognitive therapy can be used; patient manuals and workbooks exist for such treatment.

During an acute panic attack, people often believe that they are having a heart attack, feel dizzy, and are unable to catch their breath. Enforced regular breathing through the use of a paper bag helps to regulate breathing and diminish excess release of carbon dioxide.Such breathing exercises, education about symptoms, and reassurance will diminish panic symptoms for many patients.

Subacute Treatment Strategies

For many patients in early recovery from AOD abuse, treatment of anxiety disorders can be postponed unless there is a certain or verifiable history that the anxiety preceded the addiction or is incapacitating. If symptoms are mild and not interfering with function, including participation in treatment, it is judicious to wait and see if the symptoms resolve as the addiction treatment progresses. Subacute withdrawal may be difficult to differentiate from anxiety disorders.

Antecedent traumas, as well as dysfunctional family situations that have been identified during the assessments, should be addressed in a supportive and calming manner.However, affect-liberating therapies should probably be deferred until stability with respect to AOD abuse and acute anxiety has been established. Issues of importance to the patient and raised by the patient should not be ignored, but exploration of underlying trauma should not be encouraged until the patient is stabilized.

Supportive, cognitive, behavioral, and dynamic therapies can all be used, but in early recovery, patients need significant support and will have very limited tolerance for anxiety and depression. The emphasis should be on supporting recovery, attending 12-step meetings, and participating in other self-help and group therapies. Insight-oriented treatments must be carefully measured and limited by their potential to increase anxiety and trigger relapse.When psychotherapy is required, patients should be referred to recovery-oriented psychotherapists who will integrate psychotherapy with 12-step program approaches.

Patients may overuse medications or relapse on illicit drugs. Certain medications that do not produce physical dependence or withdrawal and have much lower potential for abuse have been found to be effective for treating anxiety disorders. Many are as effective as the benzodiazepines but without the abuse liability.The antidepressants fluoxetine (Prozac) and sertraline (Zoloft) and the antianxiety medication buspirone (BuSpar) are relatively new medications that can be used to treat symptoms of anxiety disorders, have good safety profiles, are not euphorigenic, and have few drug interaction cautions. They can be used in the management of subacute withdrawal states. When these drugs do not produce the desired results, the tricyclic and monoamine oxidase inhibitors (MAOIs) antidepressants may be used. (See Chapter 9 for a discussion of psychiatric medication.)

Medications should be used in combination with nondrug treatment approaches. Although studies are still under way, acupuncture, aerobic exercise, stress reduction techniques, and visualization techniques appear to be useful components of treatment and recovery. These tools can be valuable adjuncts for the reduction of stress. It appears that acupuncture is more effective if used regularly for 2 weeks or more. Patients should be taught that efforts to improve their general health, such as eating more healthful foods and exercising regularly, can lead to better mental health.

Long-Term Treatment Issues

While medications are useful for anxiety disorders, they are not a substitute for addiction treatment or other activities related to recovery from other illnesses. Cognitive and behavioral techniques used in addiction are often as effective as medications in treatment of anxiety disorders but generally take longer to achieve an equivalent response. For patients with dual disorders, psychotherapy has significant advantages over AOD counseling alone. Many techniques of cognitive and behavioral therapy can be incorporated into AOD abuse treatment.

The consumption of foods containing stimulants should not be overlooked.People who consume significant amounts of caffeine and sugar may have a higher risk for episodes of anxiety and depressive symptoms. Chocolate should be avoided. Diets that cause significant variations in blood sugar levels should be avoided. It is important to be sure that eating habits don't imitate the rushes and crashes of AOD abuse. Diets that cause variations in blood sugar levels may tend to aggravate or induce both mood and anxiety states. Patients should avoid large quantities of refined carbohydrates.

Over the long term, special attention should be given to the resolution of preexisting and long-term trauma issues. Patients with dissociation and PTSDmay manifest poor social judgment, and special attention should be given to risky practices.People who continue to experience episodes of depersonalization or MPD will require special support and counseling, especially concerning sexually transmitted diseases and risk-reduction issues. Those who continue to experience these episodes may need special counseling about risk factors. During these episodes, people may be more likely to have sex, and may forget about the risk of HIV infection.

Experts in the treatment of these disorders have developed techniques of working with patients, including the management of behavior during trance and dissociated states, as well as fugue states in which people suddenly travel away from home or work, assume a new identity, and are unable to recall their previous identity. Many of the psychotherapeutic management issues that relate to patients with dissociative disorders run parallel to those outlined in the section of Chapter 7 on borderline personality disorder.

Use of 12-Step and Other Self-Help Programs

Participation in the 12-step programs provides valuable therapeutic experiences for many recovering people who have anxiety disorders. People who have a social phobia and the fear of public speaking are often extremely resistant to attending self-help meetings. Yet, such people can make tremendous recovery gains in terms of anxiety desensitization and AOD recovery.

There are few situations that are as safe, supportive, and predictable and less demanding than the average 12-step group meeting. For this reason, groups such as Alcoholics Anonymous provide ideal situations to help patients desensitize social fears. However, anxious patients must not simply be thrust unprepared into 12-step group meetings. Rather, AOD staff should educate and prepare such patients regarding the process and approach of 12-step group meetings or other self-help groups.

A Stepwise Approach to Using Self-Help

It is important for AOD abuse treatment staff to appreciate the difficulty and distress that are experienced by people who have social phobias and fears of speaking in public. Staff who assist such patients with 12-step group participation should become knowledgeable about the signs and symptoms, course, and treatment of generalized anxiety disorder, panic disorder, the phobias -- especially social phobia -- and other anxieties related to public speaking and social situations.

Staff can help socially anxious patients participate in 12-step group meetings by using a stepwise approach of progressively active exposure and participation -- based somewhat on the principles of systematic desensitization. Patients can be encouraged and counseled to participate in progressively intense levels of group preparation and participation.

One of the least intense levels of preparation involves the use of mock Alcoholics Anonymous meetings consisting of staff and patients. This process makes it possible to frequently stop the meeting, discuss various meeting components, examine group methods, and allow potential participants to observe and practice. This type of approach can be helpful with most other patients with dual disorders.

The next level of intensity involves the attendance at a 12-step group meeting as a nonspeaking observer. However, staff should encourage patients to understand that being a nonspeaking observer is a transitional phase, and is not a substitute for active participation.For this reason, it may be helpful to limit nonspeaking observation by the patient to a specific number of meetings.

The next level of intensity involves patients attending a limited number of 12-step meetings during which they identify themselves beyond just giving their name but do not talk about themselves.The therapist can give assistance by providing easily rehearsable suggestions for self-introductions such as, "Hi, my name is Mary. I'm an alcoholic and I am glad to be here, although I am a little nervous."

Since much of the networking and mutual support associated with the 12-step group meetings occur outside of the meeting, anxious patients should be encouraged to do more than merely attend and participate in the meetings. Rather, they should be encouraged to arrive before the meeting begins and to linger and mingle with others following the meeting. Patients can be encouraged to volunteer to help set up the room, make the coffee, or clean up afterwards. In particular, socially phobic patients can be encouraged to join others for coffee and conversation after the meetings on a more one-to-one basis, a traditional aspect of 12-step group involvement.

By participating in step-by-step, rehearsed activities, many anxious and depressed patients seem to break through an internal barrier. As they do, participation in self-help group meetings becomes an integral aspect of recovery from AOD and psychiatric problems.

The stepwise approach described for patients with anxiety disorders can be adapted for patients who are depressed. Anxious patients often avoid group participation and public speaking, saying to themselves, "If I talk or if I am noticed, I will freak out." Similarly, depressed patients often avoid group participation and other recovery activities, perhaps thinking, "I just don't have the energy to go. No one will care anyway. Why bother?"

The therapist must elicit comments, understand them, and help patients to reverse these internal barriers to recovery and participation in group and other social activities.For practical guidance on these issues, the reader is encouraged to read the information on step work and "thinking-error work" in the chapter on personality disorders, adapted from Step Study Counseling With the Dual Disordered Client by K. Evans and J. M. Sullivan.


Treating Anxiety During AOD Abuse Treatment
  • It can be postponed unless anxiety interferes with AOD abuse treatment.
  • Anxiety symptoms may resolve with abstinence and AOD abuse treatment.
  • Affect-liberating therapies should be postponed until the patient is stable.
  • Psychotherapy, when required, should be recovery oriented.
  • Nonpsychoactive medications should be used when medications are needed.
  • Antianxiety treatments such as relaxation techniques can be used with and without medications.
  • A healthy diet, aerobic exercise, and avoiding caffeine can reduce anxiety.

Chapter 7 -- Personality Disorders

Overview

Definitions and Diagnoses

The word personality describes deeply ingrained patterns of behavior and the manner in which individuals perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of personality and are not necessarily pathological, although certain styles of personality traits may cause interpersonal problems. Personality disorders are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are enduring and persistent styles of behavior and thought, not atypical episodes.

Several alcohol and other drug (AOD)-induced states can mimic personality disorders. If a personality disorder coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or worsen personality disorders. The course and severity of personality disorders can be worsened by the presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.

The personality disorders include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, obsessive-compulsive, passive-aggressive, and self-defeating personality disorder. Many features of the personality disorders may occur during an episode of another mental disorder. Individuals may meet criteria for more than one personality disorder.

Four personality disorders have been selected for detailed discussion: borderline, antisocial, narcissistic, and passive-aggressive.These are among the greatest challenges to treatment providers. This TIP provides information about engagement, assessment, crisis stabilization, and longer-term care, and describes a continuum of care for patients with personality disorders.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy. Borderline personality disorder is characterized by unstable mood and self-image, and unstable, intense, interpersonal relationships. These people often display extremes of overidealization and devaluation, marked shifts from baseline to an extreme mood or anxiety state, and impulsiveness.

Narcissistic personality disorder describes a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation by others. Passive-aggressive personality disorder involves covertly hostile but dependent relationships. People with this disorder commonly lack adaptive or assertive social skills, especially with regard to authority figures. They often display a passive resistance to demands for adequate social and occupational performance. They generally fail to connect their passive-resistant behavior with their feelings of resentfulness and hostility toward others. Exhibit 7-1 describes the characteristics of passive-aggressive, antisocial, and borderline personality disorders.

Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and timidity, with accompanying depression, anxiety, and anger for failing to develop social relations. Obsessive-compulsive personality disorder describes a disorder of perfectionism and inflexibility. Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings, feelings of depression, and anger about being controlled by others. Hypersensitive to criticism, these people may be excessively conscientious, moralistic, scrupulous, and judgmental.

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Behavior may include constant seeking of approval or attention, striking self-centeredness, or sexual seductiveness in inappropriate situations. Paranoid personality disorder is characterized by a pervasive and unjustified proclivity to interpret the actions of others as intentionally threatening, demeaning, and untrustworthy.Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive behavior and an intense preoccupation with possible abandonment. Persons with this disorder often feel anxious and depressed, and may experience intense discomfort when alone for more than a brief time.

Schizoid personality disorder involves a pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression. Schizotypal personality disorder entails deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior and dysphoric states such as anxiety and depression. Self-defeating personality disorder is characterized by a pattern of self-defeating behavior in work and personal relationships, often with complaints of exploitation by others; these persons are often unaware of their contributions to the outcomes of their behavior.

Personality disorders not otherwise specified (NOS) include disorders of personality functioning that are not classifiable as specific personality disorders. Instead, individuals do not meet the full criteria for any one personality disorder; yet their symptoms cause significant impairment in social or occupational functioning, or cause subjective distress. Personality disorders NOS include impulsive, immature, and sadistic personality disorders.

Diagnoses should be clinically based, and not influenced by professional, personal, cultural, or ethnic biases. For example, in the past some African Americans were stereotyped as having paranoid personality disorders; women have been diagnosed too frequently as being histrionic, but they are seldom diagnosed as antisocial or psychopathic; Native Americans with spiritual visions have been misdiagnosed as delusional or having borderline or schizotypal personality disorders.

AOD Use Among People With Personality Disorders

People with a personality disorder often use AODs for purposes that relate to the personality disorder: to diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings of guilt, and to amplify feelings of diminished individuality.

People with borderline personality disorder often use AODs in chaotic and unpredictable patterns and in polydrug patterns involving alcohol and other sedative-hypnotics taken for self-medication. People with personality disorders often develop problems with benzodiazepines that have been prescribed for complaints such as anxiety, which may lead to relapse to the primary drug of choice.

Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial symptoms. They tend to prefer stimulants such as cocaine and the amphetamines.Rapists with severe antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial personality disorder may use heroin and alcohol to diminish feelings of depression and rage.

People with narcissistic personality disorder are often polydrug users with a preference for stimulants. Alcohol has disinhibiting effects, and may help to diminish symptoms of anxiety and depression. Socially awkward or withdrawn people with narcissistic personality disorder may be heavy marijuana users. One group of people with narcissistic personality disorder uses steroids to build up a sense of physical perfection. When not using AODs, people with narcissistic personality disorder may feel that others are hypercritical of them or do not sufficiently appreciate their work, talents, and generosity. During a crisis, these people may be severely depressed and upset.

Drug preference among people with passive-aggressive and self-defeating personality disorders often varies according to gender. Women may prefer alcohol and other sedative-hypnotics to sedate negative feelings such as anxiety and depression.Although men may use these AODs, they may also use stimulants to disinhibit aggressive or risk-taking behaviors. People with passive-aggressive personality disorder often complain of somatic problems, such as migraines, muscle aches, and ulcers.They may seek over-the-counter medications as well as cocaine and amphetamines to relieve somatic symptoms.

Key Issues and Concerns

Progress with patients who have personality disorders can be slow. Therapists should be realistic in their expectations and should know that patients will try to test them. To respond to such tests, therapists should maintain a matter-of-fact, businesslike attitude, and remember that people with personality disorders often display maladaptive behaviors that have helped them to survive in difficult situations. These behaviors may be called "survivor behaviors."

It is important to educate patients about their AOD use and psychiatric disorders.Patients should learn that recovery from AOD use is not synonymous with treatment for personality disorders. Written and oral contracts can be a useful part of the treatment plan. They should be simple, clear, direct, and time-limited.Contracts can help patients create safe environments for themselves, prevent relapse, or promote appropriate behavior in therapy sessions and in self-help meetings.

Treatment of people with personality disorders requires attention to several particular issues, such as violence to self or others, transference and countertransference, boundaries, treatment resistance, symptom substitution, and somatic complaints.

Suicidal Behavior

All suicidal behavior, from threats to attempts, must be taken seriously and assessed immediately to determine the type of immediate intervention needed. Special attention must be given to previous attempts and their seriousness, previous intervention strategies, whether the failure of the attempt was intended or accidental, the relation of previous suicidal behavior to psychiatric symptoms, and current psychiatric symptoms. All suicidal behavior should provoke the following questions:

  • How specific is the plan?
  • What method will be used?
  • When will it happen?
  • How available are materials (drugs, weapons)?

Patient Contracting

Management of self-harm can be accomplished by creating written or oral contracts with patients. In these contracts, a patient may promise to avoid certain self-harm or high-risk behavior (such as suicide or relapse), or may promise to engage in a specific healthy behavior (such as calling his or her 12-step sponsor or a suicide prevention hotline) when self-harm or a high-risk behavior appears imminent.

Therapists should attend to the patient's need for safety. Safety may range from the need for safe shelter to escape domestic violence to the need to reside in a controlled environment in order to remain abstinent.

Transference and Countertransference

Transference and countertransference can present problems in group and individual therapy.Therapists should be prepared to manage these issues. Transference refers to positive and negative feelings and perceptions that the patient projects onto the therapist. Countertransference refers to distortions in the therapeutic process due to the therapist's unresolved conflicts. Both transference and countertransference rely on the mechanism of projection.

Projection is a combination of personal past experiences along with feelings experienced during the course of therapy.Being aware of transference issues and commenting on them when appropriate is extremely important when working with these patients.

Clear Boundaries

Boundaries are clear expectations regarding limitations or requirements in roles or behavior. Boundaries are ethical and practical ground rules that help therapists to be therapeutically helpful to patients. The clinician and patient must establish and maintain clear boundaries. Boundaries must also be set in group therapy sessions. For example, therapists should not lend money to patients or involve them in financial deals. Patients should not establish intimate relationships with others in group therapy.

Changing Roles

People with personality disorders often assume certain roles or ways of social interaction. They may shift from one role to the next, depending upon the situation. Some of these roles include: the victim, the persecutor, and the rescuer.

As these patients assume a specific role (such as the victim), other people may be prompted to assume a complementary role (such as the rescuer). Therapists should be aware of the roles that people with personality disorders may assume. They should resist assuming dysfunctional complementary roles themselves and become aware when they do assume such roles.

Resistance

Patients with personality disorders often exhibit acting-out behaviors that were developed as psychological defenses and survival techniques. The patient may be reenacting a response learned during experiences of abuse or trauma. Resistances are defenses and coping mechanisms that help patients survive in situations confronted in therapy which are perceived as threatening.

Confronting a patient's resistance without helping the patient develop other strategies for safety will probably escalate the patient's tension. Therapists should view and use resistance as a therapeutic issue, not as a challenge to treatment.

Subacute Withdrawal

It is becoming increasingly clear that alcohol and most other drugs of abuse produce acute and subacute withdrawal syndromes. Depending on the specific drug, subacute withdrawal may include mood swings, irritability, impairment in cognitive functioning, short-and long-term memory problems, and intense craving for AODs. Subacute withdrawal syndromes often trigger relapse and exacerbate existing psychiatric symptoms

Symptom Substitution

During periods of abstinence from AODs, some people will engage in other types of compulsive behaviors. Some of these behaviors include eating disorders, and compulsive spending, gambling, and sex. Relationship problems may also increase.

Somatic Complaints

Patients with addictions to prescription drugs often seek treatment because of somatic complaints. Therapists should watch for use of prescription and over-the-counter drugs and for drug-seeking behaviors.

Therapist Well-Being

Therapists should be mindful of their own well-being, which can be compromised when working with patients with personality disorders. Clinicians can be drawn into playing certain roles in the lives of patients with personality disorders. To prevent this, therapists should care for themselves by seeking outside supervision. Therapists should join or develop support systems with others in the field through 12-step program participation, regular meetings with other therapists, grand rounds, and the like.

The following sections describe specific strategies and techniques that therapists can use when working with patients who have an AOD use disorder and a borderline, antisocial, narcissistic, or passive-aggressive personality disorder.

Each section describes techniques for assessing patients and engaging them in treatment, stabilizing crises, providing long-term care, and creating a continuum of care. Each section concludes with a case example in which the reader is asked to make a treatment decision.Where appropriate, clinical tools are provided.


Key Issues and Concerns in The Treatment of Personality Disorders
  • Slow progress in therapy
  • Suicidal behavior
  • Patient contracting
  • Transference and countertransference
  • Clear boundaries
  • Changing roles
  • Resistance
  • Subacute withdrawal
  • Symptom substitution
  • Somatic complaints
  • Therapist well-being

Borderline Personality Disorder

Engagement

Safety is an anchor for patients with borderline personality disorder, for whom abandonment and fear of rejection are often core issues.To engage and assess these patients, the therapist should acknowledge and join with the patient's need for safety. The therapist's absence, even for brief periods, can prompt acting-out behavior.

Acting-out behavior is a maladaptive survivor response that expresses a need for safety. Therapists should identify each patient's motivation for recovery, which may be rooted in safety. Further, therapists should discover what safety means to the patient.

Therapists can learn how patients create their own feelings of safety by asking them about safe spots, magic getaway places, closet-sitting, rocking or other repetitive movements, or other techniques the patient may use to generate a sense of security.To help patients with borderline personality disorder establish and maintain a sense of safety, therapists can continually ask patients: "What do you need right now?" "What do you want right now?"

Therapists may work with patients to develop a patient-generated list of the conditions that they need in order to feel safe. Therapists may ask patients: "What would have been helpful (in a specific situation) to make you feel safe?" Through teaching cognitive skills to promote patients' sense of safety, therapists can help patients with borderline personality disorder to assume personal responsibility for their own safety.

Written and verbal contracts can identify specific ways to help patients stay physically and emotionally safe and to prevent relapse. Written and verbal contracts for safety should be developed during the assessment process with simple and clear behavioral responses regarding the management of unsafe feelings and behaviors. These contracts can be very simple and direct:

  • "If I feel like I want to get drunk, I will call my sponsor."
  • "If I feel like getting loaded, I will go to the next NA meeting."
  • "If I feel like hurting myself, I will call a crisis hotline and go to my sister's house."
  • "I will report self-harm thoughts and behaviors to the therapist at the next session."

Assessment

When assessing a patient, the therapist is attempting to understand and view the patient within a holistic framework. Areas of assessment may include a history of AOD and mental health treatment, suicidal planning, dissociative experiences, psychosocial history, history of sexual abuse, and a history of psychotic thinking. Some patients may also require a neurological examination.

The assessment of patients with borderline personality disorder should look for a history of self-harm. Behaviors such as AOD use should be described as unsafe behaviors. However, clinicians should help people with borderline personality disorder to avoid black-and-white thinking, such as right/wrong and good/bad, and all-or-nothing styles of thinking. Specifically, the assessment should include the following:

  • A history of previous treatment, including psychiatric medications administered, and a description of what worked and what did not work in treatment, as well as information on why the patient left earlier treatment. Patients are not always a reliable source of information about themselves, and therapists should evaluate this information accordingly. The treatment history can help the therapist avoid unnecessary repetition of treatment strategies, such as skill-building activities in which the patient is already competent (for example, relaxation strategies). The history taking is an opportunity to examine patients' strengths and weaknesses.

  • A list of potential means available to patients to injure themselves in their own homes, such as a large supply of medication.

  • History and evidence of dissociative experiences, such as trance states, rocking, flashbacks, nightmares, and repressed memories.Any and all parts of a memory can be repressed. One model for assessing dissociation and identifying repressed memories is the BASK model. The BASK model is a quick way to check what part of the memory is missing, and whether or not it is Behavior, Affect, Sensation, or Knowledge. Survivors of abuse may detach themselves from their feelings so that they recall memories of abuse in a robot-like fashion.

  • Attachment to a special object. Anniversary reactions are also common to survivors of abuse, whose memories or feelings may be triggered by certain dates, events, or objects. For no apparent reason, the survivor may become sick or suicidal when faced with a situation similar to a past reminder of abuse.

  • History of fugue states and losing time.For example, patients with borderline personality disorder might start watching a movie and suddenly reorient later in the middle of another movie, with no clear memory of the elapsed time.

  • Psychosocial history and history of sexual abuse. It is common for people to feel as if they were sexually abused without having any actual memories of the abuse or trauma.Questions should be framed in a manner that facilitates the acquisition of all relevant information. By asking open-ended questions while paying attention to the patient's body language, the therapist may be able to draw useful conclusions.

  • Neurological workup of individuals who have a history of self-mutilating behaviors that could have resulted in cognitive impairment such as head-slamming. Some psychologists will conduct neurological screening;in other cases, a neurologist should be consulted.

  • Psychotic-like thinking and history of suicidal behavior, especially under intense stress. Psychotic-like thinking may be evident during episodes of trauma and stress. For example, a patient may state, "The walls are bleeding."

Crisis Stabilization

Safety issues are at the core of crisis stabilization.To ensure the patient's safety or to detox a patient, a brief psychiatric hospitalization may be necessary. Issues to be addressed during crisis stabilization might include an unwillingness or inability to contract for safety. A written release of medical information is important to coordinate care with physicians and addiction counselors.

At this stage, therapists should avoid psychodynamic confrontations with patients and should not engage patients in further therapy for abuse or trauma. The treatment focus should be on addressing the patient's need for safety, especially important with patients who have borderline personality disorder. More complicated and emotionally charged material should be deferred until the patient has better skills to manage emotional pain.

It may be helpful to describe out-of-control crisis behavior as a survivor response. Therapists and patients should avoid rigid black-and-white thinking. Describing events or issues as being more helpful or less helpful may circumvent the inflexibility of seeing life's challenges and problems only as black and white, while ignoring the numerous grey areas of experience.

During crisis stabilization, the continued use of written and verbal contracts is critical. These contracts should be rooted in the here-and-now, and should offer patients practical ways to manage crisis behavior. The contracts must focus on safety. Contracts written on 3-by-5-inch cards that they can carry and read when necessary are very helpful for patients with borderline personality disorder. Contracts should be simple and concrete and should emphasize problem-solving skills.

Therapists should work on relapse management strategies that are clear and concrete, such as: "Before I use cocaine, I will call my sponsor." At the same time, therapists should encourage patients to be honest about relapse. Therapists should assume a posture of concerned support about relapse and view it as an opportunity to learn from past mistakes and strengthen relapse prevention skills and the therapeutic relationship.

The family -- as defined by each patient -- should take part in this process. It may be useful to encourage contracts with family members. These contracts can dissuade family members from assuming dysfunctional roles such as the victim, the persecutor, and the rescuer. The family should learn how to set boundaries with the patient, and should learn not to play certain roles, especially the role of rescuer.

Longer-Term Care

Individual Counseling

In individual therapy, issues stemming both from borderline personality disorder and from AOD use may emerge. Issues related to unsafe behavior or AOD use will continue to be important.Longer-term care is a stage in which teaching the patient skills, such as assertiveness and boundary setting, can be useful.

Patients may need to be educated about survivor issues without exploring more psychodynamically based issues. Patients should be oriented to a survivor framework, but therapists must build slowly before engaging patients in retrieving painful memories.

The abuse survivor should demonstrate the necessary skills to benefit from psychotherapy. Patients should tell the therapist when they are not ready to discuss certain issues. Once patients are ready to do so, the integration of psychodynamic material and trauma therapy may begin. There is no pressing need for the retrieval of early memories of trauma. Rather, the focus of therapy may be on behavior rather than memory.

Therapists might try to frame acting-out behaviors as survivor behaviors. Complications at this stage can include a variety of compulsive and impulsive behaviors, such as eating disorders (obesity, anorexia, bulimia), compulsive spending and money mismanagement, relationship problems, inappropriate sexual behaviors, and unprotected sex (in regard to STDs and pregnancy). Other maladaptive behaviors include sexual impulsiveness, which can cause confusion about sexual identity dramatized in experimental sexual relationships, adding to the crisis and drama on which people with borderline personality disorder often thrive.

Therapists may want to consider limiting access to educational material about adult children of alcoholics (ACOAs) for patients with borderline personality disorder.Reading some ACOA material and self-help books and participating in self-help support groups may be detrimental to some patients' recovery. For some patients, self-labeling can become counter-productive -- and in worst-case scenarios, it can lead to self-fulfilling prophesies.

For example, books suggesting that some people self-mutilate in order to relieve pain may teach patients with borderline personality disorder to self-mutilate. Some books offering "inner-child work" lead the patient through age-regressive exercises that can cause an overwhelming flood of feelings the abused patient may not yet be ready to manage.

Therapists should remember that progress in treating patients with borderline personality disorder and AOD problems can be slow. There may be many setbacks. Rather than looking for enormous changes in personality or behavior, therapists should look for small, measurable signs of improvement.

In addition, therapists may want to consider the following in treating patients with borderline personality disorder:

  • Using mini-contracts for each session to encourage the patient to stay focused.
  • Immediately asking patients about any crises that have occurred, reviewing the entire week, not just a particular day.
  • Stating the purpose of each session.
  • Running through a checklist can be helpful. A list might include: homework, failing tests, arguments with others, interactions with the criminal justice system, problems in school or work life, family relationships and friends, relapses, thoughts of self-harm, nightmares, flashbacks, painful situations, and bad memories. Questions should be specific.
  • Encouraging patients to keep mood and dream journals (especially during survivor work) between sessions for brief comments on mood.
  • Conducting survivor work only after daily living skills are successfully demonstrated.
  • Keeping and dating all correspondence and notes from telephone conversations. Having previous conversations documented can help to remind the patient of earlier agreements and conversations.

Group Therapy

There are special issues concerning work with people with borderline personality disorder in group therapy. Therapists should consider the following:

  • Making contracts for all members to stay in the room.
  • Making contracts for group rules that promote safe behavior and not hurting oneself or others.
  • Working with transference and countertransference issues.
  • Discussing thoughts and feelings about other group members as they arise.
  • Setting time limits at the start of each session.
  • Making mini-contracts for those who have issues to work on in each session.
  • Having group members sign contracts for abstinence and reporting self-harm and AOD use to the group.
  • Making contracts for confidentiality.
  • Disallowing participants to form intimate or exclusive relationships. Supportive activities, such as calling one another during crises or attending 12-step meetings together, are acceptable and should be encouraged.
  • Evaluating safety issues in screening people with borderline personality disorder for group therapy. Patients should be safe from predatory, manipulative behavior of others, and should not engage in such behaviors themselves.
  • Promoting same-sex groups.

Twelve-Step Participation

Although 12-step involvement is important for patients with borderline personality disorder, some may not be immediately able to attend 12-step meetings. Some patients may find it more helpful to participate in pre-12-step practice sessions. These patients should be helped to organize their thoughts, to practice saying "pass," and to create safety in a 12-step meeting. Counselors may want to use the step work handout as a treatment tool for working with people with borderline personality disorder (see Exhibit 7-2 and Chapter 6on use of 12-step meetings).

Patients should be encouraged to join same-sex 12-step groups when possible. People with borderline personality disorder may find it helpful to use same-sex sponsors as guides to recovery. When possible, therapists should educate the sponsor about survivor behaviors. The sponsor may even attend a therapy session to learn why the patient is taking medications. Antidepressants or lithium may be an important part of the patient's recovery. Explaining how medications are helpful may enable sponsors to help improve medication compliance.

Some sponsors may have problems setting boundaries. Such sponsors should not be paired with borderline patients. If they must be paired, however, they need to understand how important boundaries are in helping borderline patients feel safe. Understanding this may keep them from taking on borderline patients, who may be more than they can handle. Material in the step program should be limited to the here-and-now. Patients should not engage in dealing with sexual abuse issues until they are ready.

Longer-term care should include specialized 12-step work. In using step one ("We admitted we were powerless over alcohol -- that our lives had become unmanageable.") with patients who have borderline personality disorder, therapists should encourage patients to recognize that powerlessness does not mean helplessness. Instead, patients should focus on gaining personal control over AOD use. Faith and hope concepts used in 12-step work may also be difficult for this group to comprehend or integrate.

Continuum of Care

An aftercare plan for patients with dual disorders is essential.This plan should integrate rather than fragment strategies for treating the patient. It should include methods to coordinate care with other treatment providers. Relapse prevention is critical and should be managed through careful planning throughout treatment. Relapse should be defined as engagement in any unsafe behavior such as AOD use, self-harm, and noncompliance with medications. Relapse prevention should focus on preventing AOD use and recurrence of psychiatric symptoms.

Patients should be encouraged to participate in 12-step groups and other self-help and support groups such as Adults Molested As Children (AMAC), Incest Survivors Anonymous (ISA), and Survivors of Incest Anonymous (SIA).

Acute hospitalization may be necessary during suicidal crises. Again, the emphasis of treatment should remain on safety. Outpatient therapy should continue. AOD treatment should be obtained when appropriate. Therapists should be wary of triangulation in coordinating with other professionals.

Case Example

Rachel was 32 years old when she was taken by ambulance to the local hospital's emergency room. Rachel had taken 80 Tylenol capsules and an unknown amount of Ativan in a suicide attempt. Once stable medically, Rachel was evaluated by the hospital's social worker to determine her clinical needs.

The social worker asked Rachel about her family of origin. Rachel gave a cold stare and said, "I don't talk about that." Asked if she had ever been sexually abused, Rachel replied, "I don't remember." Rachel acknowledged previous suicide attempts as well as a history of cutting her arm with a razor blade during stressful episodes. Rachel reported that the cutting "helps the pain."

Rachel denied having "a problem" with AODs but admitted taking "medication" and "drinking socially." A review of Rachel's medications revealed the use of Ativan "when I need it." Rachel used Ativan three or four times a week. She reported using alcohol "on weekends with friends" but was vague about the amount. Rachel did acknowledge that before her suicide attempts, she drank alone in her apartment.This last suicide attempt was a response to her breakup with her boyfriend.Rachel's insurance company is pushing for immediate discharge.

Question -- Should Rachel be discharged? Where should she be sent? Exhibit 7-3 shows a recovery model for treatment of borderline personality disorder.

Antisocial Personality Disorder

Clinicians should be careful to avoid mislabeling patients. Although some women may have antisocial personality disorder, they receive this diagnosis less often than men. Instead, they may be misdiagnosed as having borderline personality disorder. Among the male prison population, 20 percent may have antisocial personality disorder. However, once they are abstinent, many AOD-using offenders may not meet the criteria for antisocial personality disorder.

Engagement

In engaging the patient with antisocial personality disorder, it is useful to join with the patient's world view, which may include a need for control and a sense of entitlement. In this context, entitlement refers to people who believe their needs are more important than the needs of others. Entitlement may include rationalization of negative behavior (such as robbery or lying). People with antisocial personality disorder may evidence little empathy for their victims. If incarcerated, they may believe they should be released immediately. In an AOD treatment program, they may describe themselves as being unique and requiring special treatment.

The primary motivation of the patient with antisocial personality disorder is to be right and to be successful. It is useful to work with this motivation, not against it. Although this motivation may not reflect socially acceptable reasons for changing behavior, it does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a job, to avoid jail, and to become the chair of an AA meeting are reasonable goals, despite a self-serving appearance. Therapists may help patients by working with patients' world view, rather than by trying to change their value system to match those of the therapist or of society.

Patients should understand their role in the process. In engaging patients, therapists may want to use contracts to establish rules for conduct during treatment. The contract should explicitly state all expectations and rules of conduct and should be honored by all parties. Such an approach can be useful with people with antisocial personality disorder, who often view relationships as unfair contracts in which one person attempts to take advantage of the other. Therapists may find that once a level of interpersonal respect has been established, working with antisocial patients can lead to important gains for the patient.

Assessment

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial patient:

  • Taking a thorough family history.
  • Finding out whether or not the patient set fires as a child, abused animals, or was a bed-wetter.
  • Taking a thorough sexual history that includes questions about animals and objects.
  • Taking a history of the patient's ability to bond with others. Therapists can ask: "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
  • Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
  • Taking a history of head injuries, fighting, and being hit. It may be useful to perform neuropsychological testing.
  • Testing urine for recent AOD use.
  • HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of AOD use to behavior.

Useful assessment instruments include the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the PCL-R (Hare Psychopathy Checklist-Revised), and the CAGE questionnaire.

Crisis Stabilization

People with antisocial personality disorder may enter treatment profoundly depressed, feeling that all systems have failed them. Often, their scams and lofty ideas have failed and they feel exposed, feel like losers, and have no ego strength.They are at risk for suicide, especially during intoxication or acute withdrawal. They may require psychiatric hospitalization and detoxification.

They may become acutely paranoid. Containment in the form of a brief hospitalization may be indicated for patients experiencing acute paranoid reactions to avoid acting out against others. For less acute paranoid reactions, therapists should try to avoid cornering patients, disengage from any power struggle, offer lower stimulus levels, and create options, especially if those are supplied by the antisocial patient. During this phase, clarification without harsh confrontation is recommended.

When patients with antisocial personality disorder have crises, therapists should become cautious and careful. During crises, these patients may engage in dangerous physical behavior in order to avoid unpleasant situations or activities, and therapists should avoid angry confrontations.

Longer-Term Care

Individual Counseling

It is helpful to view the process of working with antisocial patients as a process of adaptation of thinking rather than the restructuring of a patient into a person whose morals and values match those of the therapist or society. Therapists may benefit from modifying their own expectations of treatment outcomes, and realize that they may not help some patients to develop empathic and loving personalities. It is enough to guide patients to lead lives that follow society's rules.

Individual therapy offers the therapist an opportunity to point out patients' errors in thinking without causing them to feel humiliated in the presence of the therapy group. Other issues for individual therapy may include continued relapse management and identity of empathy. Three key words summarize a strategy for working with people with antisocial personality disorder: corral, confront, and consequences.

Corral.

Corralling with regard to patients with antisocial personality disorder means coordinating treatment with other professionals, establishing a system of communications with other professionals and with the patient, contracting patients to be responsible for their AOD use in the recovery program, monitoring information about the patient, and working toward specific treatment goals. Patients may benefit by signing agreements to comply with the treatment plan and by receiving written clarification of what is being done and why. Interventions and interactions should be linked to original treatment goals.

One approach to treatment that adds to the notion of "corralling" is to "expand the system." Spouses, family members, friends, and treatment professionals may be invited to participate in counseling sessions as a way to provide collateral data. This is sometimes called "network therapy."

Confront.

In confronting antisocial patients, therapists can be direct without being abusive. They can be clear in pointing out antisocial thinking patterns. They can remark on contradictions between what patients say and what patients do. Random AOD testing is essential for monitoring patients. Honest reporting of AOD use should be an active part of treatment.

Consequences.

Patients should bear the consequences of their behavior. For instance, violation of probation or rules should be recorded. Patients who are offenders should be encouraged to report behavior that violates probations, thus taking responsibility for their own actions. Positive consequences that demonstrate to patients the benefits of appropriate behavior should also be designed and incorporated into the treatment plan. Financial incentives and opportunities for power or recognition can be a key element of treatment.

Case management may involve coordinating care with a variety of other professionals and individuals, including those in the criminal justice system, AOD counselors, and family members. Therapists need to make it clear to patients that the therapist must talk to other providers and to family members. Thus, it is helpful for patients to sign releases of information for all people involved in their treatment.

The question of terminating therapy can be a puzzling one for therapists treating antisocial patients. The patient may frequently express a desire to end treatment. This desire should be closely examined to determine whether it is a manifestation of patient resistance or whether it is a valid request. There is some question about whether it is appropriate to terminate therapy with patients who have antisocial personality disorder who may need ongoing treatment. Reasons for termination may include noncompliance with treatment, continued drug use without improvement, any aggressive behavior, parasitic relationship with other patients, or any unsafe behavior.

Patients with antisocial personality disorder compulsively try to break rules. If a treatment plan is not devised to work with a person who wants to redefine rules, termination should be considered and transfer to more appropriate care should be arranged.

Continued thinking-error work, as described in Exhibit 7-4, may help patients to identify various types of rationalizations that they may use regarding their behaviors.

Group Therapy

Group therapy is a useful setting in which people with antisocial personality disorder can learn to identify errors not only in their own thinking, but in the thinking of others. The group can help identify relapse thinking. For example, when an individual begins to glamorize stories of AOD use or criminal and acting-out behaviors, the group can help to limit that grandiosity. Therapists may also ask people with antisocial personality disorder to discuss feelings associated with the behavior being glamorized.

Role play exercises can be useful tools in group therapy. However, therapists should be careful to prevent patients with antisocial personality disorder from using newly learned skills to exploit or control other group members. In group therapy, patients with antisocial personality disorder can be encouraged tomodel prosocial behaviors and learn by practicing them. Role play exercises can help these patients to focus on their shortcomings rather than on the faults of others.

AOD therapists should avoid creating groups that consist entirely of patients with antisocial personality disorder. Such groups are best conducted in very controlled settings in which therapists have control over the environment.

Patients with antisocial personality disorder may be asked to sign contracts that establish healthy and nonparasitic relationships with other group members. This means not becoming romantically involved with other members, not borrowing money from them, and not developing exploitive relationships.

Therapists themselves should try not to become obsessed with being manipulated or tricked by group members. Such power struggles are not helpful.

Counseling Tips for Patients With Antisocial Personality Disorder

Corral:
  • Coordinate treatment.
  • Communicate with other providers.
  • Make contracts with patients.
Confront:
  • Be direct, not abusive.
  • Identify antisocial thinking.
  • Conduct random AOD testing.
Consequences:
  • Make patients responsible for their behavior.
  • Record violations of rules.
  • Allow patients to experience consequences of their behavior.
  • Designate positive consequences of good behavior.

Continuum of Care

A key to treating people with antisocial personality disorder is to be flexible within an array of containment interventions.Therapists should have the ability to quickly move a patient from a less controlled environment to a more controlled environment. Patients benefit from sanctions that match the degree of severity of behavior. Sanctions should not be "punishments" but responses to the need for containment and more intensive treatment. Antisocial patients need a range of treatment and other services: from residential to outpatient treatment, from vocational education to participation in long-term relapse prevention support groups, and from 12-step programs to jail.

When patients with antisocial personality disorder shed aspects of the disorder, they may become more dependent. Therapists often try to limit such dependence. However, with regard to antisocial patients, such a transition should be allowed rather than confronted. It often represents a healthy change. Feelings of dependency are easily frustrated at this stage, and disappointment may result in relapse.

Case Example

Mark was 27 years old when he was arrested for driving while intoxicated. Mark presented himself to the court counselor for evaluation of possible need for AOD treatment. Mark was on time for the appointment and was slightly irritated at having to wait 20 minutes due to the counselor's schedule. Mark was wearing a suit (which had seen better days) and was trying to present himself in a positive light.

Mark denied any "problems with alcohol" and reported having "smoked some pot as a kid." He denied any history of suicidal thinking or behavior except for a short period following his arrest. He acknowledged that he did have a "bit of a temper" and that he took pride in the ability to "kick ass and take names" when the situation required. Mark denied any childhood trauma and described his mother as a "saint." He described his father as "a real jerk" and refused to give any other information.

In describing the situation that preceded his arrest, Mark tended to see himself as the victim, using statements such as "The bartender should not have let me drink so much," "I wasn't driving that bad," and "The cop had it out for me." Mark tended to minimize his own responsibility throughout the interview. Mark had been married once but only briefly. His only comment about the marriage was, "She talked me into it but I got even with her." Mark has no children and currently lives alone in a studio apartment. Mark has attended two meetings of Alcoholics Anonymous "a couple of years ago before I learned how to control my drinking."

Question -- What might the court counselor recommend to the judge as an appropriate treatment plan for Mark?

Exhibit 7-5 shows a treatment tool for use with patients who have antisocial personality disorder.

Narcissistic Personality Disorder

Engagement

In trying to engage and assess patients, therapists should remember that patients with narcissistic personality disorder will have certain traits that should be addressed therapeutically. Therapists should try to join with patients' hypersensitivity and need for control by saying such things as "I'm impressed with what a bright and sensitive person you are. If we work as a team, I think we can help you get out of this spot."

Patients with narcissistic personality disorder often have a need to be the center of attention and to control events. They crave affection and admiration from others. They are perfectionists (about themselves). They may try to create dramatic crises to obtain attention to return the focus to themselves. As with patients with antisocial personality disorder, entitlement issues are very important. Patients with narcissistic personality disorder feel as if everyone and everything owes them -- without any contribution on their part.

It is helpful for therapists to work with these personality traits in therapy. Working with narcissistic motivations for recovery, such as an improved appearance or a desire to continue in a job or to make romantic and sexual conquests, may help the patient to change inappropriate behaviors.Therapists may benefit from working with, rather than against, ego inflation.Therapists who try to squelch the narcissistic ego may be met with rage.Therapists should position themselves as trying to help the narcissistic patient reach his or her goals.

Therapists may work with patients to identify thinking errors that interfere with the patient's ability to work. These errors may include beliefs such as "Everybody loves me." Therapists may need to work with patient's victim-stance thinking. An example of such thinking is "Everybody is out to get me." The antisocial thinking-error work described in the previous section (see Exhibit 7-4) can be a very effective tool for working with the narcissist.

To manage narcissistic rage and depression, therapists may contract for patient safety as well as for the safety of others. The therapist may offer the patient a combination of empathy and reality testing. For example, when patients say, "Everything is messed up," or "Everybody is causing me trouble," therapists may empathize with patients, while also indicating the reality of the situation and the need for behavior change.

Assessment

Some examples of items to cover during the assessment include:

  • A psychosocial history, including early childhood beliefs with regard to looks, behaviors, and thoughts
  • A history of AOD use
  • A sexual history to identify the ability to be empathic with partners
  • Early Memory Procedures test (EMP)
  • CAGE questionnaire
  • Millon Clinical Multiaxial Inventory (MCMI-II)
  • California Personality Inventory (CPI).

Crisis Stabilization

Therapists may need to assess patients' defenses, and to put those defenses to therapeutic use. For example, when a patient blames the police for "setting me up," the therapist can mention that the best way to avoid being set up again is to not drink and drive.

Patients with narcissistic personality disorder have a central concern with being perfect. For these individuals, the disease concept approach can assist in recovery by removing blame from the patient and conceptualizing the illness as a biochemical disorder. This can help to lessen the feelings of failure which can be a barrier to treatment.

People with narcissistic personality disorder may become depressed when they feel deeply wounded, when their systems have failed them, and when they sense that their world is falling apart. When wounded, they are at the highest risk for acting out against themselves and others. When in a narcissistic rage, patients may become homicidal, feeling a need to seek revenge. This rage comes from the intensity of the narcissist's wound. The counselor needs to work carefully with this rage and to avoid getting into power struggles.

When these patients are in suicidal crises, patients should sign contracts for safety. Safety may include brief psychiatric hospitalizations that are goal oriented and designed for stabilization.

When working with HIV-positive patients with narcissistic personality disorder, therapists may establish contracts with them to engage in safer-sex practices. Often sexual prowess is part of the narcissistic ego-inflation. Their need to see themselves as great lovers, coupled with self-centeredness, puts them at high risk for sexually transmitted diseases.

Longer-Term Care

Individual Counseling

There will be an ongoing need to manage the rage and depression of patients with narcissistic personality disorder and their need for attention, control, and admiration. Continued attention to self-centeredness and the need to work the 12 steps is essential. Step work designed for people with antisocial personality disorder (as previously described in Exhibit 7-5) can be helpful for patients with narcissistic personality disorder. Similarly, the individual and group approaches to the treatment of patients with antisocial personality disorder can be used for patients who have narcissistic personality disorder. Indeed, it may be helpful to view the patient with narcissistic personality disorder as a hypersensitive patient with an antisocial personality disorder.

Group Therapy

People with narcissistic personality disorder may benefit from group therapy. In group therapy, therapists may need to set time limits in a firm but pleasant manner, pointing out the need for all patients to have group time. At the start of each session, therapists should make a contract with patients with narcissistic personality disorder to encourage prosocial behaviors and to avoid attempts to dominate, control, or compete for attention with other group members. Some behaviors to contract for might include:

  • To limit the time that they can speak during group sessions
  • To not interrupt others while they speak
  • To respect other group members' time and feelings
  • To give responses to other group members
  • To receive responses and feedback from others.

It is important not to smash the narcissistic ego or to attack the narcissistic patient within the group. It is more useful to comfort and confront the narcissist simultaneously: "I understand that the part of you that is sensitive is wounded to hear that the group does not believe everything you are saying." Continue to work with the narcissist's defenses, not against them.

Continuum of Care

For patients with narcissistic personality disorder, the least restrictive treatment environment is preferable. It permits patients to feel that they are in control. These patients should be moved quickly from inpatient to outpatient levels of care. If they do not like the treatment, they will stop participating.Thus, it is critical not to overpathologize the patient's disorder with constant criticism. However, acute hospitalization for psychiatric emergencies (such as homicidal or suicidal plans) may be necessary.

Narcissistic patients generally enjoy the attention they receive through involvement in outpatient treatment;retention in the program is easily accomplished. Long-term outpatient involvement is critical to maintain narcissistic patients' prosocial behavior and sobriety.Therapists who strive to build narcissistic patients' strengths and who pay close attention to them in therapy will find them active participants in the recovery process. In addition to their personality disorder and AOD use disorder, some patients may engage in compulsive sexual or spending behaviors that should be addressed therapeutically.


Tip for Narcissistic Patients
A helpful exercise for patients with narcissistic personality disorder is to ask them not to say anything during a specific number of 12-step or self-help groups, but to simply listen. Once this has been done, narcissistic patients should discuss their feelings with the therapist in response to the exercise.

Case Example

Bill is a 45-year-old male who was referred by his employer to the company's employee assistance program (EAP). The employer was concerned about Bill's temper, his difficulty accepting criticism, and his difficulty in getting along with other staff. At the EAP appointment, Bill's appearance was that of an extremely well-groomed man who paid exceptional attention to his dress and attire. His manners were impeccable, although he was critical of the receptionist at the EAP's office for not offering him coffee when he came in. Bill was friendly but cool toward the EAP counselor, tending to gloss over the importance of his boss's concerns.

When the EAP counselor asked him for more specifics about his problems with his coworkers, Bill became extremely defensive and hammered away in a raging attack on his coworkers and their jealousy of his success. Bill felt that his boss was a well-intentioned but incompetent person who frequently made mistakes. Bill also felt that his boss didn't appreciate the caliber of his work or the time he put into his work. Bill took pride in his perfectionism, attention to detail, and firm and inflexible beliefs.

Bill was not married, although he reported that he had come close a few times only to discover that these women had "fooled him" in one way or another. Bill reported to have only one male friend and indicated that he much preferred the company of women to men. Bill denied having any "problem with drugs" but did indicate that he uses marijuana and cocaine recreationally. Bill reported using alcohol most weekends and occasionally drinking to the point where he "forgot" what happened.

Question -- What should the EAP counselor suggest as a treatment plan to address employer concerns over Bill's behavior?

Passive-Aggressive Personality Disorder

Engagement

As in working with all patients with personality disorders, therapists should attempt to join with the world-view of patients with passive-aggressive personality disorder, rather than work against it. Therapists may try to work with patients' need for safety and with their ambivalence toward recovery.Therapists should work with patients' indirect displays of anger and assertiveness.

Passive-aggressive patients try to avoid commitment and responsibility. All interventions should be focused on the patient's needs, wants, and desires, a strategy that promotes treatment compliance.

Assessment

Areas to address in the assessment include the following:

  • Survival skills and self-care assessment
  • Monitoring of use of over-the-counter drugs, such as NyQuil, Dexatrim, Benadryl, niacin, laxatives, and tryptophan (somatic illnesses are often medicated with these chemicals)
  • Information on all other professionals and medical providers being seen for treatment
  • Psychosocial and AOD history, and mental status
  • Coexisting anxiety disorders
  • Medication evaluations for antidepressants or other nonaddictive substances
  • Identification of the patient's typical passive-aggressive maneuvers or "scripts."

Useful assessment instruments include the MMPI, CAGE, or MAST, to assist clinical review and/or to evaluate substance abuse.

Crisis Stabilization

Often, several issues must be managed during crises experienced by patients with passive-aggressive personality disorder, such as responses to abusive relationships, obtaining safe housing, and receiving emergency psychiatric admissions for suicidal crises.These patients may need to be detoxified from benzodiazepines and other sedative-hypnotics. To manage various crises, therapists may need to insist that patients provide release of information authorizations for all providers of care. This can help the therapist to coordinate services. Verifying all prescribed medications can prevent medical emergencies and improve patient responsibilities.

Longer-Term Care

Patients who have AOD use disorders that involve prescription drugs will find it helpful to inform their prescribing physicians of their involvement in treatment and recovery efforts. This helps to stop the supply of psychoactive medications, to learn assertive behavior, and to teach personal responsibility for recovery.

Patients with passive-aggressive personality disorder require skill building in several areas including: assertiveness, boundary setting, anger management, and identifying and expressing their feelings directly. They will also need to work through sexual intimacy problems. This might be done in a same-sex group, individual therapy, or marital or couple therapy.Treatment planning should include goals and objectives that are reasonable and measurable. For example, a goal may be set to increase the length of time during which a patient is abstinent between relapse episodes. An excellent focus for the skill-building part of therapy is developing the ability to express anger through assertiveness rather than through indirect acting out.

Passive-aggressive patients may engage in compulsive behaviors including eating disorders and compulsive shopping and spending; money management problems, as well as AOD relapse, may also occur. Throughout treatment, therapists should continue to monitor the patient's use of alcohol, prescribed and over-the-counter medications, and other drugs.

Individual Counseling

In individual therapy, therapists may help patients to express their emotions directly. Therapists can encourage patients to process comments made when the patient appears to be passive or disinterested in the process. Therapists can prompt patients to express their needs, wants, and desires directly without waiting until a later session. Therapists can use written and verbal contracting as an ongoing therapeutic method. Therapists should not apologize for setting and enforcing limits and reinforcing boundaries between the passive-aggressive patient and the program staff.

Group Therapy

Patients with passive-aggressive personality disorder should be encouraged to join same-sex support groups. This helps them identify strongly with same-sex peers and prevents relationships built on a mutual need to avoid recovery. Group therapy sessions provide patients an opportunity to develop ways to manage hostility.

When hostility manifests itself during group sessions, therapists may manage it by commenting on the hostile behavior, asking other group members to comment, and asking the patient to respond. The therapist may then quickly assess the patient by asking: What do you need? Who can you ask for it?When can you ask for it? The patient can then rehearse appropriate behavior in group.

Parents can be taught not to assume these dysfunctional roles.Patients who are also parents may need to be taught parenting skills to help them avoid creating destructive relationships with their children. Passive-aggressive parents need direct methods for dealing with their children's behavior so that children do not develop personality and emotional problems themselves. Children raised by parents who are overcontrolling, unpredictable, and hostile can develop antisocial or dissociative defenses and styles.

Once patients with passive-aggressive personality disorder have managed to work through primary issues, therapists may want to use opposite-sex models who can demonstrate appropriate types of behavior.Learning how to set limits on opposite-sex facilitators helps with generalization of newly learned skills.

Twelve-Step Work

Control is an essential feature of the passive-aggressive personality. Therapeutic work that centers on step one of the 12 steps can be helpful. Therapists should remember to emphasize that patients can gain certain types of control by giving up other kinds of control. Step work discussed in the section on borderline personality disorder (Exhibit 7-2) can be helpful.

Patients may benefit from participation in 12-step programs for their AOD problems and for relationship dependencies and conflicts. Patients should be educated about avoiding romantic involvement with other group participants, and especially escaping a bad relationship by becoming involved in a new relationship.

Continuum of Care

Inpatient hospitalization may be necessary for detoxification of patients who have AOD use disorders that involve sedative-hypnotics such as the benzodiazepines. Ongoing therapy for substance use and psychiatric issues can be done on an outpatient basis with a combination of individual same-sex group therapies and integration into 12-step or self-help recovery groups.

Brief inpatient psychiatric stays may also be necessary to deal with psychiatric emergencies such as overwhelming depression, anxiety, or suicidal ideation or behavior.

Patients may need assistance to locate shelters and safe housing when domestic violence is a problem or threat. A primary care physician is essential so that medical management can be provided and coordinated with psychosocial treatment. A complication to recovery for many passive-aggressive patients may be compulsive eating or spending problems. Ongoing assessment and treatment of these issues as part of the overall treatment plan are encouraged.

Case Example

Jane was 37 when she sought marriage counseling with Dr. Myers. She attended the initial appointment with her husband.Both Jane and her husband were vague and nonspecific about what they needed from couple counseling. Jane was quiet until the last 10 minutes of the appointment when she started crying, stating that "nothing was going to help." Jane's husband, confused but accommodating, tried unsuccessfully to comfort Jane who withdrew to a chair in the corner of the office, refusing to talk. Dr. Myers contracted with Jane to meet with her individually for three sessions to assist in developing a better understanding of her unhappiness and frustration in the marriage.Both Jane and her husband agreed.

Jane attended the first session on time and was "ready to get to the bottom of this problem." Jane openly discussed her own "dysfunctional family," discussing parents who were both alcoholic and physically abusive. Jane discussed her difficulties dealing with feelings of depression and fear. Jane further reported how frustrated and upset she got whenever her husband criticized her or when he was angry at her.

Jane reported having thoughts of suicide, although there was no plan or history of any attempts.Jane found it helpful to have a "glass of wine" when anxious and reported to have a prescription medication that she can take for "her nerves" when she gets overwhelmed.

Further discussion revealed Jane to be getting a prescription for alprazolam (Xanax) from her family doctor. She was vague about how much alprazolam she used but said she took it "several times a week."Jane complained about recent weight gain. She felt if she could get her weight under control, "everything else would be fine." Jane reported to be drinking only juices and coffee and using over-the-counter diet pills when she got too hungry. She was somewhat defensive about her drinking and use of medications and preferred to discuss issues related to her husband. At the end of the session, she commented, "I hope this helps my marriage and my husband's drinking" and she left.Jane missed the second appointment, calling 3 days later stating she had "forgotten about the appointment." Jane attended the third appointment but was 25 minutes late.

Question -- What should Dr. Myers' treatment plan consist of and what should she do next?


Tips for Use With Passive-Aggressive Patients
To show patients the effect of letting hostilities and needs build up internally, the therapist can blow up a balloon until it nearly bursts, letting it fly around the room. This demonstrates visually what it is like to let overwhelming feelings build up. The therapist should be willing to sit in silence, forcing the patients to respond. Watch for patients enabling other group members' codependency.Relationship issues are a cornerstone of the passive-aggressive patient's problems.

Coordination of Care

Work With Other Parties

It is easy for therapists to assume dysfunctional roles with patients who have personality disorders. Also, because of the chaos that may accompany treatment, important patient information may be missed. Maintaining ongoing and up-to-date contacts is essential for all patients with personality disorders. The following are tips to remember in coordination of care of patients with personality disorders.

Primary case manager.

Frequently, patients with personality disorders have many different people and systems in their lives. The identification of one key person as a gatekeeper for information can greatly improve coordination of care and reduce interagency conflicts.

Legal issues.

Providers should obtain releases of information to monitor any new involvement in the criminal justice system or to be aware of the disposition of old charges.Issues of divorce and child custody may need to be monitored in the sessions, with the goal of having the patient spend an appropriate amount of session time on these topics.

Managed care.

Typically, managed care does not provide benefits for patients with personality disorders. Many patients with personality disorders also meet criteria for psychiatric disorders such as depression or anxiety. Brief stays in hospitals and limited insurance coverage need to be realistically evaluated so treatment goals match benefits and assets available for care.

Funding issues.

Reimbursement for the treatment of patients with dual disorders may not include patients who have personality disorders. Often, a coexisting diagnosis of depression or anxiety is appropriate. For billing or funding purposes, listing the AOD problem as the primary illness may be an option.

Staffing and cross-training.

All staff benefit from training in AOD treatment in general, and in working with AOD-using patients with personality disorders in particular. Integrated treatment for coexisting disorders is most effective.

Medical issues.

Patients participating in inpatient AOD treatment should have a complete physical examination. Outpatients should have a current (within past 30 days) physical examination on file. Physical examinations are particularly important for patients who have coexisting medical problems or who are HIV positive. HIV testing should be encouraged.

Integration into 12-step self-help groups.

It is important to encourage 12-step participation as a means of ensuring long-term recovery. Therapists and patients should discuss patients' objections to participation in these self-help group meetings. Patients should be encouraged to find 12-step groups with which they are comfortable.

Chapter 8 -- Psychotic Disorders

Dual-Focus Perspective

This chapter is an overview of current assessment and treatment principles for patients with alcohol and other drug (AOD) use disorders and psychosis.Along with an increased awareness of the treatment needs of patients with these dual disorders, an increased emphasis on service systems has evolved. These and other forces have prompted the need to reassess traditional models and service approaches to develop assessment and treatment strategies that meet the specific needs of patients with AOD use disorders and psychosis.

All too often, AOD use disorders are undetected in patients with psychotic disorders, and traditional treatment approaches are often inadequate. For example, attempts have been made to treat psychotic and AOD use disorders in a sequential manner, treating one disorder first and then the other. While a single-focus approach is helpful for differential diagnosis, and is effective in treating some patients, it is frequently unsuccessful for patients with AOD problems who have severe and recurrent psychotic episodes. This chapter provides an overview of a dual-focus approach to the assessment and treatment of patients with these dual disorders. A single-focus approach emphasizes the importance of developing a diagnosis and subsequent treatment plan -- such as is done when treating patients who have a single disorder. In a dual-focus approach, the emphasis is not on making a diagnosis, but rather on 1) the severity of presenting symptoms, 2) crisis intervention and crisis management, 3) stabilization, and 4) diagnostic efforts within the context of multiple-contact, longitudinal treatment. By concentrating on symptoms, crisis management, and stabilization, clinicians can simultaneously focus on patients' treatment needs that are caused by both the psychotic and AOD use disorders, rather than focusing on one disorder or the other.


Dual-Focus Approach for Assessing and Treating Patients with Dual Disorders
  • Initial focus on severity of presenting symptoms, not on diagnosis of one disorder or another
  • Acute crisis intervention and crisis management
  • Acute, subacute, and long-term stabilization of patient
  • Ongoing diagnostic efforts
  • Multiple-contact longitudinal treatment.

Definitions and Diagnoses

The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations and hallucinations).

Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder, brief reactive psychosis, induced psychotic disorder, and atypical psychosis.

Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations, delusions, bizarre behavior, and deterioration in the general level of functioning.

Severe disturbances occur with relation to language and communication, content of thought, perceptions, affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include bizarre delusions, prominenthallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is impaired in interpersonal, academic, or occupational relations and self-care.

Schizophrenia can be divided into subtypes: 1) in the paranoid type, delusions or hallucinations predominate; 2) in the disorganized type, speech and behavior problems predominate; 3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; 4) in the undifferentiated type, no single clinical presentation predominates;and 5) in the residual type, prominent psychotic symptoms no longer predominate.The diagnosis of schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic symptoms for 1 week (unless successfully treated).

Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech;motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication.

Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect, social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral atrophy; and generally poor response to neuroleptics. In general, acute substance-induced psychotic symptoms tend to be positive symptoms. .

Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only; others may have repeated episodes separated by varying durations of time.

Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into bipolar (history of mania) and unipolar (depression only) types. .

Delusional disorders are characterized by prominent well-organized delusions and by the relative absence of hallucinations; disorganized thought and behavior; and abnormal affect.The delusional disorders are divided into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.

Brief reactive psychosis describes a condition in which an individual develops psychotic symptomsafter being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer than 1 month). .

Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is believed and accepted by a passive partner.

Substance-Induced Disorders

AOD-induced psychotic disorders are conditions characterized by prominent delusions or hallucinations that develop during or following psychoactive drug use and cause significant distress or impairment in social or occupational functioning. This disorder does not include hallucinations caused by hallucinogens in the context of intact reality testing.

Although there can be great variability in individual susceptibility to AOD-induced psychotic symptoms, it is important for the clinician to determine if the presenting symptoms could plausibly be induced by the type and amount of drug apparently consumed. For example, vivid auditory, visual, and tactile hallucinations are plausible side effects of a 5-day, high-dose cocaine binge. However, should these symptoms emerge during a brief episode of mild alcohol intoxication, it is likely that the symptoms represent an underlying psychotic process that has been exacerbated by the use of alcohol.

Stimulant-Induced Symptoms

Psychotic symptoms induced by stimulant intoxication are unusual when stimulants are used in low doses and for brief periods. Acute stimulant intoxication in the context of a chronic, high-dose pattern can cause symptoms of psychosis, especially if coupled with a lack of sleep and food and environmental stressors. Stimulant-induced psychotic symptoms can mimic a variety of psychotic symptoms and disorders including delirium, delusions (often persecutory and paranoid), prominent hallucinations, incoherence, and loosening of associations. Stimulant delirium often includes formication, a tactile hallucination of bugs crawling on or under the skin.

Depressant-Induced Symptoms

Particularly when unmedicated, sedative-hypnotic withdrawal can include symptoms of psychosis. Acute withdrawal from alcohol, barbiturates, and the benzodiazepines can produce a withdrawal delirium, especially if use was heavy and tolerance was high orif the patient has a concomitant physical illness. Hallucinations and delusions are common features of sedative-hypnotic withdrawal delirium.

Psychedelic- and Hallucinogen-Induced Symptoms

Many psychedelic drugs, such as the amphetamine-related psychedelics (for example, MDMA and MDA), are not hallucinogenic at the lower doses associated with situational psychedelic drug use. However, in a chronic, high-dose pattern of use (which is rare), psychotic symptoms are possible, by virtue of the drugs' stimulant properties. Other psychedelic drugs, such as LSD, have strong hallucinogenic properties.

Hallucinogen intoxication can cause hallucinogenic hallucinosis, characterized by perceptual distortions, maladaptive behavioral changes, and impaired judgment. Hallucinogen intoxication may also prompt hallucinogenic delusional disorder and a hallucinogenic mood disorder. However, hallucinogen-induced perceptual distortions such as hallucinations or visions are not considered evidence of psychosis when the drug user retains reality testing and is aware that the distortions are drug induced. Acute marijuana intoxication can produce a delusional disorder that may include persecutory delusions, depersonalization, and emotional lability. Similarly, acute PCP intoxication can lead to delirium, delusions, or a PCP-induced mood disorder.

Prevalence

Various studies have noted that the lifetime prevalence rate for schizophrenia is roughly 1 percent among the general population (Africa and Schwartz, 1992). In the Epidemiologic Catchment Area (ECA) studies, the prevalence rate for schizophrenia and schizophreniform disorders combined were as follows: 1) 1-month prevalence rate: 0.7 percent; 2) 6-month prevalence rate: 0.9 percent; and 3) lifetime prevalence rate: 1.5 percent (Regier et al., 1988).

The ECA studies reported that the lifetime prevalence rate of schizophrenia was 1.5 percent, and the 6-month prevalence rate was 0.8 percent. The lifetime and 6-month prevalence rates of schizophreniform disorder were both 0.1 percent (Regier et al., 1990).

Clinical observation of high rates of AOD use disorders among patients with schizophrenia were supported by the ECA studies. Among individuals identified as having a lifetime diagnosis of schizophrenia or schizophreniform disorder, 47 percent have met criteria for some form of an AOD use disorder. Indeed, the odds of having an AOD usedisorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher (Regier et al., 1990).

One study noted that among patients with AOD use disorders, 7.4 percent had a lifetime diagnosis of schizophrenia;the 1-month prevalence rate was 4.0 percent (Ross et al., 1988), although other studies of persons in AOD abuse treatment found the prevalence of schizophrenia to be about the same as in the general population -- about 1 percent (Rounsaville et al., 1991). While patients with AOD use disorders may experience acute episodic psychotic symptoms, few meet the diagnostic criteria for schizophrenia if AOD-induced symptoms are excluded.

Among severely mentally ill outpatient treatment populations, AOD use disorders are common; often more than 50 percent have AOD use disorders, depending upon the treatment setting. Among patients being treated for psychiatric problems in acute settings such as inpatient hospitals, combined psychiatric and AOD use disorders are also common.

Among patients with combined psychotic and AOD use disorders, bizarre behavior and communication generally prompt a mental health referral. Thus, people with psychotic disorders usually receive services through the mental health system and are rarely treated in the typical addiction treatment program.


Lifetime Prevalence Rates
  • Among the general population, 1 percent have a schizophrenic disorder.
  • Among schizophrenic patients, 47 percent have an AOD use disorder.

Case Examples

The following three case examples can help to demonstrate the need for a dual-focus approach to treating patients with combined psychotic and AOD use disorders, or patients with psychotic symptoms and AOD use disorders.

Martha

Married for over 15 years, Martha was responsible for most of the duties related to raising four children and maintaining the home. In the past, she had been treated for an episode of postpartum psychosis. Untilrecently, she had not required any psychiatric medications or mental health services.

Her husband, a successful businessman, was the family's only source of financial support and was emotionally distant. While Martha believed that her husband was frequently out of town on business trips, he was actually nearby having an affair with a woman whom Martha had known for many years. One day, he abruptly informed Martha of the affair and moved out of the house.

During the next 3 days, Martha was intensely depressed and agitated. Her normally infrequent and low-dose alcohol use escalated as she attempted to diminish her agitation and insomnia. During this time, she ate and slept very little. She began to feel extremely guilty for even the smallest problem experienced by her four children. She felt burdened by what she called her "transgressions, faults, and sins." She expressed fears about being doomed to "eternal damnation." Loudly and inconsolably, she declared that she "had lost her soul" and would have to repent for the rest of her life. While being taken to a nearby clinic for evaluation, she passionately described a conspiracy by members of the Catholic Church to steal her soul.

Thomas

In his inner-city neighborhood, Thomas is well known by the local medical clinic, AOD treatment program, and community mental health program. During the day, he spends much of his time walking around the neighborhood, frequently talking to himself or arguing with an unseen individual. He spends most of his evenings in the park in a wooded area away from other people, except in the winter when he sleeps in community-run shelters.

Thomas has a prominent scar in the center of his forehead. When asked about it, he describes in great detail his "third eye," and the fact that he can see into the future through the eye. When asked about his stated reluctance to live in an apartment, he describes an aversion to "electromagnetic fields" that drain his "life force" and make it difficult for him to "think about good things." For extended periods lasting several months, Thomas appears disheveled and agitated, and can be seen drinking heavily or using whatever drugs are available.

However, he also experiences prolonged periods during which he does not drink or use other drugs, appears well groomed, and exhibits less severe psychotic behavior.In general, Thomas is pleasant and well liked, although he is known to become hostile and potentially violent during periods when he uses AODs.

Laura

During a rock concert, Laura was brought by her boyfriend Morris to the paramedics at a first aid station in a large auditorium. Morris described Laura's gradual deterioration over a 1-hour period. At first, Laura displayed abrupt shifts in affect, giddy and laughing one moment and agitated and impulsive the next. Morris said that she began "talking crazy" and not making much sense. He also mentioned that Laura had brief bursts of absolute terror lasting a few seconds or minutes, during which he had to stop her from running away. Morris believed that she was responding to hallucinations.He said that Laura stopped speaking and appeared to have lost the ability to do so. Later, she had a hard time walking and tried to crawl away from Morris. By the time that the paramedics were able to examine her, Laura was rigid, immobile, mute, and unable to communicate with others. Later, Morris admitted that they had used some PCP.

Case Example Discussion

As can be seen, Martha, Thomas, and Laura have very different long-term needs.Martha's brief reactive psychosis and depression may never recur, and the relationship between her alcohol use and psychiatric symptoms should be explored. Thomas's chronic psychosis and frequent AOD abuse episodes are intricately woven together and require combined treatment. Until Laura's boyfriend provided information about Laura's acute drug use, the reason for her psychotic episode was unclear.

These case examples are valuable to demonstrate how the absence of a dual-focus approach can lead to treatment failure. While Martha's psychotic episode was related to overwhelming stress, her alcohol use might be underemphasized in a traditional mental health setting. Doing so may obscure the possibility that her drinking severely deepened her depression, increased daytime agitation, and exacerbated the psychotic episode.

While Thomas has an ongoing psychosis and AOD abuse problems, focusing on only one set of these problems means that he bounces back and forth between the mental health and addiction treatment programs, depending upon his current symptoms. His involvement with the local medical clinic for treatment of physical injuries that are sustained during episodes of impaired thinking often complicates his already uncoordinated treatment.

While Laura's drug-induced psychosis may fade as the drug is eliminated from her body, the episode can be used as a point of entry into AOD abuse treatment.Also, her immediate needs will be the same irrespective of the cause of her psychotic episode.

As these case examples illustrate, patients who experience psychosis and AOD use problems are often highly symptomatic and may have multiple psychosocial and behavioral problems. It is common for patients with dual disorders to have undergone different approaches to treatment by different providers without long-term success. Furthermore, clarifying the diagnosis and "underlying disorder" is extremely complicated in the early phases of assessment. The first step in treatment of a person with a dual disorder is an assessment that addresses biological, psychological, and social issues.

Acute Assessment

A common difficulty that clinicians experience is determining whether psychotic symptoms represent a primary psychiatric disorder or are secondary to AOD use. However, in the early phase of assessment, the goal is to stabilize the crisis rather than to establish a final diagnosis. The final diagnosis is often best determined during a multiple-contact, longitudinal assessment process. All assessments include direct client interviews, collateral data, client observations, and a review of available documented history.

Assessment of High-Risk Conditions

The initial step of every assessment is to determine whether the individual has an imminent life-threatening condition.There are three domains of high risk that require assessment: biological (or medical), psychological, and social. At any given time, one aspect of this biopsychosocial approach may be more urgent than the others.

Medical Risks

With regard to medical or biological issues, the goal of assessment is to ensure that patients do not have life-threatening disorders such as AOD-induced toxic states or withdrawal, delirium tremens, or delirium. Also, patients may be exhibiting symptoms that represent an exacerbation of their underlying chronic mental illness. The symptoms may be due to an aggravation of medical problems such as neurological disorders (for example, brain hemorrhage, seizure disorder), infections (central nervous system infection, pneumonia, AIDS-related complications), and endocrine disorders (diabetes, hyperthyroidism). The presence of cognitive impairment (such as acute confusion, disorientation, or memory impairment), unusual hallucinations (such as visual, olfactory, or tactile), or signs of physical illness (such as fever, marked weight loss, or slurred speech) show a high risk for an acute medical illness. Patients who exhibit this degree of risk need to be immediately referred for a comprehensive medical assessment.

Psychological Risks

With regard to psychological issues, the primary goal must be an assessment of danger to self or others and other manifestations of violent or impulsive behavior. Patients with a dual disorder involving psychosis have a higher risk for self-destructive and violent behaviors. Patients should be assessed for plans, intents, and means of carrying out dangerous behaviors.Patients who are imminently suicidal, homicidal, or dangerous need to be in a secure setting for further assessment and treatment. In addition, some patients may have cognitive impairment related to their dual disorder and be unable to adequately care for basic needs.

Social Risks

With regard to social issues, the primary goal is to ensure that patients have access to minimal life supports and have their basic needs met. Patients with a dual disorder involving psychosis are particularly vulnerable to homelessness, housing instability, victimization, poor nutrition, and inadequate financial resources. Patients who lack basic supports may require aggressive crisis intervention, such as the provision of food and assistance with locating a safe shelter.Lack of these social supports can be life threatening and can worsen medical and psychiatric emergencies.


Biopsychosocial Assessment of High-Risk Conditions
  • Biological risks: Assess for life-threatening medical problems
  • Psychological risks: Assess for violent and impulsive behaviors
  • Social risks: Assess basic needs and life supports.

High-Risk Probing Questions

To provide a thorough assessment of patients who are experiencing psychotic symptoms, it is important to directly question patients about the three domains of medical, psychological, and social safety.

Medical Safety

In the absence of overwhelming medical and psychiatric crises, the clinician should ask patients a series of questions that relate to medical assessment. One example is: "Have you been diagnosed or hospitalized for any major medical disorders?" Similar questions should address the recent onset of significant medical symptoms, episodes of head trauma or loss of consciousness, prescribed and over-the-counter medications, recent changes in medications, the use of AODs, and nutritional and sleep needs.

In addition, the assessment of medical symptoms should include a thorough cognitive examination of patients' orientation, memory, concentration, language, and comprehension.

Psychological Safety

Psychological safety issues relate to self-destructive and violent behaviors or an inability to care for oneself. The clinician should ask direct questions about plans, means, and intent for violence. Plans include specificity of lethal methods, such as time and place. Means include implements such as medications, ropes, and guns. Intent refers to the desire or explicit goal to end either one's own or another's life.

In particular, patients should be asked about command hallucinations and delusions that direct the person to hurt him- or herself or another. Impaired judgment or cognition that may result in an increased likelihood of impulsive, destructive behaviors.

It is also important to ask patients about their past, and particularly recent, history of violent behaviors, since a history of suicidal and homicidal behaviors is the best predictor of current risk for such behaviors.


Assessing Psychological Safety
  • Suicide plans, means, and intent
  • Delusions and command hallucinations
  • Impulsivity or impaired judgment or cognition
  • History of suicidal or homicidal behaviors.

Social Safety

Patients should be asked direct questions about past and current access to basic needs such as food, shelter, money, medication, or clothing. Patients should be assessed for past and recent episodes of victimization and of exchanging sex for money, drugs, and shelter.

Comprehensive Assessment

It is essential to rule out imminently life-threatening medical or AOD-induced emergencies which may be causing or contributing to the psychotic symptoms.

Probing Questions for Psychiatric And AOD Abuse Assessment

Once medical and AOD-induced emergencies have been addressed or ruled out, the focus of probing assessment questions should relate to the severity of presenting behaviors and symptoms rather than to whether symptoms are primary or secondary to AOD use. The focus should be on assessing the severity of the immediate symptoms. With the exception of life-threatening emergencies, the clarification of "primary versus secondary" is an important issue in working with patients who have a dual disorder involving psychosis, but such clarification requires multiple-contact, longitudinal diagnostic differentiation.

Examples of key probing questions for delusions include the following:

  • "Do you sometimes feel as if people are talking about you?"
  • "Do you sometimes feel as if people are purposefully trying to injure or offend you?"
  • "Have you ever felt as if you were receiving special messages through the television, radio, or some other source?"
  • "Do you sometimes feel that you have special powers that other people do not have?"
  • "Have you ever felt that something or someone outside of yourself was controlling your behavior, thoughts, or feelings against your will?"Examples of key probing questions for auditory hallucinations include:
  • "Do you sometimes hear things that other people cannot hear?"
  • "During these episodes, what exactly do you hear?"
  • "If you heard voices, what were the voices saying?"
  • "If you heard voices, did the voices tell you what to do, or criticize your thoughts or behaviors?"
  • "How often do you have these experiences?"

Examples of key probing questions for AOD use disorders include:

  • "Do you often drink or use other drugs more than you plan to?"
  • "Have you made attempts to cut down or stop using alcohol and other drugs?"
  • "How much time during the week do you spend obtaining, using, or recovering from the effects of alcohol and other drugs?"
  • "Since you began using, have you stopped spending time with family and friends and begun spending more time using alcohol and other drugs or spending more time with people who do?"

It is important to recognize that direct interview questions will be of limited value for some patients in detecting substance use. Patients may underestimate, overestimate, or not recognize the severity or existence of their AOD use disorder.

Standardized Screening and Assessment Measures

There are several standardized instruments for AOD abuse screening and assessment.While valuable for assessing patients with AOD use disorders, these instruments have not been extensively tested among patients with concomitant psychotic and AOD use disorders. However, even brief instruments such as the CAGE questionnaire, the Michigan Alcohol Screening Test (MAST), and case manager rating scales will detect most AOD use disorders in this group.

Such instruments may be unreliable when used with patients who are acutely psychotic or whose residual impairments interfere with their capacity to respond to the interview questions. Since these tools involve self-report interviews, denial mechanisms may also reduce accuracy. Also, instruments that rely heavily on detecting signs of dependency syndromes (such as the Alcohol Dependency Scale) may fail to detect significant numbers of people with dual disorders. This is because even limited AOD use may be extremely problematic for patients with a psychotic disorder.

Especially for patients with psychotic symptoms, clinicians should inquire about the use, frequency, and quantity of all drugs of abuse, not merely alcohol. Also, clinicians can adapt the CAGE questionnaire (see Chapter 3) in such a way that the possible relation-ships between AOD use and psychotic symptoms can be elicited. For example, patients can be asked if they have cut down (or increased) their AOD use in relation to hearing "voices" or because of paranoia. They can be asked if they become more or less annoyed, angry, or irritable when using AODs. Clinicians can ask patients if they feel guilty about using AODs when taking medication, or if their guilt causes them to occasionally stop taking their medication.

Patients can be asked if AODs have been used to diminish the side effects of medications prescribed for psychiatric problems. Also, they should be asked if AOD use or withdrawal has ever been associated with a hospitalization or a suicide attempt. Patients should be asked if the frequency, quantity, and episode duration of their AOD use has changed and what consequences are associated with these changes.

Standardized assessment measures include the MAST, which has been demonstrated to have value for assessing this group. The Addiction Severity Index (ASI) is an instrument that guides the interviewer through a series of questions about drug use and consequences, as does the American Psychiatric Association's Structured Clinical Interview for DSM-III-R (SCID).

Alternatives to direct interview scales with demonstrated efficacy include case manager rating scales that are based on longitudinal observations of the patient, and aggregate multiple sources of information, including medical records, families, the criminal justice system, employers, landlords, and related sources. The patient's informed consent must be obtained before these contacts are made.

Clinician's Observations

An important aspect of the assessment is the clinician's observations. The clinician should make careful note of the patient's overall behavior, appearance, hygiene, speech, and gait. Of particular interest are any acute changes in these behaviors, as well as the emergence of disorganized or bizarre thinking and behavior.A long-term therapeutic relationship with the patient increases the opportunity to make clinical observations that assist in making the differential diagnosis.Within this context, clinicians can better understand the relationships between the AOD use and the psychiatric symptoms.

Collateral Resources

As previously mentioned, data obtained from direct interviews and self-reports, as well as observational data, are limited. One important way of augmenting these approaches is to obtain information from collateral sources by directly interviewing family members and significant others about the psychiatric and AOD-related behavior of patients. The family interview can also be a useful means to obtain further information regarding family history of psychiatric and AOD use disorders.

Other collateral information can include available documentation such as medical and criminal justice records, as well as information gathered from othersources such as landlords, housing settings, social services, and employers. Case managers may be in a unique position to compile aggregate reports from these various sources, since they are able to follow these patients over an extended period of time in a variety of settings.

Laboratory Tests

Laboratory tests for drug detection can be valuable both in documenting AOD use and in assessing AOD use in relation to psychotic symptoms. Objective urine and blood toxicology screens and alcohol Breathalyzer tests can be useful. Data from urine screens may be particularly useful for patients who deny regular use of AODs and who may benefit from objective feedback about the presence or absence of AOD use. Toxicology screens that document an absence of drug use can provide positive feedback for abstinent patients who are actively working to maintain sobriety.

Liver function tests have limited assessment value, particularly for patients ingesting large amounts of alcohol. However, the absence of abnormal liver findings should not be used as an indication of nonproblematic alcohol use.

Social Issues

While psychiatric, medical, or AOD-induced disorders may be more visible to the clinician than social problems, the latter can contribute significantly to the emergence and maintenance of these disorders. Indeed, the psychotic patient with dual disorders is more likely than not to have significant impairment in the social area. Thus, identifying the problem areas of a specific patient's social life becomes a core component of the service or treatment plan.

Actively helping patients to secure basic needs is a powerful way to engage them in the treatment process. Patients with dual disorders frequently face problems with living conditions, employment, homelessness, housing instability, loss of social support systems, and nutrition. The frustration and emotional turmoil that accompany problems in these areas can be intense.Indeed, many cases of treatment failure that are perceived as resistance to treatment and denial actually represent the failure of the treatment provider to recognize the impact of a patient's deteriorated social situation and to help the patient gain access to services.

In addition to social needs, clinicians should be aware of and sensitive to the impact of race, culture, ethnicity, nationality, gender issues, sexual orientation, and sexual history upon the lives of their patients.

Primary Health Care

A current or recent comprehensive medical evaluation is an essential aspect of the overall assessment. Nonmedical clinical personnel should become familiar with patients' medical histories and specifically inquire about the possible relationship between existing medical conditions and presenting symptoms.

Meeting the medical needs of patients with psychiatric and AOD use disorders is a critical aspect of treatment.For patients with psychotic disorders, attention to medical needs is even more important, since they generally have a high prevalence of medical problems, including chronic medical problems that are frequently untreated or undertreated.

During long-term treatment, it is important to evaluate the relationships between patients' medical problems and their psychotic and AOD use disorders. For example, medical problems may: 1) coexist with psychotic and AOD use disorders, 2) prompt or exacerbate psychotic and AOD use disorders, or 3) be the direct or indirect result of psychotic and AOD use disorders.

It is especially important for these patients to have easy access to treatment for medical conditions that are strongly associated with AOD use, such as tuberculosis, hepatitis, and HIV/AIDS.In addition, they should have easy access to treatment for basic medical needs, such as diabetes and hypertension, as well as cardiovascular, respiratory, and neurological disorders. Attention should be provided for the pregnant woman with regard to prenatal care and ongoing monitoring of pregnancy. The pregnant woman may be especially at risk for relapse when her regular antipsychotic medication regimen is contraindicated.

In addition to medical treatment, patients with dual disorders that involve psychosis need basic education about fundamental health care, hygiene, and AIDS prevention. A program that serves patients with dual disorders should include basic medical education components on site as a routine part of treatment, rather than referrals to another agency.

For patients who are prescribed medications, it is important to assess the types of medications, whether or not the medications are being taken, and the types of side effects they may cause. Patients should be asked specifically about the frequency, dosage, and duration of any prescription medication.

Medication noncompliance is the rule, not the exception, for people with dual disorders.Psychiatric medication noncompliance is particularly associated with dual disorders that involve psychosis, causing significant impact on presenting symptoms and level of function. Because of this common associationbetween AOD use and noncompliance and the limitation of self-reports, it is useful to complement this assessment with an assessment of serum drug levels of psychiatric medications.

In addition to considering AOD use as a primary factor that affects the use of psychiatric medications, it is also important to consider the potential role of psychiatric medications in subsequent AOD use. For example, side effects such as akathisia (severe restlessness) or sedation may be caused by antipsychotic medications, and patients may take AODs in an attempt to medicate these unwanted side effects.

Frequently, psychoactive substances become replacements for adequate and nutritious food. Nutritional impairment is associated with impaired cognition. A lack of regular meals and poor nutrition are common occurrences among patients with dual disorders; thus, access to regular meals should be assessed.

Also, acute dental problems as well as ongoing dental care should be assessed.Because this group frequently experiences financial difficulties, access to dental care is often limited or nonexistent. Attention should be given to the social and emotional consequences of poor dental health, such as poor self-esteem and diminished social interaction.

Treatment Issues

The most important initial step in treatment is to identify high-risk conditions that require immediate treatment, while recognizing that there will likely be important issues that require long-term management.

Acute Management

Within the area of acute management, it is useful to differentiate between acute management of crises and the resolution of subacute problems that may be severe but not life threatening.

High-Risk Conditions

The initial critical consideration for high-risk conditions is to determine if patients require emergency medical treatment, psychiatric treatment, or both. The critical decision is whether patients require hospitalization, and if so, what type of treatment is required (for example, primary health care, detoxifi-cation, or psychiatric care). This aspect of treatment necessarily involves medical assessment and intervention.

With regard to biological or medical issues, the priority is addressing and stabilizing the acute crisis ina hospital-based setting. Once the acute crisis has been stabilized, mental health and AOD use consultation may be necessary to address the concomitant psychiatric and AOD disorders.

With regard to high-risk psychological conditions (that is, danger to self or others and other violent and impulsive behavior), the initial focus is on stabilizing the acute psychological crisis?providing that acute medical causes have been ruled out. Stabilization may require acute involuntary psychiatric hospitalization. Thus, coordination with emergency mental health services and the local police department is necessary to ensure the immediate safety of the patient and others.

With regard to high-risk social conditions (homelessness, housing instability, victimization, and unmet basic needs), the priority is on implementing aggressive social crisis intervention. Meeting patients' basic needs is critical in the management of the treatment of dual disorders that include psychosis. The high-risk social conditions may be related to the medical or psychiatric crisis, and therefore will require followup upon hospital discharge.

Regardless of the priority of crisis intervention, the overall biopsychosocial needs of patients must be addressed in a holistic manner, considering both the psychosis and the AOD use disorder. The approach must be integrated and comprehensive despite the higher visibility of one of the disorders.

Subacute Conditions

Following the resolution of the acute crisis, subacute conditions must be addressed before long-term management can occur. (Subacute conditions can also occur as a precursor to acute relapse of psychiatric symptomatology or AOD use.) Examples of specific subacute management issues include resuming or adjusting psychotropic medication, patients' comfort with the medication, medication compliance, addressing acute psychiatric symptoms, establishing early AOD use treatment intervention, and establishing or sustaining patients' connection with support systems and services for obtaining housing and meeting basic needs.

The subacute phase allows for an opportunity to reassess the diagnosis and overall treatment needs. The ultimate goal should be to establish a long-term treatment plan, to avert imminent decompensation or relapse, and to address long-term needs.

Long-Term Management

The overall goal of long-term management should involve: 1) providing coordinated and integratedservices for both the psychiatric and AOD use disorders, and 2) doing so with a long-term focus that addresses biopsychosocial issues.

Patients with severe or persistent psychiatric and AOD use disorders, such as Thomas, require dually focused, integrated treatment. Patients like Martha, who have mild or brief symptoms of mental illness, may benefit from parallel treatment or self-help. Patients with AOD-induced psychiatric symptoms similar to Laura's should receive long-term management and treatment by AOD abuse treatment providers. Irrespective of the treatment setting, the goal is to help patients with dual disorders gain control over their psychiatric and AOD use disorders.

Gaining such control is a long-term process.For this group, the initial expectation during the engagement period should not be immediate compliance with psychiatric treatment or immediate abstinence.Indeed, mandating these treatment prerequisites may interfere with access to services or lead to the patient's rejection of the treatment services. Abstinence from AOD use is the long-term goal for patients with dual disorders that involve psychosis, but should not be a prerequisite for offering or continuing treatment services.

Therapeutic Engagement

The first step in the long-term treatment of patients with dual disorders that involve psychosis is to engage them in the treatment process. The basis of therapeutic engagement is building a relationship with patients. Engagement is a long-term process, not a single event that occurs only during the initial stages of treatment.The engagement process may need to be revisited throughout the course of treating these two unremitting disorders.

Frequently, patients with dual disorders do not acknowledge or appreciate that AOD use or a psychiatric disorder is a problem in their lives. Hence, establishing a relationship with these patients may first require knowing what they want and need. They may not want AOD treatment or psychiatric services. Rather, they may best be engaged by offering them assistance to meet their basic needs such as housing or entitlements or by providing basic medical and legal services.

A variety of approaches can be used to facilitate the engagement process. These include assertive outreach by case managers and clinicians, offering to facilitate the acquisition of basic services and entitlements and help with legal services. Similarly, engagement may be facilitated through involvement with alternative social and recreational activities, programs, clubs, and drop-in centers.

Engagement techniques can include the therapist's involvement with the family and other significant parties. Indeed, at times, clinicians may be able to maintain contact with patients only through the family.

Patients often want help finding and keeping a job. Thus, engagement includes vocational rehabilitation.

For patients who have particularly severe psychiatric or AOD use disorders and do not respond to these initial attempts at engagement in the treatment process, the use of therapeutic coercive approaches may be necessary. Patients with severe dual disorders may have gross cognitive impairment due to AOD use and may be severely disorganized due to psychiatric illness. They may be impulsive, exhibit extremely poor judgment, or be chronically dangerous to themselves or others.

Without therapeutic coercive interventions, some of these patients may be at substantial risk of catastrophic outcomes, including death, injury, violent behavior, or long-term incarceration. Examples of therapeutic coercive approaches include the appointment of a representative payee, guardian, or conservator and the use of parole or probation. Legal advocacy by a case manager for court-mandated treatment services may be essential for engaging and maintaining treatment services. Other mechanisms include commitment to outpatient treatment services, conditional discharge, and commitment to appropriate inpatient dual disorder treatment.

Therapeutic coercive efforts should be temporary and reserved for patients who have failed with other interventions. The long-term goal for these patients is to regain control over their lives. As mentioned above, service providers have traditionally expected patients to be motivated before initiating treatment. They have often misinterpreted the lack of engagement as denial or resistance to treatment.

It is essential for treatment professionals to understand that the provider is responsible for motivating or providing incentives for the patient to engage and remain in treatment.

Concurrent and Integrated Dually Focused Treatment

Service providers in traditional treatment programs have often maintained that patients with dual disorders should be treated sequentially, that is, by treating the AOD use disorder before treating the psychiatric disorder, or vice versa. Rather, there should be an ongoing dual focus on both disorders, especially for patients with psychosis or AOD use disorders.

Particularly for the severely disorganized patient or for the patient with persistently disabling conditions, integrated treatment is essential. Ideally, the services should be integrated within the same agency and program.

When mental health and addiction treatment services are not integrated, fragmentation of services and discontinuous service are significant risks. In situations where services cannot be integrated, it is crucial for one provider to accept full responsibility for the patient and to aggressively coordinate service with other programs and services. For treatment to be effective, and to ensure continuity of care, a long-term relationship and treatment approach should be developed.

For patients with milder psychiatric symptoms, parallel treatment approaches such as concurrent psychiatric and AOD treatment may be helpful, although such approaches have the disadvantage of placing the burden of integrating different treatment options on patients. This burden should be minimized by a case manager or clinician who can provide appropriate clinical liaison between different agencies.

Engaging the Chronically Psychotic Patient

Noncoercive Engagement Techniques Coercive Engagement Techniques
  • Assistance obtaining food, shelter, and clothing
  • Assistance obtaining entitlements and social services
  • Drop-in centers as entry to treatment
  • Recreational activities
  • Low-stress, nonconfrontational approaches
  • Outreach to patient's community.
  • Involuntary commitment
  • Mandated medications
  • Representative payee strategies

Long-Term Perspective

For patients with dual disorders involving psychosis, a long-term approach is imperative. Research has shown that individuals become abstinent and gain control over psychiatric symptoms through a process that frequently takes years, not days or months. Front-loaded, intensive, expensive, and highly stimulating short-term treatment modalities are likely to fail with this group of patients.

Both psychotic and AOD use disorders tend to be chronic disorders with multiple relapses and remissions, supporting the need for long-term treatment. Also, an accurate diagnosis and an assessment of the role of AODs in the patient's psychosis necessitate a multiple-contact, longitudinal assessment and treatment perspective.

Treatment Teams

Especially for programs that treat patients with psychotic and AOD use disorders, it is essential that the program philosophy be based on a multidisciplinary team approach. Ideally, team members should be cross-trained, and there should be representatives from the medical, mental health, and addiction systems. Staff members should learn to use gentle or indirect confrontation techniques with these patients.

Assertive Case Management

Team members should endorse an assertive case management approach, wherein the case manager is not limited to the treatment site, but is expected to provide services to patients in their own environments. The case manager must not attempt to solely broker treatment services or exclusively provide office-based treatment.A supportive and psychotherapeutic approach to individual, group, and family work should be employed.

For these patients, flexible hours are necessary.Because crises frequently occur during evening and weekend hours, services should be provided during these hours. In addition, alternative social activities and peer group activities often take place in the evening and on weekends.

Also, individual and group programs for patients with dual disorders that involve psychosis should be based on a behavioral and psychoeducational perspective, not a psychodynamic approach. Educational information should be frequently repeated and presented in concrete terms using a multimedia format. Programs should be modified to include frequent breaks and shorter sessions than normal.

Special care should be taken with regard to patient education and group discussion about Higher Power issues. Staff members should be trained to teach patients and lead group discussions about spiritualityand the concept of a Higher Power. Staff members should understand the difference between spirituality and religion, and especially the differences between spirituality, religion, and delusional systems that have a religious or spiritual content.

Personalized Service Planning

It is essential that the treatment plan for each patient be personalized, and based on the specific needs and stated goals of the patient, rather than on the clinician's goals. The patient should participate in the ongoing review and evaluation of the treatment plan.

Associated Psychosocial Needs

Even intensive, carefully designed AOD abuse treatment is likely to fail if the extensive psychosocial problems associated with dual disorders are not concurrently addressed. Common psychosocial concerns of this group include housing, finances and entitlements, legal services, job assistance, and access to adequate food, clothing, and medication.

Housing

A particularly common complication of dual disorder patients with psychosis is housing instability and homelessness. Among the possible housing services that may be particularly useful are shelters, supervised housing settings, congregated living settings, treatment milieu settings, and therapeutic communities. Ideally, residential options and placements should be long term, with the goal of promoting independent, stable, and safe housing.

Despite the long-term goal of sobriety, the housing needs of patients with chronic psychosis and AOD use disorders may be met temporarily by housing that is not explicitly drug free. Shelters or other forms of temporary housing that are not explicitly drug free but provide basic safety from weather and violence are better than no housing at all.

Various housing settings are necessary, including housing for current AOD-using individuals ("wet" or "damp" housing setting) and settings for individuals who are abstinent. Although there is a need for this broad range of housing, many communities do not currently have it. Within this range of agency-supported housing, there should be explicit policies regarding AOD use, understood by both the patient and the clinician.

It is also critical for treatment programs to have easy access to housing for patients with special needs, such as women and children, pregnant women, and battered women. Specific housing should be developed for patients with specialized, ongoingmedical and psychological needs associated with complications of serious medical conditions such as AIDS.

Vocational Services

Vocational services are also essential for the long-term stabilization and recovery of the dual disorder patient. Both AOD and mental health services have traditionally referred clients to generic vocational rehabilitation services. These services must be integrated and modified for the specialized needs of the individual with psychosis and AOD use disorders. Temporary hire placements and job coaching options are important elements to incorporate into rehabilitation services for this group.

Sober Support Groups

An essential part of treatment for patients with dual disorders is the development of alternative peer group settings that do not include drug use. Developing these non-AOD-using social networks can be enhanced by programs that provide social club activities, recreational activities, and drop-in centers on site, as well as linkages to other community-based social programs. At the same time, patients should be encouraged to establish and maintain relationships, including family relationships, that are supportive of treatment goals.

Family

Treatment of the dual disorder patient can be substantially supported and enhanced by direct involvement of the patient's family. Services can include family psychoeducational groups that specifically focus on education about AOD use disorders and psychosis.This also includes multifamily treatment groups that may include the individual with the dual disorder.

Families may also be helpful in identifying early signs of psychiatric or AOD use relapse symptoms. They can work with the treatment team in initiating acute relapse prevention and intervention. Confidentiality issues need to be addressed at the beginning of treatment, with the goal of identifying a significant support person who has the patient's permission to be involved in the long-term treatment process.

Relapse Prevention

An essential component of relapse prevention and relapse management is close monitoring of patients for signs of AOD relapse and a return of psychoticsymptoms. Relapse prevention also includes closely monitoring the development of patients' AOD refusal skills and their recognition of early signs of psychiatric problems and AOD use. The goals of relapse prevention are: 1) identification of patients' relapse signs, 2) identification of the causes of relapse, and 3) development of specific intervention strategies to interrupt the relapse process.

Close monitoring involves the long-term observation of patients for early signs of impending psychiatric relapse. Such signs may include the emergence of paranoid symptoms and symptoms related to AOD use such as hostile or disorganized behavior. For example, a sign of paranoid symptoms may be the patient's sudden and constant use of sunglasses. Additional important clues may involve changes in daily routine, changes in social setting, loss of daily structure, irritation with friends, and rejection of help. Family members who reside with the dual disorder patient are often the first to detect early signs of psychotic or AOD use relapse.

Additional signs of possible psychotic or AOD relapse include eviction from housing, job loss, or involvement with the criminal justice system. It is important that the clinician understand that routine daily stressors may have an intense impact on the dually diagnosed patient and may prompt relapse.

Objective laboratory tests may also be particularly useful in detecting early risk of AOD relapse.This includes the use of random urine toxicology screens, the alcohol Breathalyzer test, and blood tests to detect street drugs. As medication noncompliance is strongly associated with both AOD use and psychotic relapse, blood medication levels (including antipsychotic and lithium levels) may be particularly useful.Finally, intramuscular forms of antipsychotic medications may be particularly useful for verifying and assuring long-term compliance with antipsychotic medications.

In addition to close monitoring by health care professionals, family members, and significant others, an important component of relapse prevention is assisting the dual disorder patient to develop skills to anticipate the early warning signs of psychiatric and AOD use disorders. These skills can be acquired through direct individual psychoeducation and participation in role play exercises and psychoeducation groups. These patients should be trained to use AOD refusal skills and to recognize situations that place them at risk for AOD use.

Similarly, these patients may benefit significantly from behavioral therapy; development of relaxation, meditation, and biofeedback skills; exercise; use of visualization techniques; and use of relapse prevention workbooks. Pharmacologic strategies may include the use of disulfiram or naltrexone for certain patients.

Group Treatment

Group process is a core element of AOD abuse and mental health treatment. However, for patients with psychosis, group treatment should be modified and provided in coordination with a comprehensive service plan.The different types of groups specifically designed for the dual disorder patient include persuasion groups, active treatment groups, dual disorder-oriented 12-step groups (Double Trouble groups), pre-12-step groups, and groups that focus on medication and anger management.

Groups that are specifically designed for dual disorder patients are essential during the early phases of treatment.Patients who have accepted the goal of abstinence, have maintained psychiatric stability, and have essential social skills may benefit from carefully selected traditional 12-step programs that are sensitive to the needs of the severely mentally ill. However, during the early phases of treatment, an unfacilitated referral to traditional 12-step programs will likely result in treatment failure. (See the discussion on the use of the 12-step programs in Chapter 6.) A wide variety of group settings may be useful for the person with a dual disorder. However, the core approach should include psychoeducational, supportive, behaviorally oriented, and skill-building activities.

Medication

With patients who have dual disorders that involve psychosis, a common provider mistake that often leads to psychiatric or AOD use relapse involves a lack of attention to medication issues. Most important, treatment programs must provide aggressive treatment of medication side effects. Ignoring the side effects of prescribed medication often results in patients using AODs to diminish the unwanted medication side effects.

Equally important, patients should be educated and thoroughly informed about: 1) the specific medication being prescribed, 2) the expected results, 3) the medication's time course, 4) possible medication side effects, and 5) the expected results of combined medication and AOD use. Whenever possible, family members and significant others should be educated about the medication.

Medication should not simply be prescribed or provided to the psychotic patient with dual disorders.Rather, it is critical to discuss with patients 1) their understanding of the purpose for the medication, 2) their beliefs about the meaning of medication, and 3) their understanding of the meaning of compliance. It is important to ask patients what they expect from themedication and what they have been told about the medication. Overall, it is important to understand the use of medication from the patient's perspective. Indeed, informed consent relative to a patient's use of medication requires that the patient have a thorough understanding of the medication as described above.

It is also important to help patients prepare for peer reaction to the use of medication when they participate in certain 12-step programs. Patients should be taught to educate other people who may have biases against prescription medications or who may be misinformed about antipsychotic medications.

Patients receiving medication should participate in professionally led medication education groups and medication-specific peer support groups. These groups will help patients deal with the emotional and social aspects of medication, promote medication compliance, and help clinicians and patients identify and address early noncompliance and side-effect problems.

Overall, there must be a specific and aggressive treatment strategy that helps make medication use simple and comfortable. The scheduling and administration of medication should be simple and convenient for patients.The ideal schedule for oral medications is once per day. The use of injectable medications may be the most comfortable and effective option for some patients with dual disorders.

Anything that helps patients feel more comfortable about taking medication should be considered. In addition, an important treatment goal is a medication regimen that is self-monitoring.

When patients experience difficulty acquiring medication, the treatment program should directly help patients acquire them, not make referrals and recommendations.

Staff and Administrative Training

Traditional training in mental health and AOD abuse treatment, and in medicine in general, has been inadequate relative to the unique needs of the dual disorder patient. Thus, program staff require ongoing education about current understanding and treatment of dual disorders. It is imperative that the service principles of each discipline be presented and modified for application to people with dual disorders. Training also must be integrated, not sequential or parallel.

Perhaps the most important goal of clinical staff development and training is the cross-training of addiction and mental health personnel. Addiction specialists need training in psychiatric and mental health issues, while mental health and psychiatric specialists need training in AOD and addiction issues.In addition to cross-training, both addiction and mental health clinical staff require clinical and theoretical training in dual disorders.

Clinical staff training content must include information about the assessment and treatment of high-risk and subacute problems and about long-term treatment issues. There must be a focus on the interaction between AOD use and psychiatric symptoms. In addition, attention must be given to high-risk behaviors such as violence to self or others, suicide, impulsive behavior, and high-risk sexual behavior.

Clinical staff training must also address less obvious clinical issues such as cultural competency and sensitivity to the roles of culture, ethnicity, nationality, religion, and spirituality.

While 1- or 2-day workshops may be useful for disseminating clinical information, ongoing and routine education is critical. To emphasize the multidisciplinary team approach, staff education should be done in a group setting with interaction among group participants and trainers.

The need for clinical supervision among clinical staff is crucial. Supervision must be an ongoing, routine process, not driven by clinical crises. Nonetheless, because treatment of dual disorders involves frequent crises, the clinical supervisor must be readily available to team members and able to provide rapid coaching and support.

An important aspect of clinical supervision and clinical staff development is education in the theoretical basis of treatment. Irrespective of disciplines, all clinical staff must thoroughly understand and support the philosophical basis, values, and goals of the treatment program in which they work. Further, an important task of the clinical supervisor is to integrate the formal theory and principles within the specific treatment setting.

Clinical staff education and development must include the formation of procedures and supports to prevent staff burnout and demoralization. Components of staff burnout prevention include mechanisms for multidisciplinary group support, a focus on long-term rather than short-term gains for patients, anticipation and expectation of relapse as part of psychotic and AOD use disorders, and an understanding of relapse as a treatment opportunity rather than a treatment failure.

Program administrators, whether they are in contact with patients or not, require clinical education in dual disorder issues to provide an appropriate environment for the treatment of patients with dual disorders and to better understand the needs of staff and patients. Thus, program administrators require education in the latest conceptual and technologicaldevelopments in the fields of psychiatry and AOD treatment as well as in dual disorders.

It is important for program administrators to regularly review, articulate, and discuss the program's philosophy, goals, and objectives with all program staff. Enhanced and open communication between administration and staff in both individual and group settings is also critical. For example, administrators should regularly communicate with staff regarding administrative constraints such as financial limitations, legal mandates, and political influences.

Administrators should thoroughly understand the appropriate role of clinical supervision: that thissupervision is designed for skill enhancement and staff support. Clinical supervision skills are critical for providing effective services to high-risk populations such as patients with psychotic and AOD use disorders.

There should be open discussion of administrative styles, since these significantly affect staff morale and performance. Similarly, administrators should be aware of the influence of their personal characteristics upon staff and patients. For example, administrators should become aware of the influence that their culture, ethnicity, gender, sexual orientation, and background has on others.


Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits