Mamy patients admitted to general hospital psychiatric units have substance abuse disorders, either as the primary problem or concomitant with a major mental disorder. Conventional treatment of mental disorders is usually effective, although more time may be needed, and response to medication may be unpredictable. Depressive symptoms often clear promptly without need for specific measures. Management problems are most often seen when substance abuse is the only diagnosis. Contact with the outside should be markedly limited, and a structured milieu is more effective than a permissive one. Treatment in the general hospital must be limited to the acute problem. Efforts to unravel or resolve the problems of chronic addiction should be avoided for treatment of addictive disorder cannot be accomplished in a few weeks.
Patients with substance abuse disorders are almost always present on psychiatric units, although staff members often wish they would go elsewhere. Sometimes they are admitted for complications of substance abuse, such as intoxication or withdrawal, sometimes for treatment of substance abuse or addiction per se, and sometimes they are admitted without the recognized presence of substance abuse. If the substance abuse patient is simply treated like everyone else, without consideration of special needs, the outcome is likely to be inefficient, the treatment ineffective, and staff morale eroded.
Most drug programs are incapable of handling disturbed patients. Drug abusers who have severe psychiatric symptoms are the most likely to drop out of conventional detoxification programs, also deriving the least benefit from therapeutic communities. Many substance abusing patients seek hospital care repeatedly but refuse to accept treatment in drug or alcohol programs. Some individuals who have both serious mental disorders and who also abuse sedatives, opiates, or stimulants prefer to identify themselves as drug addicts rather than as mental patients (as do their families). Thus, patients who cannot or will not be treated in drug programs, and those who use drugs but who have an underlying mental disorder all become the responsibility of the general hospital psychiatric unit.
In this article mental disorder signifies all disorders other than substance abuse, substance dependence, and organic mental disorders associated with them. This is done for clarity, not to quarrel with the fact that substance abuse disorders are found in our classifications as a subset of the mental disorders. Addici, addicted, and addictive disorders are used as they were in past years because they are familiar and because their slightly pejorative tone conveys the attitude of most hospital staff members toward these patients.
When a patient with substance abuse disorder is to be treated on a psychiatric service, treatment must be based upon astute assessment and realistic selection of therapeutic objectives. The differential diagnosis for a newly admitted patient may include schizophrenia, mania, toxic psychosis, withdrawal syndrome, atypical psychosis, and malingering. The patient may have several of these simultaneously, and may experience untoward effects of more than one abused substance. The familiar psychopathologic characteristics of mental disorders may be modified by the addictive disorder, by underlying personality factors, or by social forces. Many individuals who have addictive disorders display a behavioral style known as "street behavior." This style, often seen in jails, is characterized by self-centeredness, contempt for authority, exploitiveness, restlessness, and wariness. Much of their time is spent "hanging out," talking about drugs. Personal responsibility is denied and, despite an air of toughness, there may be a thin-skinned quickness to take offense. An individual who has acquired this style may be interactive and approaching, even though there is a clear-cut schizophrenic disorder. While many addicts have spent years "on the street," the addict who has continued to work and maintain middle class life may behave more normally, showing only subtle characteristics of addictive style. "Street behavior" may be learned, or it may develop as a defensive maneuver, as in the "pseudopsychopathic schizophrenia" described by Geller.2 Usually, however, the addict who is also chronically schizophrenic is a relatively inept manipulator. His behavior is poorly integrated and clumsy. He may be spared the social isolation that is the lot of many schizophrenics, but he is recognized by other addicts as odd.
Acute psychotic episodes are a frequent cause of hospital admission. These episodes are commonly characterized by disturbed behavior, poorly systematized persecutory delusions, intense affect, but no thought process disorder. Level of function mayhavedeteriorated, but it may be impossible to determine whether this is a product of schizophrenia or of long-standing addictive disorder. Furthermore, when a mental disorderdevelops, after addiction has been present for several years, the link is unclear. McLellan, Woody, and O'Brien, following a group of patients for six years, observed that five of 1 1 stimulant users developed psychosis and eight of 14 depressant users developed depression.3 Use of drugs may precipitate manifestations of underlying disorder, or they may mask it, with the consequence that abstinence leads to symptoms. Opiates may have an anti-psychotic effect, may potentiate neuroleptics,4 and the structure imposed by participation in a methadone maintenance program may be beneficial to a schizophrenic patient. As Salzman has observed, the diagnosis of schizophreniform disorder is appropriate for most of the psychotic episodes thai occur within the context of addiction/ Neuroleptic medication is usually effective for controlling the episode, but years of drug usage seem to alter the body's handling of medications. Some individuals respond to rathersmall doses of neuroleptic, while others do not respond to the doses within the time period effective for most disturbed patients. Should the patient be advised to continue medication after the episode has subsided? Most opiate users simply will not take neuroleptics for an extended period. M et had one-maintained patients complain that tranquilizers do not allow them to feel their methadone. Dangerous side effects are no more common in addicted patients than in others, but use of neuroleptics is usually associated with constant complaints. Thioridazine seems to be the most acceptable agent to most opiate users. Sometimes rather small doses reduce tension and lessen the patient's sensitivity to affront. The substance abusing patient who is willing to continue taking neuroleptic medication is probably the one who needs it. Lithium is rarely continued by the opiate addici patient, possibly because of an unpleasant interaction.11 Furthermore, if there are no side effects at all, it will be rejected, for a medication that produces no palpable effect is perceived as worthless.
Substance abusing patients often seek admission with complaint of depression and thoughts of suicide.6 Insomnia, usually an indicator of the severity of depression, cannot be relied upon, for insomnia is the norm in addiction. In many instances, outward signs of depression disappear immediately after admission. Depression is frequently attributed to some environmental or interpersonal crisis, such as loss of a love object or a relative. The rapid improvement is probably related ?? the gratification of dependency needs, but malingering must be included in the differential diagnosis. If the psychiatrist listens not only to what the patient tells him, but to what the patient tells others, he may learn more from the patient's report to the admitting doctor. "I feel suicidal " is popular, but "I hear voices telling me to kill" is thought to be more potent. This most potent complaint is risky for the report of hallucinations may lead to administration of a neuroleptic. The patient who says he feels suicidal is usually communicating a need for care. The dilemma posed by such patients isthat although they are decidedly at the risk of premature death which may be associated with violence, affectless suicide, or an accidental overdose,Sl6 acute hospital care cannot resolve the chronic underlying disorder.
When depression develops after years of addiction to opiates or alcohol it is not clear whether this is a consequence of toxic or depressant effect upon the nervous system or a reactive depression associated with realistic self-appraisal related to the patient's awareness that he has nothing and lacks skills or resources upon which to build a future. The most accurate diagnosis in many cases is not depressive disorder, but what Klein has called demoralization - ". . .a belief in one's ineffectiveness. . .a change in self-image in the direction of helplessness. Demoralization responds to a wide variety of encouraging measures, but not to antidepressant medication or to psychotherapy,"7 In some instances, depression develops during withdrawal and complicates early efforts toward recovery. In the context of general hospital psychiatry, depressive symptoms usually lift immediately after admission, or they fade out during the first week of hospital care, making it impossible to determine whether recovery has occurred as a consequence of detoxification or as a response to non-specific encouraging measures. Since there are several routes to rapid recovery, antidepressant medication should not be used unless there is melancholia or unless depression continues after detoxification. Just as psychiatrists are eager to treat an affective disorder with medication, the addict is eager to discover a medication that will eradicate his pains and troubles. Psychopharmacologic approaches, even when ineffective, reinforce the patient's conviction that he should keep searching for the pill that will cure.
In addition to patients who have substance abuse problems, many individuals use substances irregularly, without apparent harm, or use them only during an episode of mental disorder. For example, excessive use of alcohol is commonly seen in mania. It is appropriate to treat such patients for the mental disorder alone. Whenever a decision is made to dismiss substance abuse as merely a symptom of mental disorder, it is essential to remember that staff members at all levels are easily seduced into believing that the patient who is successful, plausible and attractive (but not necessarily young) should be treated by insight-oriented psychotherapy, and not by the more simplistic techniques of a substance abuse program.
The impact of addicted patients on a psychiatric unit is directly proportionate to the number present. Oneortwo may be unobtrusive. When there are five or six, they may dominate the unit, for they have a need for stimuli and activity. They may intimidate other patients or staff members. In groups or community meetings, they may divert attention to what the staff is doing wrong, enumerating all the services that should be provided, or they may dominate a group discussion with talk of drugrelated exploite. It is often helpful to assign specific staff to work with addicted patients, and to maintain activities for them apart from the rest of the unit. Every effort should be made to avoid high noise level or continuous stimulation.
Management problems are inversely related to the severity of the mental disorder. The patient who needs only detoxification is apt to be bored, interested in outsmarting the staff, or pursuing sexual contact. When psychosis is present, it, not addictive behavior, dominates the clinical picture.
To a remarkable degree, the policies and procedures of psychiatric facilities are written as if the typical patient is a withdrawn schizophrenic who needs socializing experiences and who must be protected from the dehumanizing influence of a total institution. Respect for privacy, free access to visitors, passes, and use of personal clothing are embroidered into policies, standards, and regulations. For most hospitalized addicts, access to the outside is as therapeutic as introduction of bacteria to the operating room. Contraband substances are an ever-present concern, and every effort must be made to prevent their introduction. The freedom and permissiveness that alleviates power struggles with schizophrenic and personality disorder patients increases tension and difficulty with addicts. For these patients, structure is needed. Punitive approaches are useless.
Disturbed behavior, when a manifestation of psychotic illness, is treated as it would be in the non-addict patient. Treatment for intoxication or withdrawal psychosis calls for specific measures. It is important, however, that every instance of ill temper or impulsiveness not be regarded as a symptom of mental illness. To use potent medication as a "chemical strait-jacket" whenever there is poorly controlled behavior conveys the message that all bad behavior is illness and that the staff, not the patient himself, is responsible for maintaining control. Belligerent behavior is most common when contraband intoxicants have been introduced. In the general hospital psychiatric unit with its circumscribed treatment objectives, use of contraband is best conceptualized as misbehavior, not recrudescence of illness. In the longterm rehabilitation-oriented setting these issues may be handled quite differently and the dynamics of the behavior may be the main concern. In the short-term unit it is usually more appropriate to discharge the patient, conveying the message that a certain measure of control must be maintained. The patient who is discharged because hedoes not control his actions maybe readmitted a few weeks later if he is able to cooperate. When the treatment situation becomes distorted to the extent that the staff wants to treat the patient but the patient takes no responsibility, the staff will probably become worn out before the patient, for he is holding the hoop, while they are jumping Through it. To apply Jn the general hospital psychiatric unit, the attitudes and techniques of the longterm rehabilitation setting is implausible and dangerous.
The most important element of effective inpatient treatment is defining what is to be accomplished. Since the patient may have multiple and complex problems, staff members may find themselves trying to solve concrete problems, searching for an ideal after-care program, and trying to discover the psychological problems that caused the addiction. The mission of general hospital inpatient psychiatry is acute care. Definitive treatment of addictive disorder requires chronic care. The patient may seduce the staff mem ber by insisting, "I want to find out why I do these things"and by stating that talking helps him feel better. The objective of inpatient psychotherapy should be limited to exploration of the obstacles to continuing rehabilitation. The addiction must be confronted, yet not treated, Many addicts and their families have unrealistic, even magical expectations about the importance of entering a hospital, not realizing that it is not here that recovery takes place.
Some patients never follow through with outpatient or continuing care. Once it is established that a patient does not participate in recommended treatment, the most practical step is to accept that the patient's care must be delivered in episodes. The objective then is to link the episodes with a long-term treatment plan. It is often useful to concentrate during each episode on a single facet of the patient's problem, avoiding the temptation to become engulfed in complex psychosocial issues. Exhortation about the irrationality, or dangerousness of addiction is valueless. If any message is to be reiterated, perhaps it should be the message that recovery requires a very long series of small, relatively ungratifying steps. This is difficult for the individual who requires quick gratification. Education about treatment expectations may be useful. If an individual does not appreciate that therapy may involve anxiety and uncertainty, he is likely to either drop out quickly or return to drugs. The publications of Alcoholics Anonymous (AA) provide information about what many people have experienced when they begin to face life without alcohol and what they found effective as methods of coping. A A's advice may be translated into terms appropriate for drug users."
Underlying most treatment of addictive disorders is the principle that control must be established before any meaningful therapy can be conducted. Treatment is difficult because of the lack of observing ego at the start and the tendency of the addict toexternalize responsibility for almost everything. Treatment plans that are often proposed for depressed or schizophrenic patients are unproductive. "Develop trusting relationship," "enhance self-esteem," or "provide model of mature behavior," are examples of treatment approaches which cannot be accomplished in a few weeks. "Encourage expression of anger" is usually the wrong technique except in the context of long-term treatment. More useful short-term efforts might be relaxation training, exercises in problem solving, exercises in correction of misinterpretation, or workshops on alternative behaviors. Just as some people have a few days of instruction in golf or tennis each year at camp or a resort, patients who have repeated short hospital stays can be provided, each time, with additional lessons in better ways of coping. At all times the message must be reiterated that recovery can occur only if the patient makes the effort. Whether or not a mental disorder complicates the picture, the substance abuser hopes for a passive cure. He would rather discuss how he feels than how to change his behavior.
For years we have tried to teach our staffs (and the general public) that the proper response to manifestations of mental illness is understanding, that what was once described as bad behavior must now be considered illness. Because of the widespread conviction that underlying causes must be addressed, many are reluctant to accept the observation that insight-oriented therapy is usually ineffective in the presence of active substance abuse. Toa remarkable degree, those who have overcome punitiverejecting attitudes toward addicts are irresistibly driven to attempt psychotherapy with them.
Effective care of patients with addictive disorders in the acute care general hospital psychiatric unit requires that the patient's environment be structured, that he be protected from contraband medications or drugs, and that staff appreciate that add iction cannot be overcome in a short time. Even when the patient asks for psychotherapeutic sessions aimed at understanding his problem, efforts should be focused entirely on the need for abstinence and for continuing care. Toxic psychosis and a withdrawal syndrome can be treated quickly and efficiently. Detoxification from addicting substances can be easily provided. Concomitant schizophreniform episodes respond, although at times slowly, to conventional anti-psychotic treatment. The nature of depression in the context of addiction is still unclear although when major depressive disorder is clearly present, antidepressant medication may be of some value. When a mental disorder can be diagnosed, it is best to treat it as if addiction were not a factor, but in many cases, the addicted patient will not take the medication if it does not produce an effect that he likes. The message to the addicted patient in the general hospital psychiatric unit must be: "Now that we have treated your acute problem, you must do something about your chronic condition. It is a potentially fatal disease, and we have no cure for it here." For staff members to believe that their efforts can be the definitive treatment of addiction is as unrealistic as the patient's belief that the right doctor, the right medication, or the right program will make him well, without his making a prolonged, difficult effort.
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