TIP 9: Coexisting Conditions
Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse

[Front Matter]

[Title Page]

Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse Treatment Improvement Protocol (TIP) Series 9
 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857DHHS Publication No. (SMA) 95-3061
Printed 1994. Reprinted 1995.


[Disclaimer]

This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.

This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Anna Marsh, Ph.D., and Sandra Clunies, M.S., served as the Government project officers. Elayne Clift, M.A., Carolyn Davis, Joni Eisenberg, Mim Landry, and Janice Lynch served as writers.

The opinions expressed herein are those of the consensus panel participants and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions.

DHHS Publication No. (SMA) 95-3061. Printed 1994. Reprinted 1995.

What Is a TIP?

CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources.

The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice.

Once a topic has been selected, CSAT creates a Federal Resource Panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic. This group, known as a non-Federal Consensus Panel, meets in Washington for 3 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus.

The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the Chair approves the document for publication. The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment.

This TIP, titled Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug (AOD) Abuse, provides practical information about the treatment of patients with dual disorders, including the treatment of AOD patients with mood and anxiety disorders, personality disorders, and psychotic disorders. This TIP also provides pragmatic information about systems and linkage issues relative to the AOD and mental health treatment systems. There is also a discussion about pharmacologic management of patients with dual disorders.

This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment.

Consensus Panel

Richard K. Ries, M.D., Chair

Director

Inpatient Psychiatry and Dual Disorder Programs

Harborview Medical Center

Seattle, Washington

Facilitators:

Marcelino Cruces, L.C.S.W.

Administrative Coordinator

Andromeda Transcultural Mental Health Center

Substance Abuse Treatment Division

Washington, D.C.

Mary Katherine Evans, C.A.D.C., N.C.A.C. II

Program Director

Evans and Sullivan

Beaverton, Oregon

James Fine, M.D.

Director

Addictive Disease Hospital at Kings County Hospital Center

Clinical Associate Professor

Department of Psychiatry

State University of New York

Health Service Center at Brooklyn

Brooklyn, New York

Bonnie Schorske, M.A.

Coordinator

Special Populations

New Jersey Division of Mental Health and Hospitals

Trenton, New Jersey

Workgroup Members:

Stephen J. Bartels, M.D.

Medical Director

West Central Services, Inc.

Research Associate

New Hampshire-Dartmouth Psychiatric Research Center

Lebanon, New Hampshire

Dolores Burant, M.D.

Program and Medical Director

University Outpatient Recovery Service

Madison, Wisconsin

Agnes Furey, L.P.N., C.A.P.

Primary Care Coordinator

Florida Alcohol and Drug Abuse Program

Department of Health and Rehabilitation Services

Tallahassee, Florida

Malcolm Heard, M.S.

Director

Division on Alcoholism and Drug Abuse

Nebraska Department of Public Institutions

Lincoln, Nebraska

Norman Miller, M.D.

Associate Professor of Psychiatry

Chief, Addiction Programs

Department of Psychiatry

University of Illinois at Chicago

Chicago, Illinois

Ernest Quimby, Ph.D.

Assistant Graduate Professor

Howard University

Department of Sociology and Anthropology

Washington, D.C.

Henry Jay Richards, Ph.D.

Associate Director for Behavioral Sciences

Patuxent Institution

Jessup, Maryland

Candace Shelton, M.S., C. A.C.

Clinical Director

Pascua Yaqui Adult Treatment Home

Tucson, Arizona

Virginia Stiepock, A.C.S.W, R.N., C.S.

Assistant Center Director

Clinical Director

Northern Rhode Island Community Mental Health Center

Woonsocket, Rhode Island

Mathias Stricherz, Ed.D., C.D.C. III

Director

Student Counseling Center

University of South Dakota

Vermillion, South Dakota

Patricia M. Weisser

National Association of Psychiatric Survivors

Sioux Falls, South Dakota

Joan Ellen Zweben, Ph.D.

Executive Director

The East Bay Community Recovery Project

The 14th Street Clinic and Medical Group

Berkeley, California

Foreword

The Treatment Improvement Protocol Series (TIPs) fulfills CSAT's mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel's work is reviewed and critiqued by field reviewers as it evolves.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. I am grateful to all who have joined with us to contribute to advance our substance abuse treatment field.

Susan L. Becker

Associate Director for State Programs

Center for Substance Abuse Treatment

Chapter 1 --Introduction

Overview

The treatment needs of patients who have a psychiatric disorder in combination with an alcohol and other drug (AOD) use disorder differ significantly from the treatment needs of patients with either an AOD use disorder or a psychiatric disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations for the treatment of patients with dual disorders.

This TIP was developed by a multidisciplinary consensus panel that included addiction counselors, social workers, psychologists, psychiatrists, other physicians, nurses, and program administrators with active clinical involvement in the treatment of patients with dual disorders. Consumers also participated on the panel.

This TIP was written principally for addiction treatment staff. However, it contains information and treatment recommendations that can be used by healthcare providers in a variety of treatment settings. For example, it will be useful to people who work in primary care clinics, hospitals, and various mental health settings. In addition, there are recommendations that are targeted to administrators and planners of healthcare services.

A thoughtful attempt has been made to include information that the consensus panel felt was clinically relevant. While many clinical topics are explored in depth, some are only briefly mentioned, and a few are avoided altogether.

It is not the goal of this TIP to provide an exhaustive description of all of the possible issues that relate to the treatment of patients with dual disorders. Rather, the primary goal is to provide treatment recommendations that are practical and useful.

Indeed, the usefulness of this TIP can be enhanced by blending these recommendations with those of another TIP such as Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse.By doing so, treatment protocols can be developed which will meet very specific treatment needs.

Contents

Definitions and Models

Chapter 2 -- Dual Disorders: Concepts and Definitions -- provides descriptions and diagnostic criteria for AOD abuse and dependence. There is also a description of the possible interactions between AOD use and psychiatric symptoms and disorders.

Chapter 3 -- Mental Health and Addiction Treatment Systems: Philosophical and Treatment Approach Issue -- describes the similarities, differences, strengths, and weaknesses of the treatment systems used by patients with dual disorders: the mental health system, the addiction treatment system, and the medical system. Similarly, there is a description of treatment models most frequently used: sequential treatment of each disorder, parallel treatment of each disorder, and integrated treatment of both disorders. The chapter includes a discussion of critical treatment issues and general assessment issues in providing care to patients with dual disorders.

Linkages

Chapter 4 -- Linkages for Mental Health and AOD Treatment -- describes several areas of critical concern for programs that provide services to patients with dual disorders. There are discussions regarding policy and planning; funding and reimbursement; data collection and needs assessment; program development; screening, assessment, and referral; case management; staffing and training; and linkages with social service, health care, and the criminal justice systems.

This chapter should be particularly useful for administrators and political planners who address the potential administrative overlaps and gaps that exist between the mental health and addiction treatment systems. The semi-outline format of the chapter will allow planners of services a rapid checkup of specific areas such as funding and reimbursement, program development, and case management.

Specific Psychiatric Disorders

While entire books can be written regarding specific psychiatric disorders, this TIP describes the disorders that account for the majority of psychiatric problems seen in patients with dual disorders. TIP chapters that address specific psychiatric problems include Chapter 5, Mood Disorders; Chapter 6, Anxiety Disorders; Chapter 7, Personality Disorders; and Chapter 8, Psychotic Disorders.

By combining chapters, strategies for treating patients with complex disorders may be developed. For example, by combining techniques recommended for the treatment of personality and mood disorders, borderline syndrome treatment strategies can be developed.

Both content and stylistic approaches vary markedly among these chapters, reflecting the differences of consensus panel members who composed them. Since these differences in stylistic approaches may be useful to the reader, they have been retained.

Psychopharmacology

Chapter 9 -- Pharmacologic Management -- is a brief overview of the types of medications used in psychiatry and addiction medicine and for patients with dual disorders. A stepwise treatment model that can minimize medication abuse risks is discussed, and cautions about drug interactions are reviewed.

Addiction treatment program staff are increasingly encountering patients who require prescribed medications in order to participate in recovery. For this reason, it is important for clinical staff to have an understanding of the principle medications used in psychiatry and how they are used. In addition, agencies that hire a consulting psychiatrist may want to review with the psychiatrist the prescribing issues raised in this chapter.

A bibliography is provided for further study in Appendix A. A brief overview of sample cost data for the treatment of dual disorders is in Appendix B. It compares three treatment programs on features such as salary ranges and administrative costs.

Chapter 2 -- Dual Disorders: Concepts and Definitions

The Relationships Between AOD Use and Psychiatric Symptoms and Disorders

Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders.

There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process.

The primary relationships between AOD use and psychiatric symptoms or disorders are described in the following classification model (Landry et al., 1991a; Lehman et al., 1989; Meyer, 1986). All of these possible relationships must be considered during the screening and assessment process.

The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete "recovery" from AOD addiction. Psychiatric disorders may interfere with patients' ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines.

For example, patients with anxiety and phobias may fear and resist attending Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated and lethargic to participate in treatment. Patients with psychotic or manic symptoms may exhibit bizarre behavior and poor interpersonal relations during treatment, especially during group-oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse.


AOD Use and Psychiatric Symptoms


The Terminology of Dual Disorders

The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and AOD problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP).

The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).

Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders.

The combinations of AOD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. For instance, some methadone treatment programs treat a high percentage of opiate-addicted patients with personality disorders. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients.

Patients with mental disorders have an increased risk for AOD disorders, and patients with AOD disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience AOD abuse at some point (Regier et al., 1990), which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse AODs have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder (Regier et al., 1990; Ross et al., 1988), although many of these symptoms may be AOD related and might not represent an independent condition.

Compared with patients who have a mental health disorder or an AOD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both AOD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.

Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders. Each of these clusters of disorders and symptoms is dealt with in more detail in separate chapters.

AOD Abuse, Addiction, Dependence, Misuse

The characteristic feature of AOD abuse is the presence of dysfunction related to the person's AOD use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), produced by the American Psychiatric Association and updated periodically, is used throughout the medical and mental health fields for diagnosing psychiatric and AOD use disorders. It provides clinicians with a common language for communicating about these disorders and for making clinical decisions based on current knowledge. For each diagnosis, the manual lists symptom criteria, a minimum number of which must be met before a definitive diagnosis can be given to a patient.

Criteria for AOD abuse hinge on the individual's continued use of a drug despite his or her knowledge of "persistent or recurrent social, occupational, psychologic, or physical problems caused or exacerbated by the use of the [drug]" (American Psychiatric Association, 1987). Alternately, there can be "recurrent use in situations in which use is physically hazardous." The DSM-IV draft continues this emphasis (American Psychiatric Association, 1993).

Thus, AOD abuse is defined as the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning. AOD abuse may or may not involve physiologic dependence or tolerance. Importantly, evidence of physiologic dependence and tolerance is not sufficient for diagnosis of AOD abuse. For example, use of AODs in weekend binge patterns may not involve physiologic dependence, although it has adverse effects on a person's life.


AOD Abuse


Therefore, screening questions should relate to life problems that result from AOD use, taking into consideration that patients may not have the insight to perceive that their life problems are caused by AOD abuse.

The phrase AOD addiction (called "psychoactive substance dependence" in the DSM-III-R and "substance dependence" in the DSM-IV draft) is an often progressive process that typically includes the following aspects: 1) compulsion to acquire and use AODs and preoccupation with their acquisition and use, 2) loss of control over AOD use or AOD-induced behavior, 3) continued AOD use despite adverse consequences, 4) a tendency toward relapse following periods of abstinence, and 5) tolerance and/or withdrawal symptoms.


AOD Addiction or Dependence


The DSM-III-R describes nine diagnostic criteria (shown in Exhibit 2-1), of which three or more must be present for a month or more to establish a diagnosis of dependence. Screening questions can be based on these criteria. The DSM-IV draft committee deleted DSM-III-R criterion 4 and the requirement of symptoms being present for at least 1 month. The DSM-IV draft emphasizes the symptoms of tolerance and withdrawal, which the draft committee placed at the top of the list of criteria.

In the DSM-III-R, criteria 1 and 2 deal with loss of control; criterion 3 addresses time involvement; criteria 4 and 5 relate to social dysfunction; criterion 6 relates to continued use despite adverse consequences;and criteria 7, 8, and 9 relate to the development of tolerance and withdrawal. It is important to note that tolerance, physiologic dependence, and withdrawal are neither necessary nor sufficient for the establishment of a diagnosis of AOD addiction.

The term AOD dependence can be confusing because it has multiple meanings. The DSM-III-R uses the phrase "psychoactive substance dependence" to describe the process of addiction, while many pharmacologists use the term "dependence" exclusively for describing the biologic aspects of physical tolerance and/or withdrawal. The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychologic dependence and 2) physical dependence.

Psychologic dependence centers on the user's need of a drug to reach a level of functioning or feeling of well-being. Because this term is particularly subjective and almost impossible to quantify, it is of limited usefulness in making a diagnosis.

Physical dependence refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of AOD use. In this case, AOD type, volume, and chronicity are the important variables: Given a certain substance, the higher the dose and longer the period of consumption, the more likely is the development of tolerance, dependence, and subsequent withdrawal symptoms. Physical dependence and tolerance are best understood as two of many possible consequences (which may or may not include addiction and abuse) of chronic exposure to psychoactive substances.

Among patients with a psychiatric problem, any AOD use -- whether abuse or not -- can have adverse consequences. This is especially true for patients with severe psychiatric disorders and patients who are taking prescribed medications for psychiatric disorders. For patients with psychiatric disorders, the infrequent consumption of alcohol can lead to serious problems such as adverse medication interactions, decreased medication compliance, and AOD abuse. Screening questions can relate to evidence of any use of alcohol and other drugs, as well as frequency, dose, and duration.

Medication misuse describes the use of prescription medications outside of medical supervision or in a manner inconsistent with medical advice. While medication misuse is not an abuse problem per se, it is a high-risk behavior that: 1) may or may not involve AOD abuse, 2) may or may not lead to AOD abuse, 3) may represent medication noncompliance and promote the reemergence of psychiatric symptoms, and 4) may cause toxic effects and psychiatric symptoms if it involves overdose.

Thus, some patients may consume medications at higher or lower doses than recommended or in combination with AODs. Also, certain patients may respond to prescribed psychoactive medications by developing compulsive use and loss of control over their use.

Chapter 3 -- Mental Health And Addiction Treatment Systems: Philosophical and Treatment Approach Issues

Introduction

For people with dual disorders, the attempt to obtain professional help can be bewildering and confusing. They may have problems arising within themselves as a result of their psychiatric and AOD use disorders as well as problems of external origin that derive from the conflicts, limitations, and clashing philosophies of the mental health and addiction treatment systems. For example, internal problems such as frustration, denial, or depression may hinder their ability to recognize the need for help and diminish their ability to ask for help. A typical external problem might be the confusion experienced when individuals need services but lack knowledge about the different goals and processes of various types of available services. Other problems of external origin may be very fundamental, such as the inability to pay for child care services or the lack of transportation to the only available outpatient program.

Historically, when patients in AOD treatment exhibited vivid and acute psychiatric symptoms, the symptoms were either: 1) unrecognized, 2) observed but misdescribed as toxicity or "acting-out behavior," or 3) accurately identified, prompting the patients to be discharged or referred to a mental health program. Virtually the same process occurred for patients in mental health treatment who exhibited vivid and acute symptoms of AOD use disorders.

Mislabeling, rejecting, failing to recognize, or automatically transferring patients with dual disorders can result in inadequate treatment, with patients falling between the cracks of treatment systems. The symptoms of psychiatric and AOD use disorders often fluctuate in intensity and frequency. Current symptom presentation may reflect a short-term change in the course of long-term dual disorders. Thus, even when patients receive traditional professional help, treatment may address only selected aspects of their overall problem unless treatment is coordinated among services including AOD, mental health, social, and medical programs.

As a result, the treatment system itself may be a stumbling block for some people attempting to receive ongoing, appropriate, and comprehensive treatment for combined psychiatric and AOD use disorders. Thus, treatment services for patients with dual disorders must be sensitive to both the individual's and the treatment system's impediments to the initiation and continuation of treatment.

Treatment Systems: Mental Health, Addiction, And Medical

People with dual disorders who want to engage in the treatment process (or who need to do so) frequently encounter not one but several treatment systems, each having its own strengths and weaknesses. These treatment systems have different clinical approaches.

The Mental Health System

Actually, there is no single mental health system, although most States have a set of public mental health centers. Rather, mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists; other therapists and counselors including marriage, family, and child counselors (MFCCs); and paraprofessionals.

These mental health personnel work in a variety of settings, using a variety of theories about the treatment of specific psychiatric disorders. Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches.

A major strength of the mental health system is the comprehensive array of services offered, including counseling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of treatment settings. These settings are designed to provide treatment services for patients with acute, subacute, and long-term symptoms. Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis-line personnel, outreach teams, and mental health law commitment specialists. Subacute services are provided by hospitals, day treatment programs, mental health center programs, and several types of individual practitioners. Long-term settings include mental health centers, residential units, and practitioners' offices. Clinicians vary with regard to academic degrees, styles, expertise, and training. Another strength of the mental health system is the growing recognition at all system levels of the role of case management as a means to individualize and coordinate services and secure entitlements.

Medication is more often used in psychiatric treatment than in addiction treatment, especially for severe disorders. Medications used to treat psychiatric symptoms include psychoactive and nonpsychoactive medications. Psychoactive medications cause an acute change in mood, thinking, or behavior, such as sedation, stimulation, or euphoria.

Psychoactive medications (such as benzodiazepines) prescribed to the average patient with psychiatric problems are generally taken in an appropriate fashion and pose little or no risk of abuse or addiction. In contrast, the use of psychoactive medications by patients with a personal or family history of an AOD use disorder is associated with a high risk of abuse or addiction.

Some medications used in psychiatry that have mild psychoactive effects (such as some tricyclic antidepressants with mild sedative effects) appear to be misused more by patients with an AOD disorder than by others. Thus, a potential pitfall is prescribing psychoactive medications to a patient with psychiatric problems without first determining whether the individual also has an AOD use disorder.

While most clinicians in the mental health system generally have expertise in a biopsychosocial approach to the identification, diagnosis, and treatment of psychiatric disorders, some lack similar skills and knowledge about the specific drugs of abuse, the biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse. Similarly, AOD treatment professionals may have a thorough understanding of AOD abuse treatment but not psychiatric treatment.

The Addiction Treatment System

As with mental health treatment, no single addiction treatment system exists. Rather, there is a collection of different types of services such as social and medical model detoxification programs, short- and long-term treatment programs, methadone detoxification and maintenance programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step programs. These programs can vary greatly with respect to treatment goals and philosophies. For example, abstinence is a prerequisite for entry into some programs, while it is a long-term goal in other programs. Some AOD treatment programs are not abstinence oriented. For example, some methadone maintenance programs have the overt goal of eventual abstinence for all patients, while others promote continued methadone use to encourage psychosocial stabilization.

As with mental health treatment, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, certified addiction counselors, MFCCs, and other therapists, counselors, and recovering paraprofessionals. There can be a wide difference in experience, expertise, and knowledge among these diverse providers. As with mental health treatment, most States have public and private AOD treatment systems.

The strengths of addiction treatment services include the multidisciplinary team approach with a biopsychosocial emphasis, and an understanding of the addictive process combined with knowledge of the drugs of abuse and the 12-step programs. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal. However, few medications that directly treat or interrupt the addictive process, such as disulfiram and naltrexone, have been identified or regularly used. Maintenance medications such as methadone are crucial for certain patients. However, most addiction treatment professionals attempt to eliminate patients' use of all drugs.


Similarities of Mental Health and Addiction Treatment Systems


Many who work in the addiction treatment field have only a limited understanding of medications used for psychiatric disorders. Historically, some people have mistakenly assumed that all or most psychiatric medications are psychoactive or potentially addictive. Many addiction treatment staff tend to avoid the use of any medication with their patients, probably in reaction to those whose addiction included prescription medications such as diazepam (Valium). Many staff have a lack of training and experience in the use of such medications. In the treatment of dual disorders, a balance must be made between behavioral interventions and the appropriate use of nonaddicting psychiatric medications for those who need them to participate in the recovery process. Withholding medications from such individuals increases their chances of AOD relapse.

An important adjunct to addiction treatment services is the massive system of consumer-developed groups, such as the 12-step program of Alcoholics Anonymous (AA). Participants in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support and encouragement for patients in treatment. Importantly, these services are widespread nationally and internationally. While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services.

However, patients in self-help groups may give others inappropriate advice regarding medication compliance, based on personal experience, fears of medication, or incomplete knowledge about the role of medication in dual disorders. In many urban areas, there are specialized 12-step groups for people with dual disorders. In these so-called "Double Trouble" meetings, medication compliance is a part of "working the program."

The Medical System

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and AOD disorders.

However, physicians -- especially primary care physicians -- are able to devote very little time to each patient. Pressured for time, these physicians may prescribe such psychiatric medications as antidepressants or anxiolytics or medication such as disulfiram or naltrexone as a primary approach, rather than as an adjunctive approach. Indeed, primary care physicians are the largest single prescriber of antianxiety medications. Some of these medications, such as the benzodiazepines, are psychoactive and can be abused.

Also, physicians and nurses have historically been trained to focus on the medical consequences of addiction, such as withdrawal, overdose, or hepatitis, without assessing, treating, or actively referring the individual for treatment of the addiction itself. The role of physicians with regard to addiction is changing through the leadership of national organizations such as the American Society of Addiction Medicine, the American Academy of Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and Research on Substance Abuse. Similar groups exist for nurses and allied health care professionals. Such groups can provide medical professionals with important information and education about the biopsychosocial nature of addiction and treatment, especially regarding patients with dual disorders.

Differing Approaches: Individual Responsibility and Treatment Focus

Traditionally, patients in mental health settings have had the responsibility of getting themselves to treatment services and appointments as a sign of treatment motivation. More recently, and in recognition that many severely mentally ill patients are unwilling or unable to use traditional community-based services, the mental health field has emphasized the role of case management. Case management (also called care management) can help to engage, link, and support patients in needed community services. Case management can help to reduce the negative consequences to the individual from lack of followup and participation in treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless.

The case management model identifies individual limitations, deficits, and strengths and aggressively attempts to provide patients with what they need. When a patient rejects professional assistance, the case manager assumes the responsibility for finding a different way to get the individual to accept assistance. The case manager may minimize the negative consequences to the individual in order to engage or maintain the patient in treatment. This activity might be seen as "enabling" by traditional addiction treatment personnel.

In contrast, the addiction treatment system focuses on individual responsibility, including the responsibility of accepting help. Motivation for recovery is enhanced through confrontation of the adverse consequences of addiction. Further, addiction intervention and treatment involve diminishing the individual's denial about the presence and severity of the addiction through direct but therapeutic confrontation of examples of addiction-related behaviors. Thus, traditionally, patients in the addiction treatment system who did not want help or could not tolerate confrontation might not get help. Mental health personnel might regard this situation as an abandonment of the most needy. More recently, the addiction treatment system has been developing case management models to better address treatment-resistant patients.

Treatment of patients with dual disorders must blend both mental health and AOD treatment models, with each applied at appropriate times and in appropriate situations according to patients' needs. There should be a balance between clinician and patient acceptance of responsibility for treatment and recovery from dual disorders.

For example, in AOD treatment, clinical staff and fellow patients often aggressively confront patients who deny that they have an AOD problem or who minimize the severity of their problem. However, treatment of individuals with dual disorders first requires innovative approaches to engage them in treatment as a prerequisite to confrontation. The role of confrontation may need to be substantially modified, particularly in the treatment of disorganized or psychotic patients, who may tolerate confrontation only in later stages of treatment (when their symptoms are stable and they are engaged in the treatment process).

In addiction treatment, the focus is often on the "here and now," while in mental health treatment, the focus is often on past developmental issues. Mental health practitioners may identify AOD abuse as a symptom of a prior trauma rather than an illness in its own right. The focus of treatment may be on the developmental issues, with the assumption that the AOD use disorder will improve automatically once these issues are treated. Inadvertently, the mental health therapist can enable AOD use to continue.

The Role of Abstinence

Within parts of the addiction treatment system, abstinence from psychoactive drugs is a precondition to participate in treatment. For the more severely ill patients with dual disorders (such as patients with schizophrenia), abstinence from AODs is often considered a goal, possibly a long-term goal, similar to the approach at some methadone maintenance programs. On the other hand, treatment of less severe dual psychiatric conditions, such as depression or panic disorder, should require AOD abstinence, since AOD use compromises both diagnosis and treatment (see individual chapters).

For some patients with dual disorders, requiring abstinence as a condition of entering treatment may hinder or discourage engagement in the treatment process. For these patients, abstinence may be redefined as a goal, with encouragement provided for incremental steps in the reduction of amount and frequency of drug use. For example, patients who experience homelessness and housing instability likely do not live in drug-free environments. For such patients, it may be unrealistic to mandate abstinence as a requirement for treatment. Exhibit 3-1 describes some of the treatment strategy differences for managing patients in mental health, addiction, and dual disorder treatment approaches.

Treatment Models: Sequential, Parallel, Or Integrated

As the mental health and AOD abuse treatment fields have become increasingly aware of the existence of patients with dual disorders, various attempts have been made to adapt treatment to the special needs of these patients (Baker, 1991; Lehman et al., 1989; Minkoff, 1989; Minkoff and Drake, 1991; Ries, 1993a). These attempts have reflected philosophical differences about the nature of dual disorders, as well as differing opinions regarding the best way to treat them. These attempts also reflect the limitations of available resources, as well as differences in treatment responses for different types and severities of dual disorders. Three approaches have been taken to treatment.

Sequential Treatment

The first and historically most common model of dual disorder treatment is sequential treatment. In this model of treatment, the patient is treated by one system (addiction or mental health) and then by the other. Indeed, some clinicians believe that addiction treatment must always be initiated first, and that the individual must be in a stage of abstinent recovery from addiction before treatment for the psychiatric disorder can begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder should begin prior to the initiation of abstinence and addiction treatment. Still other clinicians believe that symptom severity at the time of entry to treatment should dictate whether the individual is treated in a mental health setting or an addiction treatment setting or that the disorder that emerged first should be treated first.

The term sequential treatment describes the serial or nonsimultaneous participation in both mental health and addiction treatment settings. For example, a person with dual disorders may receive treatment at a community mental health center program during occasional periods of depression and attend a local AOD treatment program following infrequent alcoholic binges. Systems that have developed serial treatment approaches generally incorporate one of the above orientations toward the treatment of patients with dual disorders.

Parallel Treatment

A related approach involves parallel treatment: the simultaneous involvement of the patient in both mental health and addiction treatment settings. For example, an individual may participate in AOD education and drug refusal classes at an addiction treatment program, participate in a 12-step group such as AA, and attend group therapy and medication education classes at a mental health center. Both parallel and sequential treatment involve the utilization of existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treatment clinicians. Coordination between settings is quite variable.

Integrated Treatment

A third model, called integrated treatment, is an approach that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for patients with dual disorders. Ideally, integrated treatment involves clinicians cross-trained in both mental health and addiction, as well as a unified case management approach, making it possible to monitor and treat patients through various psychiatric and AOD crises.

There are advantages and disadvantages in sequential, parallel, and integrated treatment approaches. Differences in dual disorder combinations, symptom severity, and degree of impairment greatly affect the appropriateness of a treatment model for a specific individual. For example, sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder, but a mild problem with the other. However, patients with dual disorders who obtain treatment from two separate systems frequently receive conflicting therapeutic messages; in addition, financial coverage and even confidentiality laws vary between the two systems.

Treatment Models

  • Sequential: The patient participates in one system, then the other.
  • Parallel: The patient participates in two systems simultaneously.
  • Integrated: The patient participates in a single unified and comprehensive treatment program for dual disorders.

In contrast, integrated treatment places the burden of treatment continuity on a case manager who is expert in both psychiatric and AOD use disorders. Further, integrated treatment involves simultaneous treatment of both disorders in a setting designed to accommodate both problems.

Critical Treatment Issues For Dual Disorders

Mental health and addiction treatment programs that are being designed to accommodate patients with dual disorders should be modified to address the specific needs of these patients. Although there are different dual disorder treatment models, all such programs must address several key issues that are critical for successful treatment. These issues include: 1) treatment engagement, 2) treatment continuity and comprehensiveness, 3) treatment phases, and 4) continual reassessment and rediagnosis.

Treatment Engagement

In general, treatment engagement refers to the process of initiating and sustaining the patient's participation in the ongoing treatment process. Engagement can involve such enticements as providing help with the procurement of social services, such as food, shelter, and medical services. Engagement can also involve removing barriers to treatment and making treatment more accessible and acceptable, for example, by providing day and evening treatment services. Engagement can be enhanced by providing adjunctive services that may appear to be indirectly related to the disorders, such as child care services, job skills counseling, and recreational activities. It may also be coercive, such as through involuntary commitment or a designated payee.

Engagement begins with efforts that are designed to enlist people into treatment, but it is a long-term process with the goals of keeping patients in treatment and helping them manage ongoing problems and crises. Essential to the engagement process is: 1) a personalized relationship with the individual, 2) over an extended period of time, with 3) a focus on the stated needs of the individual.

For patients with dual disorders, engagement in the treatment process is essential, although the techniques used will depend upon the nature, severity, and disability caused by an individual's dual disorders. An employed person with panic disorder and episodic alcohol abuse will require a different type of engagement than a homeless person with schizophrenia and polysubstance dependence. With respect to severe conditions such as psychosis and violent behaviors, therapeutic coercive engagement techniques may include involuntary detoxification, involuntary psychiatric treatment, or court-mandated acute treatment.

Treatment Continuity

To treat patients with dual disorders, it is critical to develop continuity between treatment programs and treatment components, as well as treatment continuity over time. In practice, many patients participate in treatment at different sites. Even in integrated treatment programs, many patients require different treatment services during different phases of treatment. For this reason, treatment should include an integrated dual disorder case management program, which can be located within a mental health setting, an addiction treatment setting, or a collaborative program.

Treatment Comprehensiveness

An overall system for treating dual disorders includes mental health and addiction treatment programs, as well as collaborative integrated programs. Programs should be designed to: 1) engage clients, 2) accommodate various levels of severity and disability, 3) accommodate various levels of motivation and compliance, and 4) accommodate patients in different phases of treatment. There should be access to abstinence-mandated programs and abstinence-oriented programs, as well as to drug maintenance programs. Different levels of care, ranging from more to less intense treatment, should be available.

Phases of Treatment

In general, the medical term acute describes phenomena that begin quickly and require rapid response. Acute problems are contrasted with chronic problems. Most commonly, acute stabilization of patients with dual disorders refers to the management of physical, psychiatric, or drug toxicity crises. These include injury, illness, AOD-induced toxic or withdrawal states, and behavior that is suicidal, violent, impulsive, or psychotic.

The acute stabilization of AOD use disorders typically begins with detoxification, such as inpatient detoxification for patients with significant withdrawal or outpatient detoxification for mild to moderate withdrawal, as well as nonmedical withdrawal, such as occurs in social-model detoxification programs. Also, initiation of methadone maintenance can provide outpatient acute stabilization for patients addicted to opioids.

Acute stabilization of psychiatric symptoms more frequently occurs within a mental health or emergency medical setting, but involves a range of treatment intensity. Patients with severe symptoms, especially psychotic, violent, or impulsive behaviors, usually require acute psychiatric inpatient treatment and psychiatric medications, while patients with less severe symptoms can be treated in outpatient or day treatment settings.

Dual disorder programs that provide stabilization to patients with acute needs should have the capability to:

These programs should be capable of promoting the patient's engagement with the treatment system. They should be able to aggressively provide linkages to other programs that will provide ongoing treatment and engagement.

Subacute Stabilization

The medical term subacute describes the status of a medical disorder at points between the acute condition and either resolution or chronic state. The subacute phase of a medical problem occurs as the acute course of the problem begins to diminish, or when symptoms emerge or reemerge but are not yet severe enough to be described as acute.

For example, patients recently detoxified from AODs frequently experience subacute symptoms such as insomnia and anxiety that may linger for a few days or weeks. On the other hand, recently detoxified patients with dual disorders may experience subacute symptoms of insomnia and anxiety either as subacute withdrawal symptoms or as a prelude to relapse with depression. Although the subacute phase is not generally regarded as a period of crisis, ignoring these symptoms and failing to assess and treat them may lead to symptom escalation, decompensation, and relapse.

As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment and rediagnosis is required. During this phase, a psychoeducational and behavioral approach should be used to educate patients about their disorders and symptomatology. During this phase, treatment providers should provide assessment and planning for dealing with long-term issues such as housing, long-term treatment, and financial stability.

Biopsychosocial Assessment Issues From the AOD and Psychiatric Perspectives

 

AOD

Psychiatric

Biological:

Alcohol on breath
Positive drug tests
Abnormal laboratory tests
Injuries and trauma
Toxicity and withdrawal
Impaired cognition

Abnormal laboratory tests
Neurological exams
Using psychiatric medications
Other medications, conditions

Psychological:

Intoxicated behavior
Withdrawal symptoms
Denial and manipulation
Responses to AOD assessments
AOD use history

Mental status exam: Affect mood, psychosis, etc.
Stress, situational factors
Self-image, defenses, etc.

Social:

Collateral information from others
Social interactions and lifestyle
Involvement with other AOD groups
Family history of AOD use disorders
Family history
Housing and employment histories

Support systems: Family, friends, others
Current psychiatric therapy
Hospitalization

ABC Model for Psychiatric Screening

Appearance:

General appearance, hygiene, and dress.

Alertness:

What is the level of consciousness?

Affect:

Elation or depression: gestures, facial expression, and speech.

Anxiety:

Is the individual nervous, phobic, or panicky?

Movements:

Rate (Hyperactive, hypoactive, abrupt, or constant?).

Organization:

Coherent and goal-oriented?

Purpose:

Bizarre, stereotypical, dangerous, or impulsive?

Speech:

Rate, organization, coherence, and content.

Orientation:

Person, place, time, and condition.

Calculation:

Memory and simple tasks.

Reasoning:

Insight, judgment, problem solving.

Coherence:

Incoherent ideas, delusions, and hallucinations?

Long-Term Stabilization

The treatment settings for long-term treatment, rehabilitation, and recovery from dual disorders include outpatient, day treatment, and residential settings. Ideally, treatment intensity is dictated by disorder severity and motivation for treatment, as well as by personal and local treatment resources. In more severe conditions, ongoing dual disorder case management is essential. The management of long-term severe conditions is described in more detail in the chapter on psychotic disorders (Chapter 8).

With regard to the initiation and maintenance of sobriety in patients with dual disorders, another way of looking at acute, subacute, and long-term phases involves a four-step approach that leads to abstinence. This approach is particularly important for patients with severe psychiatric problems and an AOD use disorder (Minkoff and Drake, 1991; Ries, 1993a).

Individual case management.

Individual case management provides an initial introduction to treatment goals and concepts and may provide assistance with regard to crises, housing, and entitlements. An individual treatment plan is developed.

Persuasion groups.

Patients who display strong denial about their AOD use disorder and lack motivation can attend persuasion groups, which provide basic AOD education and treatment engagement. Premature, potent, and direct confrontation and an insistence on abstinence should be avoided since these approaches may prompt more fragile patients to leave treatment.

Active treatment groups.

Active treatment groups consist of patients who have accepted the goal of abstinence and are relatively mentally stable. These groups use supervised peer confrontation and a psychoeducational-behavioral approach to AOD abuse.

Abstinence support groups.

Finally, abstinence support groups consist of patients who are essentially committed to abstinence and are relatively stable mentally, who require ongoing education and support for sobriety and the development of relapse prevention skills.

Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concrete issues (such as medication compliance) are addressed in persuasion groups, while abstract concepts (such as self-image) are addressed in active treatment or abstinence support groups. Some patients -- such as severely psychotic patients -- may not be able to advance beyond persuasion groups or active treatment groups.

General Assessment Issues

Each of the following chapters will address assessment and evaluation issues relative to specific psychiatric disorders. Specific assessment tools may be recommended for certain interventions and certain settings. Irrespective of the treatment or intervention setting, and notwithstanding the crisis that may have initiated the treatment contact, all treatment contacts with patients who may have dual disorders should include a basic screening for psychiatric and AOD use disorders. These issues are addressed in detail in the chapters on mood, personality, and psychotic disorders. With respect to both psychiatric and AOD use disorders, the assessment process should be sensitive to biological, psychological, and social issues.

Full assessments of patients with dual disorders should be performed by clinicians who have certified training in the areas that they assess. However, clinicians who are not certified can learn to perform screening tests. Assessments of patients who may have dual disorders should include at least a brief mental status exam to assess for the presence and severity of psychiatric problems, as well as a screening for AOD use disorders.

The "ABC" model described on the previous page is a simple screening technique for the presence of psychiatric disorders. The CAGE questionnaire and the CAGE questionnaire modified for other drugs (CAGEAID) are rapid and accurate screening tools for AOD use disorders (Exhibit 3-2). The substances used most often by patients with dual disorders are the same as those used by society in general: alcohol, marijuana, cocaine, and more rarely, opioids. It is recommended that all front-line AOD and mental health staff receive detailed training in the use of a mental status exam and AOD screening tests.

Chapter 4 -- Linkages For Mental Health and AOD Treatment

Overview

Conventional boundaries between single-focus agencies have impeded the clinical progress of patients who have psychiatric disorders and alcohol and other drug (AOD) use disorders (Baker, 1991; Schorske and Bedard, 1988).

The treatment of patients with dual disorders is a clinical challenge, as well as a systems challenge, requiring innovation and coordination. The goal of this chapter is to help State and local administrators consider strategies for linkages across systems in order to improve service delivery and treatment outcomes.

Profiles of patients with dual disorders demonstrate that they are more or differently disabled and require more services than patients with a single disorder. They have higher rates of homelessness and legal and medical problems. They have more frequent and longer hospitalizations and higher acute care utilization rates. For example, among patients with schizophrenia, episodes of violence and suicide are twice as likely to occur among those who abuse street drugs as among those who do not.

Treatment and social needs of patients with dual disorders differ depending on the type and severity of the disorders. Patients with dual disorders are generally less able to navigate between, engage in, and remain engaged in treatment services. Focusing on linkages highlights the fact that treatment providers, rather than patients and their families, have the responsibility for coordinating diverse and often conflicting treatment services.

Treatment must be suited to patients' personal needs and characteristics, linking services across several different systems of care. Instead of blaming patients for poor treatment outcomes as they fall through the cracks of separate service systems, patients can be empowered and better treated when given effective options.

Collaboration across multiple systems and philosophies of care is needed to treat patients with dual disorders effectively. The systems often affected include:

For the treatment of patients with dual disorders, the primary systems involved are AOD and mental health treatment. Programs that focus on dual disorders operate in both the mental health and AOD systems. Staff and administrative initiative is required to collaborate across systems. At a minimum, both systems should be involved when developing initiatives to improve linkages. This TIP is focused on the linkages between these systems.

In order to work effectively together, AOD treatment providers and mental health professionals need to understand and respect the different historical and philosophical underpinnings of both systems. As explained in the third chapter, the systems developed separately. There are inherent stresses and strengths among medical, psychoanalytic, psychosocial, and self-help care orientations, as well as between AOD treatment and mental health treatment.

These differences have frequently been a source of conflict and have caused problems for some patients. For example, if a patient with a dual disorder is told by his psychiatrist that he needs psychotropic medication to treat his psychiatric disorder, but members of his self-help AA group tell him to give up all mood-altering drugs to recover from his AOD abuse, to whom does he listen?

Patients with dual disorders challenge the treatment systems. Their involvement in treatment can become an opportunity for providers to examine the philosophical and practical aspects of treatment.

In spite of the historical and philosophical differences that have separated the fields, the consensus panel identified several shared treatment concepts that administrators can use to help move toward integration.

Areas of Primary Concern

To establish and maintain linkages among the various systems working with patients who have dual disorders, several primary administrative areas need to be examined.

It is beyond the scope of this document to provide detailed discussion of each area, but the following discussion of problems and solutions will help readers in their problem solving. The areas to be discussed in this chapter include:

Policy and Planning Structures

Problems

Often there is little or no communication or collaboration among various departments and levels of government that have separate administrative structures, constituencies, mandates, and target groups. There are also different Federal, State, and local planning cycles within the AOD use and mental health treatment systems.

The Federal Government requires two separate planning processes for programs receiving Federal funds: A State mental health plan and a State substance abuse plan. The federally mandated State planning processes required under the Public Health Service Act for mental health treatment and AOD abuse treatment are separate and have no requirements for coordination.

Solutions

Amendments are needed to the Public Health Service Act to encourage coordinated long-term planning between the State mental health and AOD abuse treatment systems for patients with dual disorders.

The development and use of long-term structural mechanisms (such as coordinating bodies, task forces, memoranda of understanding, and letters of agreement) can help improve planning for and integration of services for patients who have dual disorders.

To accomplish this goal, States might create a joint planning mechanism -- an officially organized planning group -- that would: 1) have diverse composition, 2) carry out specific types of tasks, and 3) maintain specific foci.

1. The planning organization should have diverse composition.
2. The planning group should accomplish the following tasks:
3. The planning group should maintain the following foci:

Funding and Reimbursement

Problems

Because of diminishing fiscal resources and competition among many interest groups for particular types of treatment, those who seek funds for the treatment of patients with dual disorders have an increasingly difficult task. In many areas, patients with dual disorders may not be recognized as a priority group for funding. No specific monies are set aside for patients with dual disorders under the block grants. The amount of funds that the Federal Government allocates to States for the AOD and mental health block grant programs changes from year to year and often includes mandated set-asides for specific groups (for example, needle users, women, etc.). Set-asides tend to be different for mental health and AOD abuse treatment and limit the amount available for special groups not specifically targeted.

States often do not take advantage of Federal monies that can be used for patients with dual disorders. It is difficult to identify Federal grants that can be used for dual disorders, since grants and announcements are scattered across many agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH), and the Center for Mental Health Services (CMHS), to name a few.

Current reimbursement practices inhibit integration of services and effective treatment, and there are several problems related to reimbursement from both public and private third-party payers. These problems include the following:

Solutions

1. Facilitate the aggressive pursuit of Federal funds by the following actions:
2. Facilitate the use of block grant funds for treating patients with dual disorders.
3. Promote Requests for Proposals (RFPs) for treating patients with dual disorders.
4. Encourage initiatives within third-party reimbursement mechanisms to cover treatment for patients with dual disorders.

Data Collection and Needs Assessment

Problems

Only limited treatment and research data are available, and those that are available are not in a standardized format. Existing data also tend to be general and not useful to local planners for developing a continuum of care. Data collection systems are mandated to be separate from each other. It is difficult to gather prevalence data on patients with dual disorders because many of them interact with several treatment agencies or systems, while others do not interact with any.

There are systemic disincentives to gathering data on patients with dual disorders. For example, Medicaid may cover a patient who makes a suicide attempt as a result of major depression, but may not cover a patient who makes a drug-induced suicide attempt.

Solutions

At least on the State level, common identifiers in data collection should exist for both AOD abuse and mental health treatment systems. Research should be in a form that allows for evaluation of cost-effectiveness and outcome. Outcomes should be measured across several categories encompassing biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2) housing, 3) service involvement and utilization, and 4) vocational involvement. Collaboration with local colleges and universities to conduct such research should be encouraged.

State planning bodies should encourage or require local needs and resource assessment and data collection. Local planners should collect data from various systems, examining and comparing data from different groups, programs, and locations. The State could gather all the data and compile them for use in improved planning and in evaluating outcomes.

Confidentiality laws must protect the patient, but also must allow for inclusion of anonymous case number data in pools to promote better assessment and treatment outcome studies.

There should be aggressive efforts to examine cost-effectiveness and outcomes of specific models of treatment services for patients with dual disorders. These research efforts can be incorporated into State and local initiatives, perhaps involving local colleges and universities.

Program Development

Problems

Linkages in the development of programs for treating patients with dual disorders are impeded by several factors:

Solutions

Screening, Assessment, And Referral

Problems

The screening process amplifies the tendency to look for a single diagnosis. Staff in single-focus screening services are not trained to assess patients for dual disorders.

There is no "gold standard" instrument to diagnose dual disorders. Some of the instruments that are used often yield false positive results.

Screeners are not adequately trained to make effective referrals across systems, which can result in denial of treatment services.

Screening for dual disorders may take longer than screening for a single disorder. For example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms clear.

Solutions

Case Management

Problems

There frequently is no single person or agency responsible for following up on referrals and ensuring that patients are linked to treatment and that services are coordinated. People with dual disorders need others to help them obtain the services that they require, which are often fragmented.

The Public Health Service Act requires that State mental health agencies that receive Federal funds provide case management services to patients with severe mental illness. However, a comparable requirement is not built into the Federal mandate for AOD abuse treatment services. AOD abuse treatment agencies usually do not have enough social service staff to handle the case management functions of linkage or followup for many dual disorder patients.

Solutions

Staffing

Problems

All too often, treatment staff are knowledgeable about either mental health or AOD treatment. They lack thorough training and education about dual disorder patients.

There is often insufficient staff time available for the level of case management required for dual disorder patients.

Staff selection is often driven more by clinicians' academic degree and their ability to provide reimbursable services than by clinicians' expertise in dual disorders.

Solutions

Training and Staffing

Problems

Clinicians in AOD abuse treatment and mental health treatment usually are not trained in the other discipline. The availability of staff trained in both fields is limited. Agencies frequently lack the resources to recruit and retain staff who have sufficient education and experience. There is both a shortage of qualified staff and an inability to financially compensate qualified staff for their specialized abilities.

The diagnosis and treatment of dual disorders are not generally understood by staff, administrators, and legislators, let alone the general public. Agency directors and supervisors often assign whom they believe to be the most appropriate staff member to work with dual disorder patients without a clear idea of the knowledge and skills required.

Professionals in AOD abuse and mental health treatment have accumulated biases against the other discipline, as well as negative stereotypes of both patients and staff.

There are no structured incentives for individuals or programs to develop or take part in training, such as pay differentials and career opportunities specific to dual disorders. Opportunities and incentives for cross-training are lacking.

Consumers are not adequately involved in the training process.

Relatively few academic programs involve training or research in this field.

Solutions

Cross-training is one of the most effective tools administrators have for bridging gaps between clinicians and services from different fields. Training programs that provide knowledge about local networking can greatly improve linkages for patients with dual disorders.

Solutions for administrators:

Solutions for staff:

Solutions for the community:

Solutions for consumers and their families:

Linkages With Social Service Systems

Problems

A large proportion of patients with dual disorders require social services. The scope of social services is extremely broad, encompassing public and private multisystems.

Federally mandated income support programs are notoriously complex, each with its own set of regulations. Some, such as the Social Security Income (SSI) maintenance program, are administered by the Federal Government, while others are administered by the State and vary from State to State.

Income support programs include SSI, Medicaid, Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps.

Regulations for each program are often not understood by professionals and others who provide services to potential recipients. This makes it even more difficult for the potential recipient to get and retain benefits.

Some programs, such as SSI, require proof of a permanent and total disability. Mental health problems often do not neatly fit into categories, making it difficult to obtain this support.

Income support programs for single individuals have been cut drastically in recent years.

Applications for these income support programs are often taken at a site other than where either mental health or AOD services are provided for the patient.

The complexity of the application and appeal process adds to the stress of a person with a dual disorder.

Overburdened staff who are processing income support applications often do not understand dual disorders.

Federally mandated services for children, youth, and families include services that fall under the child welfare system (for example, child protective services and foster care placement).

Child welfare system staff are overburdened and understaffed. A large percentage of caseloads involve family AOD use problems.

Most child welfare staff are not trained in recognizing or treating dual disorder problems. Mental health and AOD abuse staff are not trained in child welfare. There is a lack of knowledge of each other's systems and resources.

Other social service programs serve a wide range of special needs populations, including the homeless and victims of domestic violence or sexual abuse, who require a broad array of support services. Although many users of these services have mental health and AOD abuse problems, these services are often not available on site. Social service staff often lack knowledge of how to refer people with such problems into these systems.

Solutions

Linkages With the Health Care System

Problems

The medical system is vast, covering a wide range of public and private programs including primary, secondary, and tertiary care.

Public primary care clinics are often overburdened, understaffed, and underfinanced. They are often oriented to treating presenting physical problems, and staff may not be trained in screening for either AOD abuse or mental health problems. The same problems often exist in nonprofit primary care facilities. Staff are often not knowledgeable about how and where to refer patients.

Historically, physicians have not received any education about AOD treatment and little education about mental health problems in medical school. Primary care physicians are often unaware of the signs and symptoms of AOD use disorders, and may have only a basic understanding of a few psychiatric problems such as depression and anxiety. For example, persons who experience physical trauma, such as burn injuries or falls, often have AOD use disorders. Yet, when presented with injured patients, primary care physicians may not screen for AOD use disorders.

At hospital discharge, personnel often have difficulty dealing with AOD abuse and mental health concerns. Patients are sometimes discharged inappropriately with inadequate discharge planning and linkage with aftercare services.

Staff in mental health and AOD abuse treatment systems often do not know how to gain access to medical systems and therefore are ineffective in providing information and ongoing education.

Solutions

Linkages With the Criminal Justice System

Problems

The criminal justice is a top-down system. There is often no mandated joint planning.

The mental health system has no formal responsibility for inmates with dual disorders.

Incarceration is often a substitute for AOD abuse and mental health treatment. Treatment may not begin until shortly prior to release.

Medical services for the incarcerated are not reimbursable under Medicaid or any third-party payer. There is often an interagency debate regarding who should pay for care.

Offenders who should be committed are often released. Prerelease assessments are often inadequate. There usually is no coordinated plan for release. No systemic funding incentives to provide care exist. There is a range of custody status.

Criminal justice staff often have AOD abuse or mental health problems. There are many inadequate employee assistance programs within the criminal justice system.

The criminal justice system and community AOD abuse and mental health treatment agencies may compete for the same AOD abuse and mental health treatment dollars.

Solutions

1. State

2. County and locality

3. Consumers

4. Pretrial process

5. During incarceration

6. During the probation-parole period

7. Criminal justice staff

Chapter 5 -- Mood Disorders

Definitions and Diagnoses

The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual's life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or mania. A mood episode (for example, major depression) is a cluster of symptoms that occur together for a discrete period of time.

A major depressive episode involves a depression in mood with an accompanying loss of pleasure or indifference to most activities, most of the time for at least 2 weeks. These deviations from normal mood may include significant changes in energy, sleep patterns, concentration, and weight. Symptoms may include psychomotor agitation or retardation, persistent feelings of worthlessness or inappropriate guilt, or recurrent thoughts of death or suicide. The diagnosis of major depression requires evidence of one or more major depressive episodes occurring without clearly being related to another psychiatric, AOD use, or medical disorder. Major depression is subclassified as major depressive disorder, single episode and recurrent. There are nine symptoms of a major depressive episode listed in the DSM-IV draft, and diagnosis of this disorder requires at least five of them to be present for 2 weeks.

Dysthymia is a chronic mood disturbance characterized by a loss of interest or pleasure in most activities of daily life but not meeting the full criteria for a major depressive episode. The diagnosis of dysthymia requires mild to moderate mood depression most of the time for a duration of at least 2 years.

A manic episode is a discrete period (at least 1 week) of persistently elevated, euphoric, irritable, or expansive mood. Symptoms may include hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased need for sleep, and distractibility. Manic episodes, often having a rapid onset and symptom progression over a few days, generally impair occupational or social functioning, and may require hospitalization to prevent harm to self or others. In an extreme form, people with mania frequently have psychotic hallucinations or delusions. This form of mania may be difficult to differentiate from schizophrenia or stimulant intoxication.

A hypomanic episode is a period (weeks or months) of pathologically elevated mood that resembles but is less severe than a manic episode. Hypomanic episodes are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization.

A bipolar disorder is diagnosed upon evidence of one or more manic episodes, often in an individual with a history of one or more major depressive episodes. Bipolar disorder is subclassified as manic, depressed, or mixed, depending upon the clinical features of the current or most recent episodes. Major depressive or manic episodes may be followed by a brief episode of the other.

Cyclothymia can be described as a mild form of bipolar disorder, but with more frequent and chronic mood variability. Cyclothymia includes multiple hypomanic episodes and periods of depressed mood insufficient to meet the criteria for either a manic or a major depressive episode. The revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) states that for a diagnosis of cyclothymia to be made, there must be a 2-year period during which the patient is never without hypomanic or dysthymic symptoms for more than 2 months.

Substance-induced mood disorder is described in the DSM-IV draft according to the following criteria:

A. A prominent and persistent disturbance in mood characterized by either (or both) of the following:

1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,

2) elevated, expansive, or irritable mood.

B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in criterion A developed during, or within a month of, significant substance intoxication or withdrawal.

C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include: the symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder (e.g., a history of recurrent non-substance-related major depressive episodes) .

D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance does not occur exclusively during the course of delirium.

Substance-induced mood disorder can be specified as having 1) manic features, 2) depressive features, or 3) mixed features. Also, it can be described as having an onset during intoxication or withdrawal. For most of the major mental illnesses, the DSM-IV draft includes the alternative of a substance-induced disorder within that diagnosis.

Prevalence

Using structured interviews, the Epidemiologic Catchment Area (ECA) studies found that nearly 40 percent of people with an alcohol disorder also fulfilled criteria for a psychiatric disorder. Among people with other drug disorders, more than half reported symptoms of a psychiatric disorder (Regier et al., 1990).

The most common psychiatric diagnoses among patients with an AOD disorder are anxiety and mood disorders. Among those with a mood disorder, a significant proportion has major depression. Mood disorders may be more prevalent among patients using methadone and heroin than among other drug users. In an addiction treatment setting, the proportion of patients diagnosed with major depression is lower than in a mental health setting.

The prevalence rates of mood disorders in the general population can be estimated from the results of the ECA studies (Regier et al., 1988; Robins et al., 1988). These studies indicate that:

Some studies demonstrate that the prevalence of mood and anxiety disorders is no greater among AOD abusers than in the general population. Other studies show elevated rates of these disorders among people with AOD disorders. Many patients receiving treatment for addiction appear depressed, but only a small percent receive a formal diagnosis of major depression as a concurrent illness.

During the first months of sobriety, many AOD abusers may exhibit symptoms of depression that fade over time and that are related to acute withdrawal. Thus, depressive symptoms during withdrawal and early recovery may result from AOD disorders, not an underlying depression. A period of time should elapse before depression is diagnosed.

Among women with an AOD disorder, the prevalence of mood disorders may be high. The prevalence rate for depression among alcoholic women is greater than the rate among men. Counselors should be reminded that women in both addiction and nonaddiction treatment settings are more likely than men to be clinically depressed.

In addition to women, other populations require special consideration. Native Americans, patients with HIV, patients maintained on methadone, and elderly people may all have a higher risk for depression. The elderly may be the group at highest risk for combined mood disorder and AOD problems. Episodes of mood disturbance generally increase in frequency with age. Elderly people with concurrent mood and AOD disorders tend to have more mood episodes as they get older even when their AOD use is controlled.

Differential Diagnosis

Diagnostic Process

Diagnoses of psychiatric disorders should be provisional and constantly reevaluated. In addiction treatment populations, many psychiatric disorders are substance-induced disorders that are caused by AOD use. Treatment of the AOD disorder and an abstinent period of weeks or months may be required for a definitive diagnosis of an independent psychiatric disorder. Unfortunately, the severely depressed person may drop out of treatment or even commit suicide while the clinician is trying to sort things out (see section on "Assessing Danger to Self or Others.")

Acute manic symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations. They may also be caused by withdrawal from depressants such as alcohol and by medical disorders such as AIDS and thyroid problems. Acute mania with its hyperactivity, psychosis, and often aggressive and impulsive behavior is an emergency and should be referred to emergency mental health professionals. This is true whatever the causes may appear to be.

Other psychiatric conditions can mimic mood disorders. The predominant condition that mimics a mood disorder is addiction, which is frequently undiagnosed or misdiagnosed. Disorders that can complicate diagnosis include schizophrenia, brief reactive psychosis, and anxiety disorders.

Patients with personality disorders, especially of the borderline, narcissistic, and antisocial types, frequently manifest symptoms of mood disorders. These symptoms are often fluid and may not meet the diagnostic criterion of persistence over time. In addition, all of the psychiatric disorders noted here can coexist with AOD and mood disorders.

Case Examples: George and Mary

George is a 37-year-old divorced male who was brought into the emergency room intoxicated. His blood alcohol level was 152, and the toxicology screen was positive for cocaine. He was also suicidal ("I'm going to do it right this time! I've got a gun."). He has a history of three psychiatric hospitalizations and two inpatient AOD treatments. Each psychiatric admission was preceded by AOD use. George has never followed through with psychiatric treatment. He has intermittently attended AA, but not recently.

Mary is a 37-year-old divorced female who was brought into a detoxification unit with a blood alcohol level of 150 and was noted to be depressed and withdrawn. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol-related problems since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32. She reports a positive response to antidepressants. She is currently not receiving AOD or psychiatric treatment.

Differential diagnostic issues for case examples.

Many factors must be examined when making initial diagnostic and treatment decisions. For example, what if George's psychiatric admissions were 2 or 3 days long -- usually with discharges related to leaving against medical advice? Decisions about diagnosis and treatment would be quite different if two of his psychiatric admissions were 4 to 6 weeks long with clearly defined manic and psychotic symptoms continuing throughout the course, despite aggressive use of psychiatric treatment and medication.

Similarly, what if Mary had abstained from alcohol for 6 months "on her own," but over the past 3 months, she had become increasingly depressed, tired, and withdrawn, with disordered sleep and poor concentration, as well as suicidal thoughts? In addition, last night, while planning to kill herself, she relapsed. A different diagnostic picture would emerge in this case if Mary had been using antidepressants for the past year and, during the past month, she had experienced an increase in heavy drinking, losing her job yesterday because of alcohol use.

AOD-Induced Mood Disorders

It is important to distinguish between mood disorders and AOD intoxication, withdrawal, and/or chronic effects. These distinctions are especially important following the chronic use of drugs that cause physiologic dependence.

All psychoactive drugs cause alterations in normal mood. The severity and manner of these alterations are regulated by preexisting mood states, type and amount of drug used, chronicity of drug use, route of drug administration, current psychiatric status, and history of mood disorders.

AOD-induced mood alterations can result from acute and chronic drug use as well as from drug withdrawal. AOD-induced mood disorders, most notably acute depression lasting from hours to days, can result from sedative-hypnotic intoxication. Similarly, prolonged or subacute withdrawal, lasting from weeks to months, can cause episodes of depression, sometimes accompanied by suicidal ideation or attempts.

Also, stimulant withdrawal may provoke episodes of depression lasting from hours to days, especially following high-dose, chronic use. Stimulant-induced episodes of mania may include symptoms of paranoia lasting from hours to days. Overall, the process of addiction per se can result in biopsychosocial disintegration, leading to chronic dysthymia or depression often lasting from months to years.

Since symptoms of mood disorders that accompany acute withdrawal syndromes are often the result of the withdrawal, adequate time should elapse before a definitive diagnosis of an independent mood disorder is made.

Conditions that most frequently cause and mimic mood disorders and symptoms must be differentiated from AOD-induced conditions. When symptoms persist or intensify, they may represent AOD-induced mental disorders. Transient dysphoria following the cessation of stimulants can mimic a depressive episode. According to the DSM-IV draft, if symptoms are intense and persist for more than a month after acute withdrawal, a depressive episode can be diagnosed. Symptoms of shorter duration can be diagnosed as a substance-induced mood disorder.

It is difficult to generalize about specific drugs causing specific behavioral syndromes. There is tremendous variability, as demonstrated in Exhibit 5-1. Multiple drug use further complicates the differential diagnosis. Diagnostic procedures such as urinalysis and toxicology screens should be used if possible. It should also be emphasized that addicted patients may experience withdrawal from one drug despite using another drug.

Stimulants

Stimulants such as cocaine and the amphetamines cause potent psychomotor stimulation. Stimulant intoxication generally includes increased mental and physical energy, feelings of well-being and grandiosity, and rapid pressured speech. Chronic, high-dose stimulant intoxication, especially when combined with sleep deprivation, may prompt an episode of mania. Symptoms may include euphoric, expansive, or irritable mood, often with flight of ideas, severe impairment of social functioning, and insomnia.

Acute stimulant withdrawal generally lasts from several hours to 1 week and is characterized by depressed mood, agitation, fatigue, voracious appetite, and insomnia or hypersomnia. Depression resulting from stimulant withdrawal may be severe and can be worsened by the individual's awareness of addiction-related adverse consequences. Symptoms of craving for stimulants are likely and suicide is possible.

Protracted stimulant withdrawal often includes sustained episodes of anhedonia and lethargy with frequent ruminations and dreams about stimulant use. There may be bursts of dysphoria, intense depression, insomnia, and agitation for several months following stimulant cessation. These symptoms may be either worsened or lessened by the quality of the patient's recovery program.

Depressants

The general effect of the central nervous system depressants such as alcohol, the benzodiazepines, and the opioids is a slowing down of an individual's psychomotor processes. However, acute alcohol intoxication and opioid intoxication often include two phases: an initial period of euphoria followed by a longer period of relaxation, sedation, lethargy, apathy, and drowsiness.

Alcohol, barbiturates, and the benzodiazepines can cause sedative-hypnotic intoxication, especially when taken in high doses. Psychomotor symptoms include mood lability, mental impairment, impaired memory and attention, loss of coordination, unsteady gait, slurred speech, and confusion.

Hallucinogens, Marijuana, and PCP

The hallucinogens can cause a state of intoxication called hallucinosis, which has several features in common with psychotic disorders and a few in common with mood disorders. Hallucinogens such as LSD and drugs such as MDMA (methylenedioxy-methamphetamine, or Ecstasy) and MDA (methylenedioxyamphetamine) may precipitate intense emotional experiences that may be perceived as positive or negative mood states by the drug user.

These experiences are affected greatly by personality, preexisting mood state, personal expectations, drug dosage, and environmental surroundings. While many users will experience sensory and perceptual distortions, some will experience euphoric religious or spiritual experiences that may resemble aspects of a manic or psychotic episode. Others may have a deeply troubling introspective experience, causing symptoms of depression.

Marijuana, which has sedative and psychedelic properties, can cause a variety of mood-related effects. In the individual who has not developed tolerance for the drug's effects, high doses of marijuana can cause acute marijuana intoxication with euphoria or agitation, grandiosity, and "profound thoughts." Together, these symptoms can mimic mania. Because marijuana is only slowly eliminated from the body, chronic use results in relatively constant marijuana levels. Thus, daily marijuana use can be, in effect, a chronic marijuana intoxication. This state may include symptoms of chronic, low-grade lethargy and depression, perhaps accompanied by anxiety and memory loss. Phencyclidine (PCP) intoxication can include symptoms of euphoria, mania, or depression, in addition to sensory dissociation, hallucinations, delusions, psychotic thinking, altered body image, and disorientation.

Mood Disorders Due to A Medical Condition

The DSM-IV draft describes diagnostic criteria for mood disorder due to a general medical condition. The five criteria are:

A. A prominent and persistent mood disturbance is characterized by either (or both) of the following:

1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,

2) elevated, expansive, or irritable mood.

B. There is evidence from the history, physical examination, or laboratory findings of a general medical condition judged to be etiologically related to the disturbance.

C. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood, in response to the stress of having a general medical condition).

D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance does not occur exclusively during the course of delirium or dementia.

Mood disorder due to a general medical condition can be described as having 1) manic features, 2) depressive features, or 3) mixed features in which symptoms of both mania and depression are present and neither predominates.

Medical conditions that can either precipitate or mimic mood disorders include the following:

Medications, including reserpine and other medications that treat hypertension and hypotension, can cause conditions that may be confused with psychiatric or AOD disorders. Both prescribed and over-the-counter (OTC) medications can precipitate depression. Diet pills and other OTC medications can lead to mania. Patients treated with neuroleptic (antipsychotic) drugs may have a marked constriction of affect that can be misinterpreted as a symptom of depression.

Stages of Assessment

The patient with coexisting AOD and mood disorders requires a thorough assessment and treatment for both disorders. The assessment process can be divided into three clinical phases: acute, subacute, and long term.

Acute and subacute assessment may not be applicable to certain patients seen in some clinical settings. For instance, AOD treatment program staff in outpatient settings may see fewer patients with acute psychiatric symptoms than are seen in detoxification settings.

Acute Evaluation

Assessing Danger to Self or Others

It is critical to assess whether patients are threats to themselves or others. This evaluation helps to determine if there is a duty to protect patients from self-harm, interrupt intentions of violence toward others, and/or warn intended victims of patients' announced violent intent.

The responsibility to protect some patients from suicide or violence due to mental illness is not mitigated by confidentiality laws with respect to AOD addiction. Imminent risk, according to the laws of most States, justifies and requires commitment of patients or the warning of potential victims.

Generally, AOD confidentiality laws are very stringent. While some States protect against involuntary commitment for AOD abuse, they do not protect against commitment for AOD-induced psychiatric states which involve danger to oneself or others.

Screening personnel should assess whether suicidal feelings are transitory or reflect a chronic condition. Consider: Do patients have a suicide plan or serious intentions? Have they made past attempts? Whether the patients have had prior psychiatric hospitalization or are in current treatment should be determined. If patients are acutely dangerous to themselves or others, either voluntary or involuntary methods such as commitment should be pursued through local resources. AOD staff should have a thorough knowledge of local resources prior to and in anticipation of crises.

Placement in a safe holding environment can have a positive effect on patients with AOD problems and apparent suicidal intentions. If an intake facility cannot hold such patients, referral to an appropriate facility is recommended. For example, if someone walks into a program at 8:00 a.m. on Monday saying he wants to hurt himself, there should be time to talk the person down, assess treatment needs, and begin treatment or make assessment referrals. When necessary, an assessment should include a rapid triage. See the sections on the assessment of high-risk conditions in Chapter 7 (Personality Disorders) and Chapter 8 (Psychotic Disorders).

In virtually every recent study of successful or attempted suicide, AOD use and major depression are among the top associated conditions. Having both conditions simultaneously leads to even greater risk of suicide.

Patients with manic symptoms that approach psychotic proportions require thorough evaluation and require urgent care. Evaluation of mania should be done on a priority basis and should be monitored during subacute assessments.

Patients who have manic and hypomanic symptoms often minimize AOD and psychiatric disorders. Because of the symptom of grandiosity, manic patients may have poor insight into their AOD disorder, their mania, and their social situation. Manic patients may not see themselves as ill. They are usually hyperactive and irritable, and often become a danger to themselves or others through impulsivity, irritability, and poor judgment. When such people are also intoxicated, most will require involuntary commitment. See Chapter 8 for a discussion of assessment of patients with psychosis.

Medical Assessment

Patients, particularly the elderly, with mood disorders may have life-threatening medical conditions, including hypoglycemia (insulin overdose), stroke, or infections. These conditions, as well as withdrawal and toxic drug reactions, must always be considered and require a thorough physical examination and laboratory assessment. Assessment personnel should make appropriate referrals for medical assessment and treatment. Facilities that have no medical component should train assessment staff in triage and referral.

A plan should be developed to assess and treat medical conditions that precipitate or complicate mood disturbances. Endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection should be considered. In addition to obvious medical problems, it can be assumed that basic medical needs of patients with dual disorders are not being met, and a plan should be developed to address these deficits.

Initial Addiction Assessment Using the CAGE Questions

Clinicians can easily use the CAGE questions for screening (see Chapter 3) as well as adapt them for use with patients who may have mood disorders. For example, consider the following questions adapted from the CAGE questionnaire. "Have you ever cut down or increased your AOD use related to being severely depressed (or manic, etc.)?" "Do you ever get more irritable, angry, depressed, or annoyed when using AODs?" "Do you drink or use other drugs to deal with guilt feelings?" "Do you feel more moody in the morning or evening?" "Have you ever been suicidal when intoxicated?"

Initial AOD assessment should focus on recent use of alcohol and other drugs and a behavioral history. The assessor needs to know what drug has been used, in what quantity, with what frequency, and how recently. Past treatments, past episodes of delirium tremens, hallucinosis, blackouts, and destructive behavior should be recorded.

Social Assessment

The social assessment should evaluate the patient's social environment, especially in relation to AOD and psychiatric disorders. It is important to assess whether the patient experiences housing instability or homelessness. Where does the patient live? Does the patient live in a home? With whom does the patient live? With whom does the patient have regular social contact? Are the social and home environments stable?

In the patient's social life, is there a precipitating crisis occurring? What is the patient's existing support structure in the home and community? What role do others have? Is the home free of AODs? Are the home and social environments safe and free from violence? Do the home and social environments support an abstinent lifestyle? If not, it should be assessed whether the patient has the support necessary to overcome the adverse effect of home and social environments that do not support abstinence and recovery.

Violence by Others

During the screening interview, it is important to determine whether the patient's family members are physically abusive. It should be determined whether the patient is in danger. Physical and behavioral observation can be an important aspect of evaluation. The best predictor of future violence is previous violence.

Assessing Mood Symptomatology

During AOD use history taking and psychiatric screening and assessment sessions, patients with AOD disorders may overemphasize or underemphasize their psychiatric symptoms. For instance, patients who feel depressed during the assessment may distort their past psychiatric experiences and unwittingly exaggerate the intensity or frequency of past depressive episodes.

In contrast, patients who are profoundly depressed during the assessment may minimize their depressive illness because they think it represents a normal state. Indeed, some patients may believe that they "deserve" to be depressed, rather than recognizing that depression is a deviation from normal mood states.

Some patients experience feelings of guilt that are excessive and inappropriate. Other patients do not accurately label their depression and fail to remember that they have experienced depression before. Since patients frequently confuse depression with sadness and other emotions, it is important during the assessment to ask such questions as: "Have you ever seen a psychiatrist or therapist?" (If yes: "Why?") "Are you able to get out of bed in the morning or do you feel chronically tired?" "Have there been any recent changes in your sleeping patterns or in your appetite?"

Patients may select details from their psychiatric history consistent with their current mood. Those who are depressed may give a generally negative self-report. Addicted patients tend to emphasize psychiatric symptoms; psychiatric patients often underemphasize them. Unhappy addicted patients in a transient disturbance of mood will often rationalize their histories as lifelong depression. Thus, it is important to obtain collateral information from other people and from documents such as medical and psychiatric records. It is critical to continue the process of evaluation past the period of drug withdrawal.


Tips for Assessment


The following are sample questions to ask during the assessment process.

For depression:

         "During the past month, has there been a period of time during which you felt depressed most of the day nearly every day?"

         "During this period of time, did you gain or lose any weight?"

         "Did you have trouble concentrating?"

         "Did you have problems sleeping or did you sleep too much?"

         "Did you try to hurt yourself?"

For mania:

         "During the past month, have you experienced times during which you felt so hyperactive that you got into trouble or were told by others that your behavior was not normal for you?"

         "Have you recently experienced bouts of irritability during which you would yell or fight with others?"

         "During this period, did you feel more self-confident than usual?"

         "Did you feel pressured to talk a great deal or feel that your thoughts were racing?"

         "Did you feel restless and irritable?"

         "How much sleep do you need?"


Patients' responses to questions are often influenced by the way questions are asked. Most patients being interviewed tend to say what they believe the interviewer wants to hear. Therefore, the manner in which the interview is conducted is important. The interviewer should not lead the patient or make suggestions regarding the "correct" answer.

Because of the subjective nature of mood disturbances, the way in which questions are asked is important. Subjective and quantifiable questions should be asked in an objective way. Neutral, open-ended questions can be effective. Questions should be asked about impairment and disturbance of sleep, appetite, and sexual function, as well as other disturbances in functional impairment. Interviewers must be alert to contradictory responses and recognize that AOD-dependent patients have a tendency to distort information.

Subacute and Longer-Term Assessment

Settings for subacute assessment include the following:

This section will focus on patients who likely have coexisting AOD use and mood disorders, are not imminently dangerous, and are candidates for treatment. Their functional levels, liabilities, and strengths should be assessed. The goal of subacute assessment is to develop treatment plans with less need for the focus on acute protection (as in the case of acute assessment). Treatment planning is based on a full assessment of treatment needs.

Assessments can be considered part of the treatment process since the assessment process often facilitates breaking through the addicted person's denial mechanisms. By asking specific questions (about work, relationships, health, or legal problems), the clinician calls attention to the consequences of AOD use. Toxicology screens and/or abnormal liver function tests such as the GGT should be obtained when symptoms and AOD use reports don't match. Such results can be identified as "consequences" of AOD use. Diagnostic and assessment sessions can be the first intervention. The boundary between assessment and treatment is fluid.

Medical Assessment

A plan should be developed to assess and treat medical conditions that can precipitate or complicate mood disturbances. Such conditions include endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection.

Some medical problems may have a heightened visibility because of their more obvious need for ongoing treatment. However, frequently the primary health care needs of patients with combined AOD and mood disorders are not pursued. For this reason, a plan to assess and meet these treatment needs should be developed.

Psychiatric and Addiction Screening

A subacute nonemergency setting is appropriate for screening and in depth diagnostic interviews for AOD and psychiatric disorders. The following sources can provide valuable information for screening and assessment: psychiatric history, previous medical and psychiatric records, and information from collateral sources such as employers, family members, and laboratory data.

A diagnostic interview, unlike a screening interview, can be done over the course of several sessions. Collateral sources, especially family members, can help clarify diagnostic issues and to help patients recognize the denial that may accompany their disorders.

A thorough history of AOD use, problems, patterns, and treatments should be obtained at this stage. Such information should be collected in a supportive nonjudgmental manner and over multiple interviews when possible. As with the psychiatric assessment, interviews with family and collateral sources are important.

Assessment Instruments

The diagnostic evaluation can include the clinical application of the DSM-III-R (or DSM-IV), perhaps in the form of the Structured Clinical Interview from DSM-III-R (SCID). The Brief Psychiatric Rating Scale, the Hamilton Scale, the Addiction Severity Index (ASI), and the Beck Scale can also be used to assess patients with dual disorders.

The SCID and the ASI are research instruments, but their demonstrated reliability and the advantages of consistent, standardized tools make it reasonable to administer them. Facilities that use these instruments should provide training in their use.

Psychosocial Assessment

A comprehensive psychosocial and vocational assessment can be an important aspect of the overall assessment. Evaluation of the patient's ongoing support system is important: What is the patient's support network, including friends and family? What patterns of interpersonal and family relationships exist within the nuclear family, the extended family, and the family of choice? What means of financial support does the patient have? What job skills does the patient have? Also, both ethnic and cultural backgrounds may alter a person's experience of both AOD and psychiatric conditions.

Treatment Strategies, Issues, and Goals

Acute Treatment Strategies

Management of Intoxication And Withdrawal

Management of withdrawal is often crucial to patients' safety and comfort. Withdrawal management can foster patient engagement in an ongoing treatment and recovery process. Although withdrawal management does not in itself produce enduring abstinence, it can help to increase retention in the treatment process, which improves long-term outcome.

Treatment strategies for intoxication range from letting patients "sleep it off" to confinement in a medical or psychiatric unit. Treatment for acute sedative-hypnotic withdrawal should include medically managed detoxification. Hospital settings are preferable, especially for depressed patients. Opiate withdrawal, while not life threatening, should also be treated medically and on an inpatient basis when possible. When such hospital-based settings are unavailable, residential or outpatient support with or without medication should be attempted.

Since unassisted withdrawal can cause seizure, psychosis, depression, and suicidal thoughts, it can be dangerous. Thus, successful detoxification is often a lifesaving process. Also, the medical management of withdrawal alleviates patients' suffering. It can provide a safe, supportive, and nonthreatening environment for depressed patients.

Medical Treatment

Acute treatment may be required for medical conditions identified in the medical assessment. For example, thyrotoxicosis (thyroid storm) is a life-threatening imitator of mania. Also, low blood sugar resulting from insulin overdose can resemble intoxication and depression.

Psychiatric Treatment

Patients who are imminently dangerous to themselves or others due to a psychiatric disturbance require emergency psychiatric treatment. Such treatment may involve voluntary or involuntary confinement.

The presence of a coexisting AOD use disorder or the suspicion that the psychiatric disturbance is AOD induced does not mitigate requirements for confinement. Rather, it may necessitate addiction-specific emergency treatment such as detoxification.

Patients not requiring confinement after evaluation may benefit from the support of existing family networks, existing programs, or when available, a rapid referral to a dual disorders treatment program.

Medical management of acute psychiatric symptoms is a treatment strategy during the acute phase regardless of long-term diagnostic results. Patients who experience hallucinations, delusions, mania, or significant disorganization of thought can benefit from medical treatment with antipsychotic medication (such as haloperidol or thioridazine) whether or not their symptoms are AOD induced. If potentially abusable medications are required (such as benzodiazepines for acute mania), a period of tapering or reduction of the medication within 1 or 2 weeks should be built into the original treatment plan.

Subacute Treatment Issues

Matching Patients and Treatment

During subacute treatment, the first decision to be made is whether patients should receive treatment in a psychiatric or addiction setting. In some locations, a third alternative is available: the dual disorders treatment setting. When realistic, both types of treatment should be provided simultaneously; integrated treatment generally is preferable.

Criteria for determining placement include the patient's treatment needs and potential for loss of control, as well as program features such as intensity, structure, and limitations. There are also considerations specific to mood disorders.

For example, if patients are experiencing mania or psychotic depression with disordered thinking, it must be determined whether the program is capable of handling and treating patients with these problems. While psychotic depression or mania is being managed, patients may then be shifted to an addiction or dual disorder setting. Appropriate matching of patients to facilities is important.

Some patients with dual disorders require rare or minimal psychiatric intervention, such as AOD patients whose bipolar disorder is successfully managed with lithium and regular blood level monitoring. Patients who require a strong recovery-oriented AOD abuse treatment program should also receive treatment for their psychiatric disorder (parallel treatment), with an emphasis on AOD treatment.

In contrast, patients who experience chronic and severe psychiatric disturbances and who episodically use AODs in a markedly destructive fashion will be better treated in a psychiatric program that has staff with expertise in addiction treatment. The optimal match for the patient with two active disorders that require treatment is the integrated facility. The intensity of each disorder dictates the relative intensity of each treatment component required.

Referral to an appropriate facility should be based on practical clinical criteria rather than on diagnosis alone. For example, patients' ability to understand, interpret, and tolerate the level of care being provided is most important. Some patients can participate in standard 12-step groups. Others will require 12-step groups that are intended for people with dual disorders (Double Trouble groups). Still others will require professionally run therapy groups that include patients with similar problems.

Effective treatment is based on what patients can understand and tolerate, which is not always predicted by diagnosis. Some psychotic patients function well in traditional programs, while others require special settings. An individual plan and a flexible ongoing reassessment of effectiveness are the best ways to ensure fit.

Psychiatric Medications

The judicious use of antidepressant and mood-regulating medication is appropriate for AOD patients with mood disorders. For example, patients who experience debilitating, misery-provoking, and incapacitating depressive symptoms may require antidepressant medication to participate in addiction recovery. (See Chapter 9 for further discussions of psychiatric medications.)

When depressive symptoms interfere with functioning, antidepressant medication can provide symptom relief and allow participation in recovery activities and activities of daily living. Relief from depression and anxiety can be significant motivating factors in recovery. Left untreated, symptoms can keep patients from taking part in recovery activities.

Patients who have difficulty engaging in Alcoholics Anonymous and other support groups and who do not exhibit evidence of a personality disorder may be depressed. Depression may manifest as social withdrawal, reclusiveness, or inability to complete activities of daily living such as going to work. Regularly spending many hours a day in bed or having serious insomnia may be cardinal signs of depression but are often seen among patients with AOD disorders during the first weeks and months of abstinence.

When prescribing antidepressants for people participating in addiction treatment, the acronym MASST is a reminder for clinicians of the areas of AOD recovery that need to be continually assessed. MASST is an acronym that reminds clinicians to assess patients' treatment needs regarding: 1) Meetings, 2) Abstinence from all psychoactive drugs, 3) Sponsor (or other helping people), 4) Social support systems, and 5) overall Treatment efforts. (See the discussion on the use of 12-step programs in Chapter 6.)


MASST Areas of Recovery

M: Meetings (12-step or other recovery-oriented self-help)

A: Abstinence from all psychoactive drugs

S: Sponsor and other helping people

S: Social support systems

T: Treatment efforts.


Case Management

Case management is crucial when patients are receiving simultaneous AOD and psychiatric care at separate settings (parallel treatment). There must be good linkages between the two treatment programs or providers. For example, patients might see their mental health counselor three times a week, go to both AOD self-help group meetings and mental health support group meetings, and receive AOD counseling. This level and mix of treatment can be overwhelming and confusing for the patient. An effective case manager can help with planning sensible treatment. Case managers can also facilitate the use of self-help groups. (See the discussion on the use of 12-step programs and other self-help groups in Chapter 6).

The separate disorders, their distinct treatment needs, and the divergent treatment approaches can cause staff splitting and turf problems that exacerbate the patient's denial and can cause other treatment problems. These problems can be avoided in almost all cases by effective communication and coordinated treatment planning. Good psychiatric and addiction treatment efforts are rarely truly conflicting.

Counseling and Psychotherapy For Depression

It is beyond the scope of this TIP to provide comprehensive details on the use of psychotherapeutic treatment. However, there are numerous resources regarding counseling and psychotherapy and depression. Recent publications written for both counselors and patients include The Good News About Depression by M.S. Gold and When Self-Help Fails by P. Quinnet.

Levels of Care

Once psychiatric and addiction severity has been determined, the treatment intensity, structure, and level of care required must be decided. From the least to the greatest intensity, the levels of care are:

  1. Individual treatment with a psychotherapist or counselor. This is the least intensive level of care and includes few, if any, additional treatment services such as education.
  2. Outpatient treatment. Within this level of care are services that vary greatly in structure and intensity. They include weekly to daily individual or group counseling, often in combination with additional treatment services such as detoxification, education, medical services, and specially focused groups. A multidisciplinary treatment team that includes assertive and intensive case management services may be needed for patients with severe and persistent mood disorders coexisting with AOD disorders.
  3. Intensive outpatient treatment. This level of care includes treatment models such as partial hospitalization (which includes day treatment, evening, and weekend programs). For example, patients in day treatment generally participate in a full day of treatment for 5 or more days per week. Intensive outpatient treatment represents a range of treatment intensities. The level of intensity of a given program is based primarily on the number of treatment services offered. Generally, intensive outpatient treatment programs offer several treatment components such as group therapy, educational sessions, and social support services.
  4. Halfway houses. These are settings that serve as safe AOD-free homes for people who can manage independent daily activities and can benefit from a structured and recovery-oriented group living arrangement. They vary widely in style and purpose.
  5. Residential rehabilitation setting. Participation can vary from 30 days to 3 months or more, with patients removed from familiar surroundings and separated from AODs. In residential settings, patients receive education about dual disorders and learn important recovery skills such as utilizing groups, building trust, and talking about feelings. Therapy and support groups provide socialization and support and are the core of treatment. They prepare the patient for increased reliance on group support systems after discharge.
  6. Therapeutic communities. Long-term therapeutic communities often require patient participation lasting from 6 months to 2 years. They are generally considered to be appropriate for patients with severe AOD disorders who have significant social and vocational deficits and who require long-term and intensive support, skill building, interpersonal abilities refinement, and trauma resolution.
  7. Hospitals. Psychiatric or AOD hospitalization may be required for acute and subacute stabilization. In this age of managed care, hospitalization episodes have become much shorter and more acute than a few years ago. This puts more responsibility and risk on outpatient treatment providers.

Patients with severe and persistent mood and AOD disorders frequently require intensive and assertive treatment approaches as outlined in Chapter 8 on psychotic disorders. These patients will benefit from programs that can provide concurrent, integrated dually focused treatment. Also, these patients may require assertive case management to encourage medication compliance and to help them secure all psychiatric, addiction, and social services that they may need.

While some programs for dual disorders exist at all levels of care and in several program models, few AOD or mental health residential programs are dually focused, and many AOD programs refuse to accept patients who have histories of psychiatric disorders or who currently are prescribed medication for psychiatric disorders.

Traditional biases in the addiction field against psychiatric medication should be shed in light of the evidence that medicating existing disorders is humane, can be provided safely, and is necessary for some patients to engage in treatment. It is helpful to use psychiatrists who are skilled and are perhaps specialists in the treatment of coexisting psychiatric and AOD disorders.

Similarly, traditional psychiatric biases regarding rapid medication intervention and some clinicians' emphases on "getting in touch with feelings" can impede or reverse the AOD recovery process. Encouraging emotional expression without regard for the patient's stage of AOD recovery and stability can aggravate AOD disorders. Many residential facilities in the mental health system are inadequately controlled for the presence of AODs, are not abstinence based, and are not safe environments for AOD users.

Family Involvement In Treatment Settings

In all of the above settings, patients should receive family therapy and education, addiction and recovery counseling, and psychiatric counseling. Special attention must be focused on the chronic and cyclical nature of addiction and mood disorders and the likelihood of relapse.

Manic patients' uncontrolled grandiose behaviors have frequently caused their families great stress. Thus, family members need education about the nature of addiction, mania, and recovery. It is necessary for staff to ally with family members to ensure cooperation with treatment and reduce collusion between family members and the patient.

Similarly, the depressed patient is frequently seen as a family burden. Families need assistance to engage the depressed patient. The combination of depression and addiction can be very difficult for family members, and the challenges for the family must be considered.

Family and friends are often mistakenly afraid that they might exacerbate or aggravate depression or mania if they confront the dangerous and maladaptive behaviors and denial that result from addiction and mood disorders. Such fears are ungrounded. In fact, supportive intervention by the patient's social network is helpful with respect to both disorders.

The patient's family should be encouraged to confront the patient rather than remain reticent, and they should be coached to confront the patient in a supportive way. Support for and education of family members are necessary to encourage their constructive involvement and to help them avoid collusion in the patient's drug-using behavior or denial of psychiatric disturbance.

Professional and Vocational Planning

While some patients with dual disorders have severe and poorly remitting mood and AOD disorders, most patients improve, especially with careful psychiatric treatment. Since these disorders are generally well controlled, patients can experience very high levels of vocational, social, and creative functioning. As a result, vocational planning should be long term and accentuate patient strengths.

AIDS and HIV Risk Reduction

Studies demonstrate that HIV/AIDS risk reduction measures can make a difference in the rate of HIV infection. Potential and actual risk behaviors that are identified in evaluation should be addressed by referral to specific educational, training, and intervention programs.

Staff at these programs should be sensitive to patients' cultural and ethnic backgrounds, and understand how these can influence AOD use, sexual behaviors, and patients' receptivity to risk reduction measures. Programs should be proficient in communicating with patients using culturally sensitive language. However, the most culturally insensitive position is to avoid raising these issues out of fear or hesitancy.

With respect to risk reduction, special attention should be paid to the fact that, while depressed, many patients may be sexually abstinent, but this behavior may not reflect their typical behavior patterns. If patients are assessed while they are depressed, they should be asked to describe their sexual behavior during times when not depressed, or perhaps they should be assessed when they are not depressed. Mania and active AOD use markedly elevate the potential for high-risk behaviors and should be seen as extremely dangerous situations for the transmission of HIV and other sexually transmitted diseases.

HIV counseling and testing is appropriate and advisable for patients with coexisting AOD and mood disorders. There is no evidence that people with mood disorders become suicidal or experience thought disorganization in response to HIV testing.

Long-Term Treatment Goals

Treatment goals should include consolidating the AOD-free lifestyle, establishing psychiatric stability, achieving social independence and stability, and enhancing vocational choices and goals. Long-term treatment can be viewed as a maintenance period -- a time for personal growth and development and consolidation of long-term, satisfying patterns of social adaptation.

Addiction Treatment

The long-term management of addiction includes participation in 12-step programs and other support groups, individual and group counseling, and in some cases, continued participation in a treatment program. The severity of a patient's illness should be matched with the appropriate treatment intensity and level of care.

Patients with dual disorders who experience low levels of psychiatric impairment require a level of care that can be provided in traditional low-structure abstinence-oriented addiction treatment programs. Dual disorder patients who experience severe psychiatric symptoms or cognitive impairment require a more intense level of care such as that provided by a highly structured dual disorders treatment program. Matching patients to the appropriate treatment and level of care can help achieve desired outcomes.

Psychiatric Treatment

The majority of patients receiving treatment for combined mood disorders and addiction improve in response to treatment. When they don't improve, there should be a reevaluation of the treatment plan. For example, a patient receiving antidepressant medication who is abstinent from AODs but anhedonic (unable to feel pleasure or happiness) requires a careful evaluation and assessment to identify resistant psychiatric conditions that require treatment. In this example, based on assessment, an additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of addiction treatment and of psychiatric treatment that involves antidepressant medication.

When patients do not improve as expected, it is not necessarily because of treatment failure or patient noncompliance. Patients may be compliant and plans may be adequate, but disease processes remain resistant. Persistent attention to the addictive process and its complications as well as meticulous attention to psychiatric therapy usually leads to improvement. However, patients with severe and persistent AOD and mood disorders should not be seen as resistant, manipulative, or unmotivated but as extremely ill and requiring intensive treatment.

Long-Term Treatment Needs

Patients who have experienced sexual, physical, or psychological abuse may have problems that surface during acute treatment or that are identified during long-term treatment evaluations. Treatment needs resulting from these types of abuse should be addressed in the long-term treatment plan.

The resolution of problems related to sexual, physical, and psychological abuse usually requires specialized, long-term treatment. However, these problems should be addressed whenever they surface in any phase of treatment for AOD and mood disorders.

For example, addressing these problems during early recovery should be viewed from the perspective of anxiety reduction and consolidation of abstinence. At that phase of recovery, the treatment goal is to have patients contain or express their potent and surfacing feelings without using alcohol and other drugs. Later in recovery, these problems can be dealt with in terms of long-term stabilization and psychological resolution.

Continuing addiction counseling and participation in group support activities are useful to help consolidate abstinence. These recovery maintenance activities include participation in social clubs, 12-step programs, religious organizations, and other cultural institutions. Community-based activities can provide long-term stability to these patients.

At this stage of treatment, special treatment needs can be identified through targeted testing in such areas as neurologic, cognitive, and personality disorders. Special treatment needs should be specifically addressed by the appropriate treatment strategy. STD and HIV risk reduction, evaluated throughout the progression of illness, should now address the importance of long-term stable changes in behavior.

Family Issues

Family members should be evaluated for AOD problems in acute and subacute stages when the family members begin to become involved in the patient's treatment. There is usually adequate time to deal with family issues in the subacute phase, when personnel and family members become acquainted. Family members include household members as well as members of the patient's support system.

The family often needs and should receive treatment. After careful evaluation of family dynamics, the presence of addictive disorders or codependent behavior in the family should be evaluated. The presence of AOD and mood disorders in the patient is the best predictor of AOD and mood disorders in the family. A family history of one disease increases the risk for the other; a family history of both disorders multiplies the risk factor.

Family therapy can be provided on site. Individual family members should be referred for the treatment of specific problems when required. It is often necessary to help families "mop up the rage" that has accumulated. It is important to determine when to deal with the family as a group to resolve conflicts and when members need to work with a therapist alone to develop independence from dysfunctional reliance. Participation in Al-Anon and related self-help groups for family members should be encouraged and incorporated in the treatment schedule for family members.

Eating Disorders and Gambling

Other conditions that coexist with dual disorders include eating disorders and pathologic gambling. It may be helpful to refer patients to support groups that deal with these conditions. Eating disorders are more commonly diagnosed in women, and pathologic gambling is more commonly diagnosed in men.

Reassessment and Reassessment...

The purposes of ongoing reassessments are: 1) to continue to refine prior diagnostic assessments, 2) to evaluate life adjustment in general, 3) to evaluate the effectiveness of treatment efforts for the dual disorders, and 4) to evaluate the discontinuation or continued use of medication and other treatments.

Persistently emerging and remitting problems should be addressed. For example, patients who chronically exhibit a negative disposition should be assessed for a personality disorder. Such patients may have a personality disorder with depressive features rather than a mood disorder.

Testing

Specific neuropsychological, psychological, educational, and vocational testing assessments should be performed when necessary and appropriate. These include testing for learning disorders, cognitive or literacy impairments, and personality disorders. These tests are more reliable and accurate when performed following several months of sobriety.

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. Agoraphobia is 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:

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 intoxication can 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


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:

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


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:

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:

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:

Group Therapy

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

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 6 on 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:

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:

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:

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:

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.