Published on August 9, 2007
Midas Dual Disorders Programme: Midas Dual Disorders Programme Adapting Addiction Treatment for People with Personality Problems David Rich CNC Dual Disorder South Western Sydney Area Health Service What is Dual Disorder?: What is Dual Disorder? Dual Disorder refers to co-existing psychological, psychiatric or emotional problem and a drug problem: Also called Dual Diagnosis Comorbidity Double-Trouble Double-Whammy Is it Common ?: Is it Common ? 30% to 60% of drug abusers have mental disorders: Major depression Schizophrenia Bipolar disorder Obsessive Compulsive Disorder Anxiety Panic Post Traumatic Stress 40% to 70% of people receiving help for mental or emotional problems misuse drugs: Self medication Control of side effects of medication Loneliness Boredom Loss of recreational opportunities Is it a Problem?: Is it a Problem? Dual Disorder is the main reason people drop out of treatment The main cause of relapse The most common reason for rejection by treatment agencies The biggest source of misdiagnosis and treatment failure There is controversy surrounding substance abuse clients who have a personality disorder. Many services require an Axis I Disorder before they will acknowledge a Mental Illness.: There is controversy surrounding substance abuse clients who have a personality disorder. Many services require an Axis I Disorder before they will acknowledge a Mental Illness. When Is a Dual Diagnosis Not a Dual Diagnosis? The Reality: The Reality Many people with drug abuse disorders have personality disorders People with other mental illnesses have personality disorders Many of those who have personality disorders abuse drugs You cannot escape us…We are everywhere! Facing Reality: Facing Reality Making addictive behaviours the first treatment priority without concurrent focus on the personality disorder will compromise recovery, while treating only the personality disorder does not deal with the issues of addiction Adapting to Reality: Adapting to Reality Treatment programs have to employ the knowledge and treatment techniques of substance abuse and mental health practitioners. Clients with all types of personality disorders experience cognitive, affective and impulse control difficulties. These influence vulnerability to drugs and the way addiction is expressed. Medication, abstinence as a prerequisite or goal in treatment, confrontation and treatment response to substance use must be modified for each personality disorder. Challenging Behaviour: Challenging Behaviour Substance abuse clients with a personality disorder can present serious treatment challenges because they often demonstrate behaviours that are tenaciously combative, resistive, and manipulative. Issues : Issues Dual diagnosis treatment Defining personality disorder Treatment: Treatment Dual diagnosis requires accessible, comprehensive, integrated and coordinated treatment focused on both psychiatric and substance abuse disorders It is a flexible approach using the knowledge base and treatment techniques of both mental health and addiction specialists Dual Diagnosis Treatment : Dual Diagnosis Treatment Understanding the intricacies of dually diagnosed clients, it is essential to think through definitions of personality disorders, addiction and dual diagnosis and the classifications of co-occurring substance abuse disorders. Basic Definition: Basic Definition Personality disorders exist when personality traits are inflexible and maladaptive and cause impairment in functioning across a wide range of personal and social situations The DSM-IV Axis II Personality Disorders: The DSM-IV Axis II Personality Disorders Divided into 'clusters': Cluster A ~ Paranoid, Schizoid, Schizotypal Cluster B ~ Antisocial, Borderline, Histrionic Cluster C ~ Avoidant, Dependant, Obsessive-Compulsive Cluster A: Cluster A Antisocial Borderline Histrionic Paranoid Personality Disorder: Paranoid Personality Disorder A pattern of pervasive distrust and suspiciousness of others will not forgive injuries received from others they perceive people as deceptive, treacherous, and manipulative These are people who provoke hostility in others via their abrasive, irritable, and antagonistic behavior. Combative and tenacious regarding their personal rights they are largely driven by fear and can be attracted to the 'dominance' drugs~ alcohol, cocaine, amphetamines, steroids. Treatment:Paranoid Personality: Treatment:Paranoid Personality They are usually forced into therapy by family or the legal system, but treatment can involve developing a collaborative partnership against drugs, alcohol, or compulsive behaviors that have 'betrayed' them and allowed the intrusion of the criminal justice system into their lives. Individuals with PPD need to identify and reduce provocative behavior so that others are less inclined to be hostile in return. Treatment:Paranoid Personality: Treatment:Paranoid Personality The confrontation that sometimes occurs in substance abuse treatment will provoke hostility and escalation of dysfunctional defenses; they are comfortable confronting others but interpret ultimatums from authority figures (service providers) as an abuse of power which they will resist and counterattack. Schizoid Personality Disorder : Schizoid Personality Disorder A pattern of detachment from social relationships and a restricted range of emotional expression They fear engulfment and preserve a sense of safety by maintaining distance from others. They withdraw from a world that seems filled with threats against their security and individuality They appear colorless, shy, uninteresting and humorless; they are often ignored Clients with SPD may be attracted to psychedelic drugs and become addicted to the state of arousal and satisfaction involved in facilitated fantasy. They often have a susceptibility to psychiatric crisis following substance use; substance abuse is not necessary. Treatment: Schizoid Personality: Treatment: Schizoid Personality Limited verbal skills require patience; what little is said gives a basis for connection with them. Treatment should address social skills development. The confrontation common in addiction treatment may be ignored by these individuals or result in discharge.. Abstinence cannot be a prerequisite for treatment and use should not result in termination. Extensive psychoeducation is needed on the interaction between substance abuse and psychiatric vulnerability. Schizotypal Personality Disorder: Schizotypal Personality Disorder A pattern of interpersonal deficits with acute discomfort in close relationships marked by cognitive or perceptual distortions and eccentric behavior may lead idle, ineffectual lives and rarely accept enduring responsibilities they are self-absorbed, lost in daydreams, and have peculiar mannerisms These are people who need to believe they have extraordinary, supernatural powers so that they feel less empty Treatment: Schizotypal Personality: Treatment: Schizotypal Personality There is compelling evidence that StPD and schizophrenia are related disorders. Low-dose antipsychotic medication can be effective; Prozac appears to reduce interpersonal sensitivity, anxiety, paranoid ideation, and self-injury. They may resist treatment and/or medication for fear it will make them 'ordinary.' Treatment goals should be similar to those for serious mental illness: concrete, focused, measurable, and modulated to meet the individuals’ capacity. Increasing social networks and development of social skills can be effective. Confrontation can be overwhelming. Abstinence cannot be a prerequisite to treatment nor should use result in termination from treatment. Drug Use: Schizotypal Personality Disorder: Drug Use: Schizotypal Personality Disorder Drugs such as marijuana and LSD may replicate the digressive, tangential quality of thought patterns already present in these individuals Mere drug use can be enough to precipitate a psychiatric crisis Psychoeducation is vital Cluster B: Cluster B Antisocial Borderline Histrionic Antisocial Personality Disorder : Antisocial Personality Disorder A pattern of disregard for, and violation of other people’s rights Deceit and manipulation are integral behaviors Easily frustrated and have a low threshold for discharge of aggression Have a grandiose sense of self-worth View themselves as free and unconfined by obligations Antisocial Personality Disorder : Antisocial Personality Disorder These clients often view others with contempt and detachment but can be gracious, cheerful, and clever when things go their way. They are easily provoked to attack and are inclined to demean and dominate. People with APD are intimidating, brusque, and belligerent. Even if some 'mellow-out' with age, they remain irritable, isolated, and tense. Drug Use: Antisocial Personality: Drug Use: Antisocial Personality Clients with APDs often seek thrills and are often attracted to stimulants. Their use of alcohol and drugs only bothers them because of the pressure they receive from employers, family, or the criminal justice system They assume service providers are predatory but will not relate well to a counselor they think is powerless. The recommended treatment approach is active confrontation of denial of antisocial behavior. Treatment: Antisocial Personality: Treatment: Antisocial Personality Few come into treatment voluntarily Lithium carbonate, beta-blockers, and SSRIs are being used with APD disordered clients to manage symptoms of impulsivity and aggressiveness These individuals are savvy and informed about medication; drug-seeking behavior is a significant problem Clients with APD can be predatory and should not be placed in groups with the seriously mentally ill or vulnerable personality disordered dually diagnosed individuals Confrontation is appropriate and useful. Emphasis needs to be on responsibility for self/behavior, limit-setting, and consequences. Abstinence can be a prerequisite to treatment; use should result in termination from treatment. Borderline Personality Disorder: Borderline Personality Disorder A pattern of instability in interpersonal relationships, self-image, and affect Impulsivity Excessive efforts to avoid abandonment Recurrent threats or acts of self-harm Borderline Personality: Borderline Personality Clients with BPD believe that their distress is to be taken care of by others; they become enraged as they are repeatedly disappointed. They cannot self-comfort and will flee into impulsive behavior. Other people are alternately idealized and hated; they 'love without measure the people they will soon hate' (Benjamin, L.S., 1993). Drug Use: Borderline Personality: Drug Use: Borderline Personality They are the best candidates of all for developing addictive disorders; they will use almost any drug to worst advantage . Binge drug abuse can alternate with periods of intensified compulsive behaviors, e.g., shopping, impulsive and unsafe sexual, eating, and gambling. Initially, engaging, then demanding, they eventually become, draining, exhausting, and infuriating. Treatment: Borderline Personality : Treatment: Borderline Personality Current research indicates that BPD is related to the affective disorders spectrum Medication appears to be more successful for short-term symptom management than long-term stabilization Medication must be matched to the specific target symptoms lithium carbonate and carbamazepine for affective instability, SSRIs for impulsive aggressiveness and low-dose antipsychotics for transient psychotic phenomena Treatment: Borderline Personality: Treatment: Borderline Personality Those who cannot contain their anger and vengefulness often remain marginal in society until they wear out their caretakers and find themselves alone. Confrontation may be useful with high-functioning borderlines; it may overwhelm lower-functioning clients. Abstinence can be a prerequisite to treatment only if the client has significant ego strength. Otherwise, control should be the initial goal of treatment, and use should not result in termination. Histrionic Personality Disorder: Histrionic Personality Disorder A pattern of excessive emotionality and attention-seeking behavior Shallow and labile affect Self-dramatization Suggestibility Self-indulgence Lack of consideration for others Easily hurt feelings Histrionic Personality Disorder: Histrionic Personality Disorder They experience and describe relationships as more intimate than they really are Engage in coercive dependency Controlling and disrespectful behavior is masked by attractiveness and seductiveness An exaggerated expression of emotions makes them appear inauthentic, unconvincing, and infantile. Drug Use: Histrionic Personality : Drug Use: Histrionic Personality Drugs and alcohol or compulsive behaviors are valued for social enhancement Anti-anxiety drugs are often sought; but stimulants provide HPD clients with dramatic mood boosts Unable to sustain control or abstinence in isolation They are likely to enjoy support groups and may integrate with them easily, depending on the support structure and group approval for recovery Treatment: Histrionic Personality : Treatment: Histrionic Personality Treatment involves pressure to delay gratification and learn to think clearly, focus, and hold steady under pressure Confrontation can often be useful Abstinence can be made a prerequisite of treatment Drug use should be confronted but need not result in termination from treatment Medication: Histrionic Personality : Medication: Histrionic Personality SSRIs (antidepressants) have been useful when there is a cluster of symptoms involving Compulsivity Unstable mood Disorganized thinking Narcissistic Personality Disorder: Narcissistic Personality Disorder A pattern of pervasive grandiosity, need for admiration, and lack of empathy Expect to be acknowledged as superior without commensurate achievements Preoccupied with fantasies about themselves They assume other people will submerge their needs in favor of their own comfort and welfare Narcissistic Personality Disorder: Narcissistic Personality Disorder They have an inflated self-image but are vulnerable to the most trivial 'insults' Even when gifted, they seem arrogant, impatient, abrasive, abrupt and hypersensitive Drug Use: Narcissistic Personality Disorder: Drug Use: Narcissistic Personality Disorder They typically feel sorry for people who cannot handle alcohol or drugs. They believe they have unusual will-power and the strength to control the substances they use. Many are attracted to drugs that enhance feelings of vigor, power, or euphoria. They are prone to hidden or secret addictions; they fear discovery and the loss of admiration of others. Since reality is not a serious check on how NPD clients view themselves, negative consequences can accumulate to a substantial degree without challenging their denial system. Treatment: Narcissistic Personality : Treatment: Narcissistic Personality Not likely to enter treatment through self-referral Antidepressants may be needed if defenses break down and depression emerges Clients must learn to recognize and block their patterns of entitlement, grandiosity, and envy Treatment must include confrontation regarding the aspects of reality which are denied, devalued, or avoided Support and possible crisis intervention may be needed for resultant depression Abstinence can be a prerequisite of treatment; consequences do apply and need to be enforced Cluster C: Cluster C Avoidant Dependant Obsessive-compulsive Avoidant Personality Disorder : Avoidant Personality Disorder A pattern of social inhibition and hypersensitivity to negative evaluation Characterized by feelings of apprehension, insecurity, and inadequacy They believe themselves to be inept, unappealing or inferior They avoid others out of fear of rejection, ridicule and humiliation Avoidant Personality Disorder : Avoidant Personality Disorder The avoidant pattern envelopes all of the client’s functioning; situations, feelings and thoughts are intolerable and therefore avoided because of the pain produced Drug Use: Avoidant Personality: Drug Use: Avoidant Personality Vulnerable to substance use that can reduce interpersonal vulnerability or ease social paralysis, including: Sedative-hypnotics (calm anxiety) Stimulants (sense of strength or reduced vulnerability) Mild hallucinogens (escape into fantasy and distract from the pain) Compulsive behaviors are also problematic; they are vulnerable to activities that involve self-adornment (shopping), fantasy, and eating. Medication: Avoidant Personality : Medication: Avoidant Personality They are reluctant to disclose very much and are hypersensitive to perceived degradation Extreme social anxiety may be responsive to MAO inhibitors, beta-blockers or to newer reversible inhibitors of monoamine oxidase (RIMAs) Client may overvalue and actively seek minor tranquilizers or sedative-hypnotics Often the drug of choice with tolerance already in place. Iatrogenic addiction is a significant concern Treatment: Avoidant Personality : Treatment: Avoidant Personality Treatment progress is usually quite slow Critical (sometimes vicious) self-talk must be addressed if treatment is to be successful Confrontation may defeat these individuals and overwhelm their defenses Treatment should be more supportive than is needed for individuals with more self-confidence. Abstinence should not be a prerequisite to treatment but as a goal it can bolster the clients’ sense of personal efficacy through manageable treatment objectives Dependent Personality Disorder: Dependent Personality Disorder A pattern of excessive need to be taken care of that leads to submissive behavior and fear of separation Clients with DPD feel helpless and incompetent; they show passive compliance with others and a weak response to the demands of daily life They will subordinate their desires and refrain from making demands they may tolerate abuse to maintain a relationship. Dependent Personality Disorder : Dependent Personality Disorder DPD clients deny or minimize trouble They avoid tension and limit their awareness of both themselves and others They act friendly, naive, and self-effacing Treatment: Dependent Personality : Treatment: Dependent Personality clients may use alcoholism and other substance abuse as a passive way to escape from problems However, substance abuse may be as much generated via dependency relationships as by true vulnerability to addiction. If these clients can integrate into the recovery community they may be able to achieve and maintain abstinence with relative ease. Relationship addiction may be the powerful and operative dependency; if this issue is not addressed, they will have extraordinary difficulty avoiding relapse Treatment: Dependent Personality : Treatment: Dependent Personality Individuals with DPD may enter treatment via the criminal justice system or self-referral. Early in treatment, they appear attentive, appreciative, and easy to engage. When real change is required, however, the resistance toward independent functioning and autonomy become apparent. Treatment: Dependent Personality : Treatment: Dependent Personality Confrontation should be modified; confrontation that emphasizes self-empowerment will assist in addressing personality issues. If Abstinence it is a prerequisite, most clients will remain self-destructive to preserve existing relationships. Drug use must be confronted; termination may be necessary when clients are not ready to let go of negative or abusive relationships. Medication: Dependent Personality : Medication: Dependent Personality Beyond antidepressants these clients do not usually need medication The passive dependence characteristic of this personality disorder reinforces reliance on mood-altering drugs Iatrogenic addiction is a significant concern Obsessive-Compulsive Personality Disorder: Obsessive-Compulsive Personality Disorder A pattern of preoccupation with orderliness, perfectionism, and control Excessive adherence to social conventions Individuals are pedantic, rigid, and stubborn Obsessive-Compulsive Personality Disorder: Obsessive-Compulsive Personality Disorder They see others as self-indulgent or incompetent OCPD clients are deferential toward authority figures and autocratic toward subordinates They will justify aggressive behavior by recourse to rules or authorities higher than themselves They are tense, grim, and resentful Drug Use: Obsessive-Compulsive Personality: Drug Use: Obsessive-Compulsive Personality OCPD clients may have some protection against addiction because of their adherence to rules and distaste for losing control, although drugs and alcohol can provide relief from their unremitting tension They become vulnerable to abusing prescribed medication because it can be obtained through avenues that are not illegal or dangerous. More muted and controlled expressions of the addictive cycle than other personality disorders May remain functional addicts for long periods of time Medication: Obsessive-Compulsive Personality: Medication: Obsessive-Compulsive Personality OCPD clients may enter treatment via the criminal justice system or self-referral. In treatment, apparent compliance will tend to mask strong resistance. OCPD is frequently accompanied by depression; a medication trial of antidepressants may be appropriate Treatment: Obsessive-Compulsive Personality: Treatment: Obsessive-Compulsive Personality Treatment must address the issue of control; these individuals need to develop tolerance for emotional vulnerability, chance, uncertainty, and impermanence. OCPD clients do not generally inspire warmth in the people around them; sometimes just treating them with ordinary kindness will be enough to develop the collaboration needed for successful change. Treatment: Obsessive-Compulsive Personality: Treatment: Obsessive-Compulsive Personality Confrontation may be needed to launch a successful assault on OCPD clients’ formidable array of defenses. However, given the level of fear and shame underneath the defenses, the support behind the confrontation must be apparent and reliable. Abstinence can be a prerequisite for treatment. OCPD clients often have such a powerful defensive structure that firm limits are beneficial to the treatment process. Use can result in termination from treatment. Conclusion: Conclusion The combination of personality and substance abuse disorders is a complex interweaving of denial, minimization, and externalization. Severe distortions in self-reported symptoms, history and behavior, make diagnosis a critical but difficult endeavor. Intense resistance to change and chronic inability to accept responsibility complicate the task of treating substance abuse and addiction. Conclusion: Conclusion When the services they use take into account their particular issues, people with comorbid Personality Disorders and Drug Abuse respond well to treatment. Patience, flexibility and a long term view are the keys to success.