Psychiatric Annals

DIAGNOSIS AND TREATMENT OF ADDICTIVE DISORDERS 

Diagnosis and Treatment of Psychiatric Comorbidity in Alcoholics and Drug Addicts

Dennis D Beedle, MD; Mark P McGovern, PhD

Abstract

The disease model of addiction, perhaps identified most significantly by the seminal work of E. M. Jellinek, grew out of frustration with the moral and self-medication models. The increased sophistication in medicine and psychiatry has also clarified that there are underlying biologic changes associated with addiction. Afflicted persons aided by the self-help community (by its philosophy and fellowship) are increasingly willing to reveal and discuss their illness. People are more likely to talk about and demonstrate the changes brought about in their lives by being abstinent. This openness may help destigmatize the illness of addiction, especially when those people recovering are public or popular figures held in some regard by the general culture.1

Traditional addiction treatment was born of these influences and flourished during the 1960s to mid 1980s. To some extent, bastioned against these earlier intruders, the addiction treatment community had separate funding mechanisms, research institutes, scientific journals, treatment institutions, specialized training, and a unique clinical provider in the recovering addiction counselor. The 12-step and disease model-based addiction treatment program offered the alcoholic and addict a level of empathy and understanding that had previously been nonexistent, resulting in remarkable success and a devoted following that continues to the present.2

The coexistence of addiction and other forms of mental illness is being increasingly recognized and discussed by clinicians who have historically treated either addiction or major mental illness.3 The illness model is well established for addictions within mainstream medicine, but the long history of addictive behaviors and addictive treatment as distinct from the treatment of other mental illnesses poses special problems for those afflicted with dual mental illnesses and for those who provide services for this group. The separation of the addiction treatment community from other mental health professionals has resulted in a certain isolation and restriction of knowledge about other forms of mental illness that contributes to the difficulty the dually diagnosed patient faces. Traditional psychiatry might misidentify addictive illness as a mood or anxiety disorder and traditional addiction services might ask the patient to suffer from symptoms of major mental illness in the belief that sobriety and recovery would certainly be jeopardized by the recovering person receiving other mental health services. The old belief that all symptoms would eventually remit if one was sober and earnestly worked the 12 steps is no longer the mainstream of thinking. The current dual diagnosis model allows for both provider groups to cooperate and sometimes collaborate in programs to address the needs of the dually diagnosed patient.

BACKGROUND ISSUES

Dually ill patients present in different fashions that are affected by the nature of both illnesses and their combination. For example, alcoholism and borderline personality present differently from alcoholism and schizophrenia. Also, the system of care making the diagnosis may affect the timing of diagnosis. An inpatient psychiatric unit may be quicker to make the diagnosis of depression and an addictions program quicker to make the diagnosis of addictive illness, with the diagnosis of the other illnesses being delayed or being seen as reflective of the primary problem, which is usually what the treatment provider or system is most familiar and comfortable with. The failure to consider the dually ill state of the patient may delay effective treatment of either problem.

The dually ill patient presenting to the traditional psychiatric program might present with depressive, psychotic, or interpersonal symptoms that might identify the patient as suffering from an Axis I or Axis II disorder. If the patient was obviously intoxicated or otherwise screened for substance use, the issue of addiction might or might not be raised. If the patient was suffering from a…

The disease model of addiction, perhaps identified most significantly by the seminal work of E. M. Jellinek, grew out of frustration with the moral and self-medication models. The increased sophistication in medicine and psychiatry has also clarified that there are underlying biologic changes associated with addiction. Afflicted persons aided by the self-help community (by its philosophy and fellowship) are increasingly willing to reveal and discuss their illness. People are more likely to talk about and demonstrate the changes brought about in their lives by being abstinent. This openness may help destigmatize the illness of addiction, especially when those people recovering are public or popular figures held in some regard by the general culture.1

Traditional addiction treatment was born of these influences and flourished during the 1960s to mid 1980s. To some extent, bastioned against these earlier intruders, the addiction treatment community had separate funding mechanisms, research institutes, scientific journals, treatment institutions, specialized training, and a unique clinical provider in the recovering addiction counselor. The 12-step and disease model-based addiction treatment program offered the alcoholic and addict a level of empathy and understanding that had previously been nonexistent, resulting in remarkable success and a devoted following that continues to the present.2

The coexistence of addiction and other forms of mental illness is being increasingly recognized and discussed by clinicians who have historically treated either addiction or major mental illness.3 The illness model is well established for addictions within mainstream medicine, but the long history of addictive behaviors and addictive treatment as distinct from the treatment of other mental illnesses poses special problems for those afflicted with dual mental illnesses and for those who provide services for this group. The separation of the addiction treatment community from other mental health professionals has resulted in a certain isolation and restriction of knowledge about other forms of mental illness that contributes to the difficulty the dually diagnosed patient faces. Traditional psychiatry might misidentify addictive illness as a mood or anxiety disorder and traditional addiction services might ask the patient to suffer from symptoms of major mental illness in the belief that sobriety and recovery would certainly be jeopardized by the recovering person receiving other mental health services. The old belief that all symptoms would eventually remit if one was sober and earnestly worked the 12 steps is no longer the mainstream of thinking. The current dual diagnosis model allows for both provider groups to cooperate and sometimes collaborate in programs to address the needs of the dually diagnosed patient.

BACKGROUND ISSUES

Dually ill patients present in different fashions that are affected by the nature of both illnesses and their combination. For example, alcoholism and borderline personality present differently from alcoholism and schizophrenia. Also, the system of care making the diagnosis may affect the timing of diagnosis. An inpatient psychiatric unit may be quicker to make the diagnosis of depression and an addictions program quicker to make the diagnosis of addictive illness, with the diagnosis of the other illnesses being delayed or being seen as reflective of the primary problem, which is usually what the treatment provider or system is most familiar and comfortable with. The failure to consider the dually ill state of the patient may delay effective treatment of either problem.

The dually ill patient presenting to the traditional psychiatric program might present with depressive, psychotic, or interpersonal symptoms that might identify the patient as suffering from an Axis I or Axis II disorder. If the patient was obviously intoxicated or otherwise screened for substance use, the issue of addiction might or might not be raised. If the patient was suffering from a substance-induced disorder, the sometimes rapid improvement with detoxification would be missed by the decision to immediately start psychotropic medication, or by the belief that the therapeutic milieu had somehow led to a flight into health. Theories of self-medication and a generally more tolerant societal attitude toward substance use and abuse might delay the diagnosis of chemical dependency problems and, in some cases, the psychiatrist might inadvertently end up prescribing other addicting substances for a patient with symptoms that might have best responded to detoxification (eg, prescribing addicting sleeping pills to patients with sleep problems secondary to alcohol or drug use).

The diagnosis and treatment of dually ill patients has increasingly been a focus of both psychiatric- and addictions-based service providers, with extensive literature accumulating in both psychiatric and addictive journals and innovative programming being developed for patients who are dually diagnosed.4 Yet for many patients, treatment services remain fragmented and accurate diagnosis remains problematic.

As traditional psychiatric service providers have become more knowledgeable about addictive illness, there is a parallel process of 12step-based programs likewise becoming more knowledgeable of and open to psychiatric treatments. It is not uncommon for Alcoholics Anonymous (AA) members to be receiving medication or individual treatment, although a strong knowledge of and concurrent focus on the addictive illness are needed by the professional treating the psychiatric illness.5

During the past decade, there has been convergent awareness of the heterogeneity of addicted persons and the consequent need for heterogeneity in treatments (ie, patient-treatment matching). Influenced by clinical research, health care financing mechanisms, and clinical experience, the traditional addictions treatment community has needed to recognize that addiction problems may exist alone, but are often coexistent with other psychiatric disorders. The traditional psychiatric hospital and clinic has also had to recognize that the patient who solely suffers the effects of addictive illness may present requesting services and interventions unlikely to be helpful without a strong addiction focus, despite the patient's strong desire not to look at this problem.6 The traditional psychiatric provider has also had to develop successful strategies to address the problem of patents who suffer from clearly separate problems of major mental illness and comorbid addictive illnesses.7

Prevalence studies document the coexistence of disorders in the community, prisons, psychiatric hospitals, outpatient clinics, and addiction treatment programs.8 This has resulted in a new model for understanding the causes of and treatment for persons suffering from addictive disorders, known as the dual-diagnosis model. In this model, there is a recognition of the possibility of the presence of two undoubtedly related but separate disorder sets with similar yet distinctive etiologies, but with a necessity for discrete diagnoses and specificity in treatment for each.

Acceptance of the dual-diagnosis model of addiction has been slow but steady among both addiction and psychiatric service providers. Preferences for a singular model of addiction with a single path to recovery, concern that psychiatry has not given up the self-medication model, and negative countertransferences toward psychiatric problems (both severe Axis I and Axis ? disorders) have been major obstacles toward the acceptance of the reality of high degrees of comorbidity in patients with addiction and other forms of mental disorder among the addictions treatment community.9 Psychiatric providers often have negative countertransferences toward addictive problems, prefer to work with patients who do not present with the added problems and complexities of acute intoxication, or still believe that patients are truly self-medicating.

ASSESSMENT FOR COMORBID PSYCHIATRIC ILLNESS

In patients with severe and persistent mental illness, the psychiatric disorder may or may not be manifest in both the history and the present signs and symptoms. In patients with psychotic or manic symptoms, the indication for concurrent treatment is immediately apparent. In patients with mild to moderate psychiatric symptoms, depressive mood, poor sleep, anxiety, and interpersonal conflicts, the distinction between the symptoms' being part of a separate illness versus being the consequence of substance use is difficult to determine. 10

The assessment of the relationship between the psychiatric and substance use disorder may reveal that: (1) the psychiatric disorders serve as risk factors for addiction; (2) the psychopathology has modified the course of the addiction; (3) intoxication has caused the psychiatric symptoms; (4) chronic substance use has caused an organic mental disorder; and (5) the substance use and psychiatric disorders are causally linked (eg, benzodiazepine dependency and anxiety disorder). In some cases, the patient will be found to be truly dually diagnosed, and it will also be found that the substance dependence and psychiatric syndrome are not directly connected etiologically. Précipitants, symptom context and sequencing, collateral and laboratory data, and a detailed treatment history can be useful in assessment; however, in general, it is only after detoxification and a period of abstinence that the patient can be observed and diagnostic determinations can be accurately made.3

Patients presenting with an addictive disorder in the addiction treatment setting are at least in a "contemplative" stage of motivation to change their behavior. Some may also be in the "action" stage. With the advent of the cognitive behavioral technique of motivational in tende wing as an important aspect of the addiction assessment, one finds that often the other psychiatric disorder is a motivational barrier to treatment. For example, the fear that the predictable evening of boredom, loneliness, shame, and insomnia will worsen without the nightly pint of vodka provides a "reason" to continue drinking, even when the drinking is the cause of that person's symptoms. A motivational interviewing approach would assess for these disorders (alcohol and depressive) and suggest alternate approaches for symptomatic relief for both.11 The clinician's accuracy in diagnosing two sets of disorders or at least considering the possibility of comorbidity, conveying an empathy and understanding for each, and offering treatment for both can enhance morale and positive expectations for treatment.

TREATMENT PROCESS

Psychiatric disorders, including depression, may not always adversely affect the outcome of addiction treatment.12 There is recent evidence that patients with addiction and comorbid major depression are more likely to seek addiction treatment than those with addiction alone.13 In the case of personality disorders, it is possible that some symptoms or patterns may stabilize, remit, or change as a direct or indirect consequence of the addictions treatment. In traditional 12-step-based addiction treatment, the person and his or her life must be inventoried and changed. Grandiosity, self-centeredness, dishonesty, and manipulation are common "character defects" that the recovering person might address as part of traditional recovery in a 12step model.

In some cases, the attempt to engage in individual treatment may delay the recovery process and in general should not be undertaken until a significant period of abstinence and 12-step involvement. For patients whose character pathology is so significant that engagement in recovery and 12-step programming has failed on several occasions, it may be necessary to address these issues on an individual basis; however, the primary goal is for the patient to enter addictions treatment and achieve stable abstinence. Problems related to the ongoing use of substances need to be pointed out as evidence that the addiction is a separate illness for the patient.

Severe coexisting psychiatric symptoms can undermine the treatment processes.14 In mood, thought, or cognitive disorders this may involve the patient's not being able to apprehend or act on the psycho-educational components. Socia] anxiety, agoraphobia, claustrophobia, and panic attacks make attending 12-step groups aversive for some patients otherwise motivated for recovery. Patients with personality disorders, particularly narcissistic, borderline, antisocial, and avoidant disorders, are highly prevalent in addiction treatment settings. The behavior and dynamics of individuals with personality disorders in an intensive outpatient milieu or residential program can generate chaos, splitting, sexual and aggressive acting out, and boundary violations and can elicit strong countertransference responses, which the untrained clinician may nontherapeutically act on. Being able to diagnose Axis ? problems and anticipate and appropriately respond to their interpersonal dynamics is imperative in milieu-based addiction programs.

During the course of detoxification and early primary treatment for an addiction, a patient is assessed and presented with data about the cumulative consequences of his or her problematic use of substances. This is intended to instill motivation, break down denial, and facilitate acceptance of the need for a recovery. For patients with depression, this process, if handled unempathically, can plummet them into deteriorative despair, shame, and guilt. Risks of attrition, relapse, impulsivity, increased depression, and suicidality become greater.

The current process of the treatment of addiction must clearly have the capability to recognize and respond to psychiatric disorders. This can be accomplished with either an integrated model (ie, a dual-diagnosis program) or a parallel model, where psychiatric and addictive services are separate but highly coordinated (ie, concurrent treatment in two different programs). A less preferable, option is sequential programming (the serial model) in which the most acute problem is dealt with first and the other, often more chronic problem is treated later by an unrelated treatment provider.15

POST-TREATMENT, AHERCARE, AND RECOVERY

Because addiction can be understood as a chronic relapsing illness, efficacy in management versus a cure is the goal of primary treatment. Accordingly, the patient "discharged" from addictions treatment is transitioned to "aftercare" that often consists of weekly group sessions led by a professional. These sessions have a relapse prevention focus. In addition, regular attendance and participation in 12-step meetings is recommended, and doing so has been demonstrated to be associated with positive outcomes.2 The aftercare therapist or relapse prevention specialist should be assessing for ongoing vulnerabilities or triggers to relapse. Often it is this clinician who identifies the appearance or development of psychiatric disorders, and makes a referral accordingly. Also, during this aftercare phase, relational tensions (marital or workplace) or patterned interpersonal problems (personality disorder, posttraumatic stress disorder, or trauma issues) can be identified and a referral to a specialized psychotherapy considered.

In previous decades, the notion of an alcoholic or addicted person being treated with psychotropic medication or in psychotherapy was an anathema to the 12-step recovery community. The use of medication was perceived as yet another escape to a drug, and psychotherapy was perceived as a futile effort at intellectualization, of seeing oneself as special or different, and as a resistance to true surrender and fellowship. Currently, surveys of AA members report more than one-third with psychiatric medication and close to half in psychotherapy or counseling. The growing number of women in 12-step groups may account in part for this increased openness to accepting outside professional help. There is increasing awareness that there are differences and that some people attempting 12-step recovery need more help to obtain this goal and to remain sober than the traditional program can offer.1 For patients whose comorbid disorders were identified at assessment or during treatment, medication management, milieu, and group or individual psychotherapies should be continued along with case management services for the severely ill.11

Pharmacotherapy for primary psychiatric disorders should be continued and regularly monitored. As with other medications used by these patients, such individuals may need to be seen more frequently and be closely monitored for abusive use patterns of medications, even when nonhabituating medications are used. The use of medications for patients who suffer from addictive illness needs to take into account the likelihood of relapse or continued substance use in patients who have not yet demonstrated motivation or ability to maintain sobriety. Generally, providing small quantities of medication and, when possible, having use supervised by a responsible person is the safest course to minimize the risk of toxicity associated with relapse. The development of pharmacologic agents to decrease relapse rates is under intense investigation, but currently use of these agents should be as adjunctive to other, more well-established therapeutic strategies.

SUMMARY

There is increased awareness of comorbid psychiatric disorders in addiction treatment settings and in patients who present in other settings with addiction problems. Comorbidity complicates treatment entry, diagnosis, motivation, successful utilization, and outcomes. Fortunately, the addiction field has evolved in its sophistication in the understanding of the dual-diagnosis issue, and has developed capacities for integrated and parallel service delivery.16 Given the challenging nature of the work with addicted patients, as well as the continued stigmatization of those who suffer its effects, it is likely that addiction programs will remain viable in the future as distinct clinical entities. Addictionologists will continue to develop capacities to deal with a broader range of coexisting psychiatric disorders and will increasingly work in broader collaboration with other mental health care providers.

REFERENCES

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10.3928/0048-5713-19981201-09

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