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Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 42.)
The co-occurrence of mental disorders with substance use disorders (SUDs) is the rule, not the exception. Addiction counselors should expect and prepare to see clients with these disorders in their settings.
Addiction counselors generally do not diagnose mental disorders. But to engage in accurate treatment planning and to offer comprehensive, efficacious, and responsive services (or referral for such), clinicians must be able to recognize the disorders most likely to be seen in populations who misuse substances.
It is not always readily apparent whether a co-occurring mental disorder is directly caused by substance misuse or is an independent disorder merely appearing alongside an SUD. This differentiation can be difficult to make but is critically important, as it informs treatment decision making.
Suicide and trauma are sadly common across most combinations of co-occurring disorders (CODs) and require special attention. Addiction counselors have an ethical and professional responsibility to keep clients safe and to provide services that are supportive, empathie, and person-centered, and that reduce suffering.
Disentangling symptoms of SUDs from those of co-occurring mental disorders is a complex but necessary step in correctly assessing, diagnosing, determining level of service, selecting appropriate and effective treatments, and planning follow-up care. This chapter is designed to facilitate those processes by ensuring addiction counselors and other providers have a clear understanding of mental disorder symptoms and diagnostic criteria, their relationships with SUDs, and pertinent management strategies.
This chapter provides an overview for working with SUD treatment clients who also have mental disorders. The audiences for this chapter are counselors, other treatment/service providers, Supervisors, and Administrators. It is presented in concise form so that user can refer to this one chapter to obtain basic information. The material included is not a complete review of all mental disorders and is not intended to be a primer on diagnosis. Rather, it offers a summary of mental disorders with special relevance to co-occurring SUDs (see the section “Scope of the Chapter”).
Since the original publication of this Treatment Improvement Protocol (TIP), updated mental disorder criteria have been published in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). This chapter contains these latest criteria and, where available, data from prevalence studies and randomized controlled trials in reflection of DSM-5.
The chapter begins with a brief description of selected mental disorders and their DSM-5 diagnostic criteria. For each disorder, material highlights some of the descriptive and diagnostic features, prevalence statistics, and relationship to SUDs. In general, the mental disorders in this chapter are presented in the following descending order by how commonly they co-occur with SUDs, although this is not applied rigidly: Depressive disorders, bipolar I disorder, posttraumatic stress disorder (PTSD), personality disorders (PDs), anxiety disorders, schizophrenia and psychosis, attention deficit hyperactivity disorder (ADHD), and feeding and eating disorders.
Because of the greater availability of case histories from the mental health literature, the illustrative material has more emphasis on the mental disorders. Although not intended to offer extensive guidance on treatment, this chapter's coverage of specific mental disorders does include brief information about interventions for and clinical approaches to managing CODs involving each. (Chapter 7 focuses on treatment models for people with CODs.) Case histories illustrate the interaction between mental disorders and SUDs. Each diagnostic topic contains an Advice to the Counselor box containing key considerations related to diagnosis, treatment, or both.
The next main section of this chapter addresses substance-related disorders, including SUDs and substance-induced mental disorders. (DSM-5 uses the term “substance/medication-induced disorders”; this TIP focuses on nonmedication substances and thus will exclude the term “medication.”) Because the primary audience for this chapter is addiction counselors, readers are assumed to be highly familiar with SUDs and their diagnostic criteria. Thus, the SUD section is briefer than the mental disorders section. The overall focus remains on substance-induced mental disorders, their relationship to independent co-occurring mental disorders, and what counselors need to know in terms of assessment and treatment.
Licit and illicit drugs of misuse can cause symptoms that are identical to the symptoms of mental Illness. Mental disorder diagnoses should be provisional and reevaluated constantly. Some mental disorders are really substance-induced mental disorders, meaning they are caused by substance use. Treatment of the SUD and an abstinent period of weeks or months may be required for a definitive diagnosis of an independent, cooccurring mental disorder. A fuller discussion of substance-induced disorders is provided later In this chapter.
The chapter ends with an overview of two concerns that appear across nearly all COD populations: suicidality and trauma. Although suicidality is not strictly speaking a DSM-5-diagnosed mental disorder, it is a high-risk behavior requiring serious attention by providers. The discussion of suicidality highlights key information addiction counselors should know about risk of self-harm in combination with substance misuse, mental disorders, or both. The section offers factual information (e.g., prevalence data), commonly agreed-on clinical practices, and other general information that may be best characterized as “working formulations.” Like suicide, trauma itself is not a mental disorder but is extremely common in many psychiatric conditions, frequently coincides with addiction, and increases the odds of negative outcomes, including suicide. Having at least a basic understanding of suicide and trauma is a core competency for addiction counselors working with clients who have CODs and will help improve their ability to not only offer effective services but keep clients safe.
The mental disorder section of this chapter does not include all DSM-5 mental disorders. The consensus panel acknowledges that people with CODs may have multiple combinations of the various mental disorders presented in this chapter (e.g., a person could have an SUD, bipolar I disorder, and borderline PD [BPD]). However, for purposes of clarity and brevity, the panel chose to focus the discussion on the main disorders primarily seen in people with CODs and not explore the multitude of possible combinations. This does not mean that other mental disorders excluded from this chapter cannot and do not co-occur with substance misuse. But the scope of this chapter is such that it focuses only on mental disorders most likely to be seen by SUD treatment professionals.
The consensus panel recognizes that although this chapter covers a broad range of mental disorders and diagnostic material, it cannot and should not replace the comprehensive training necessary for diagnosing and treating clients with specific mental disorders cooccurring with SUDs. Readers of this TIP are assumed to already have working knowledge of mental disorders and their symptoms. The “Advice to the Counselor” boxes cannot fully address the complexity involved in treating clients with CODs. These boxes distill for counselors the main actions and approaches they can take in working with clients in SUD treatment who have the specific mental disorder being discussed.
The consensus panel recognizes that this chapter cannot cover each mental disorder exhaustively and that addiction counselors are not expected to diagnose mental disorders. The panel's limited goals for this chapter are to increase SUD treatment counselors’ familiarity with mental disorder terminology and criteria and to guide them on how to proceed with clients who have these disorders. The chapter also is meant to stimulate further work in this area and to make this research accessible to the addiction field.
The depressive disorders category in DSM-5 comprises numerous conditions; addiction counselors are most likely to encounter major depressive disorder (MDD) and persistent depressive disorder (PDD; also called dysthymia) among their clients. Common features of all depressive disorders are excessively sad, empty, or irritable mood and somatic and cognitive changes that significantly affect ability to function.
WARNING TO COUNSELORS: KNOW YOUR LIMITS OF PRACTICE.
MDD is not merely extreme sadness, although sad mood is a defining characteristic. MDD is marked by either depressed mood or loss of interest in nearly all previously enjoyed activities. At least one of those symptoms must be present and must persist most of the day, almost every day over a 2-week period (Exhibit 4.1). Other core physical, cognitive, and psychosocial features of MDD also must be present nearly every day, with the exception of weight change and suicidal ideation.
EXHIBIT 4.1. Diagnostic Criteria for MDD.
MDD is highly associated with suicide risk. A study reported 39 percent of people with a lifetime MDD diagnosis contemplated suicide; nearly 14 percent had a lifetime history of suicide attempt (Hasin et al., 2018). Yet suicide is not isolated to those with depressed mood. Counselors always should ask clients whether they have been thinking of suicide, whether or not they have, or mention, symptoms of depression.
Severe depressive episodes can include psychotic features, such as an auditory hallucination of a voice saying that the person is “horrible,” a visual hallucination of a lost relative mocking the person, or a delusion that one's internal body parts have rotted away. However, most people who have an MDE do not exhibit psychotic symptoms even when the depression is severe (for more information on psychosis, see the section “Schizophrenia and Other Psychotic Disorders”).
MDE must be distinguished from grief or bereavement, which are not mental disorders but rather normal human responses to loss. However, grief and MDD can be experienced at the same time; that is, the presence of grief does not rule out the presence of MDD. DSM-5 provides detailed guidance on diagnosing MDD in people who are bereaved.
PDD presents as excessively sad or depressed mood that lasts most of the day, more days than not, for at least 2 years. PDD is somewhat of an “umbrella” diagnosis in that it covers two different types of people with depression: people with chronic MDD (i.e., depression lasting at least 2 years) and people who do not meet criteria for an MDD (see Criteria A through C in Exhibit 4.1) but otherwise have had depressive symptoms for at least 2 years. Thus, the criteria for PDD (Exhibit 4.2) are similar to, but less severe than, those of MDD.
EXHIBIT 4.2. Diagnostic Criteria for PDD.
Data from a national epidemiological survey indicate the 12-month and lifetime prevalence rates of DSM-5 MDD are 10 percent and 21 percent, respectively (Hasin et al., 2018). Prevalence of MDD in emerging adults (ages 1 8 to 29 years) is 3 times higher than the prevalence in older adults (ages 60 years and older). Women are 1.5 times as likely to report depression as men (Hasin et al., 2018).
Twelve-month and lifetime prevalence rates for DSM-5 PDD in U.S. samples have not been reported at the time of this publication. Using DSM-IV criteria, 12-month and lifetime prevalence of PDD in U.S. adults are estimated at 1.5 percent and 3 percent, respectively; DSM-IV dysthymia has an estimated 12-month and lifetime prevalence of 0.5 percent and 1 percent, respectively (Blanco et al, 2010).
Depressive disorders are highly comorbid with SUDs. For instance:
Presence of a 12-month or lifetime DSM-5 drug use disorder (i.e., a nonalcohol SUD) is associated with a 1.5 to 1.9 increased odds of having any mood disorder, a 1.3 to 1.5 increased odds of having dysthymia, and a 1.2 to 1.3 increased odds of having MDD (Grant et al., 2016).
Twelve-month alcohol use disorder (AUD) is also associated with an increased risk of MDD and lifetime AUD with persistent depression (Grant et al., 2015).
A lifetime diagnosis of DSM-5 MDD is more likely to occur in individuals with a history of SUDs (58 percent; for AUD, 41 percent) than in people with a history of any anxiety disorder (37 percent) or PD (32 percent) (Hasin et al., 2018).
People with depression and co-occurring SUDs tend to have more severe mood symptoms (e.g., sleep disturbance, feelings of worthlessness), higher risk of suicidal ideation and suicide attempts, worse functioning, more psychiatric comorbidities, and greater disease burden (including increased mortality) than people with MDD alone (Blanco et al., 2012; Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012). They are less likely than people with MDD alone to receive antidepressants—despite strong evidence supporting the efficacy of antidepressant medication in alleviating mood and even some SUD symptoms (Blanco et al., 2012).
Addiction counselors may represent a way to reduce lags in adequate depression care in people with depressive disorders and SUDs. Among 3.3 million people who reported both MDEs and SUDs between 2008 to 2014, only 55 percent received services for depression in the previous year (Han, Olfson, & Mojtabai, 2017). However, people who had received SUD treatment in the past year were 1.5 times more likely to have received depression care than people who had not engaged in SUD treatment (80 percent vs. 50 percent, respectively) and were 1.6 times more likely to perceive their depressive care as being helpful (48 percent vs. 32 percent) than people who did not access SUD treatment in the previous 1 2 months (Han, Olfson, & Mojtabai, 2017).
Other facts about depression and SUDs that addiction counselors should know include the following:
Both substance use and discontinuance can be associated with depressive symptoms.
During the first months of sobriety, many people with SUDs can exhibit symptoms of depression that fade over time and that are related to acute and protracted withdrawal.
People with co-occurring depressive disorders and SUDs typically use a variety of drugs.
Recent evidence suggests there is increasing cannabis use with depression, although cannabinoids have not been shown to be effective in self-management of depression. In fact, cannabis may actually worsen the course of MDD and reduce chances of treatment seeking (Bahorik et al., 2018).
Psychotherapy (e.g., integrated cognitive-behavioral therapy [CBT], group CBT), with or without adjunct antidepressant use, can effectively reduce frequency of substance use and depressive symptoms and improve functioning briefly and over the long term (Paddock, Hunter, & Leininger, 2014; Vujanovic et al., 2017). In a review examining MDD and AUD specifically (Riper et al., 2014), treatment as usual supplemented with CBT and motivational interviewing had small but significant effects in improving depression and decreasing alcohol use versus treatment as usual alone or other brief psychosocial interventions.
For more extensive guidance about counseling clients with addiction and depression, see TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (Center for Substance Abuse Treatment [CSAT], 2008).
Bipolar I disorder, also sometimes termed manic-depression, refers to a mental state wherein a person's mood fluctuates wildly between depressive and manic episodes (Exhibit 4.3). During depressive episodes, a person experiences symptoms of MDD (e.g., excessive sadness, loss of interest in normally pleasurably activities, physical and cognitive symptoms). During manic episodes, a person experiences the opposite—extreme euphoria, energy, and activity. Manic episodes vary with intensity and can be manifest in a variety of ways, such as having little or no need for sleep, very fast or “pressured” speech, impulsivity and erratic decision making (especially decisions of major consequence, like spending a large amount of money), and racing thoughts. Some manic episodes are milder in nature; these are known as hypomanie episodes. People with bipolar I disorder can experience both manic and hypomanie episodes. Bipolar II disorder is a related disorder in which the person only experiences hypomania and not full-blown mania. For the purposes of this chapter, only bipolar I disorder, which has ample research strongly linking it to SUDs, will be discussed.
EXHIBIT 4.3. Diagnostic Criteria for Bipolar I Disorder.
Sometimes, manic episodes can produce symptoms that conflict with reality and are delusional in nature (e.g., a man believing he is going to marry the Queen of England). Because of these delusional and bizarre beliefs, bipolar disorder can sometimes appear similar to schizophrenia and other psychotic disorders (see the section “Schizophrenia and Other Psychotic Disorders”). In fact, increasing research supports a shared genetic risk between the bipolar and psychotic disorders (Cardno & Owen, 2014).
Suicidal thoughts and behaviors are common among people with bipolar disorder (APA, 2013), with some believing it could have the highest suicide risk of all mental disorders (Schaffer et al., 2015). An estimated 20 percent of people with bipolar disorder try to commit suicide (Carra, Bartoli, Crocamo, Brady, & Clerici, 2014), leading to a standardized mortality ratio of suicide deaths that is 1 0 to 30 times greater than that of the general population (Schaffer et al., 2015). People with bipolar disorder and SUD are significantly more likely to try to commit suicide than people without both conditions (Carra et al., 2014; Schaffer et al., 2015). Interestingly, current or lifetime SUD is a significant risk factor for suicide attempt in bipolar disorder but not suicide death (Schaffer et al., 2015).
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH A DEPRESSIVE DISORDER.
The 12-month and lifetime prevalence rates of DSM-5 bipolar I disorder are 1.5 percent and 2 percent, respectively (Blanco et al., 2017). Rates are nearly equivalent between men and women for both 12-month and lifetime prevalence (Blanco et al., 2017).
Individuals with bipolar I have high prevalence rates (65 percent) of lifetime SUD, AUD (54 percent), and drug use disorder (32 percent) (McDermid et al., 2015). Presence of a 12-month or lifetime DSM-5 drug use disorder (i.e., an SUD excluding alcohol) is associated with a 1.4 to 1.5 increased odds in having bipolar I disorder (Grant et al., 2016). Similarly, presence of past-year or lifetime bipolar I disorder carries a 2 to 5.8 times greater risk of also having any 12-month or lifetime SUD (Blanco et al., 2017). A systematic review and meta-analysis found strong associations between co-occurring SUDs and bipolar illness in individuals in clinical settings, with the highest prevalence (average: 30 percent) for alcohol use, 20 percent (mean) for cannabis, and 17 percent (mean) for any drug use disorder (Hunt, Malhi, Cleary, Lai, & Sitharthan, 2016b).
Co-occurring bipolar illness and substance misuse are associated with numerous adverse clinical, social, and economic consequences, including increased symptom severity, poorer treatment outcomes, and greater suicide risk (Ma, Coles, & George, 2018). Presence of a co-occurring SUD with bipolar disorder has been linked to lower SUD treatment adherence and retention, protracted mood episodes, poorer recovery of functional abilities (even after abstaining from substances), increased utilization of emergency services, greater hospitalizations, more variable disease course, greater affective instability, more impulsivity, and poor response to lithium (the standard pharmacotherapy of choice) (Swann, 2010; Tolliver & Anton, 2015).
Substance misuse by people with bipolar disorder complicates diagnosis and treatment. Evidence exists of a bidirectional relationship between bipolar disorder and SUDs, yet the ways in which these conditions influence one another is still unclear (Tolliver & Anton, 2015). Little research has examined nonpharmacological approaches to managing comorbid bipolar I disorder and SUDs. Group CBT, integrated therapy, and relapse prevention techniques may help reduce hospitalizations, increase abstinence, improve medication adherence, reduce addiction severity, and (to a lesser extent) improve mood symptoms (Gold et al., 2018). However, results are inconsistent across studies, underscoring the need for more research.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH BIPOLAR I DISORDER.
Case Study: Counseling an SUD treatment Client With Bipolar I Disorder.
PTSD is an exaggerated fear response that occurs following exposure to one or more extremely upsetting events. Such events can include, but are not limited to, war, terrorist attacks, threatened or actual physical or sexual violence, being kidnapped, natural and man-made disasters, and serious motor vehicle accidents. Events may be experienced firsthand, witnessed, experienced through repeated exposure as a part of one's job (e.g., police officers repeatedly hearing details about child abuse, murder, and other violent and upsetting crimes), or by learning about such events occurring to a close loved one (e.g., learning of the murder of one's child). People with PTSD report the most distressing trauma to be sexual abuse before age 18 years (Goldstein et al., 2016).
Symptoms of PTSD are grouped into four categories:
Intrusive, persistent re-experiences of the trauma, including recurrent dreams or nightmares, flashbacks, and distressing memories
Persistent avoidance of people, places, objects, and events that remind the person of the trauma or otherwise trigger distressing memories, thoughts, feelings, and physiological reactions
Negative alterations in cognitions and mood, such as memory loss (particularly regarding details surrounding the event), self-blame, guilt, hopelessness, social withdrawal, and an inability to experience positive emotions
Marked alterations in arousal and reactivity, such as experiencing sleeplessness or feeling “jumpy,” “on edge,” easily started, irritable, angry, or unable to concentrate
Exhibit 4.4 lists the DSM-5 criteria for PTSD in adults and children older than age 6; separate criteria are available for children ages 6 years and younger and can be found in DSM-5.
EXHIBIT 4.4. Diagnostic Criteria for PTSD.
Twelve-month and lifetime prevalence rates of DSM-5 PTSD are 4.7 percent and 6.1 percent, respectively (Goldstein et al., 2016). Rates are markedly higher among women than men, about 6 percent and 8 percent for past-year and lifetime PTSD, respectively (Goldstein et al., 2016). Lifetime prevalence is even higher for female veterans (1 3.9 percent) and younger adults (ages 1 8 to 29 years, 15.3 percent) (Smith, Goldstein, & Grant, 2016). A 2016 study of veterans using DSM-5 criteria found the lifetime prevalence of PTSD to be 6.9 percent, with significantly higher prevalence rates noted for women and younger age groups (Smith et al., 2016).
Individuals in occupations at risk of exposure to traumatic events (e.g., police, firefighters, emergency medical personnel) have higher rates of PTSD. Among high-risk individuals (those who have survived rape, military combat, and captivity or ethnically or politically motivated internment and genocide), the proportion of those with PTSD ranges from one-third to one-half (APA, 2013).
A strong association exists between PTSD and substance misuse, including lifetime SUDs (Hasin & Kilcoyne, 2012), lifetime drug use disorders (Grant et al., 2016), and lifetime AUD (Grant et al., 2015). Among people with SUDs, lifetime prevalence of PTSD is thought to range between 26 percent and 52 percent and rates of current PTSD between 15 percent and 42 percent (Vujanovic, Bonn-Miller, & Petry, 2016). Among people with PTSD, lifetime rates of SUD are likely between 36 percent and 52 percent (Vujanovic et al., 2016). Presence of a 12-month or lifetime DSM-5 drug use disorder (i.e., an SUD excluding alcohol) is associated with a 1.5 to 1.6 increased odds of having PTSD (Grant et al., 2016). Similarly, presence of 12-month or lifetime PTSD is associated with a 1.3 to 1.5 increased odds of having a past-year or lifetime SUD (Goldstein et al., 2016).
Comorbid PTSD and addiction are highly complex and associated with worse treatment outcomes (including lower rates of remission and faster relapse), poorer treatment response, more cognitive difficulties, worse social functioning, greater risk of suicide attempt, and heightened mortality (Flanagan, Korte, Killeen, & Back, 2016; Schumm & Gore, 2016). Compared with people with PTSD or alcohol dependence alone, those with both report more traumatic childhoods, more psychiatric comorbidities, an increased risk of suicide, more severe symptoms, and greater disability (Blanco et al., 2013).
People with PTSD tend to misuse the most serious substances (cocaine and opioids); however, misuse of prescription medications, cannabis, and alcohol also are common.
WARNING TO COUNSELORS: PTSD OR DEPRESSION?
Historically, there has been debate about whether to treat PTSD and addiction concurrently or sequentially, with most providers falling on the side of treating the SUD separately and first (Schumm & Gore, 2016). Some believe that substance misuse among people with PTSD is a means of self-medicating to help manage distressing mood and anxiety symptoms, thus making PTSD the priority target for treatment. Alternatively, others have feared that treating PTSD first could exacerbate SUD symptoms or cause clients to use substances as a means of coping with the hyperarousal and negative mood that can occur while progressing through PTSD treatment. However, integrated, concurrent treatment that addresses both conditions simultaneously has generated strong empirical support, appears to be preferable to clients, and is increasingly considered the current standard of care, particularly when combining psychosocial and pharmacologic approaches (Flanagan et al., 2016; Schümm & Gore, 2016; Simpson, Lehavot, & Petrakis, 2017).
Despite the evidence that concurrent treatment can be effective, people with PTSD and SUD are frequently only treated for addiction; further, clients in SUD treatment settings are often not even assessed for PTSD (Vujanovic et al., 2016). Whereas treating SUD alone rarely leads to Improvement In PTSD symptoms, reducing PTSD symptoms can significantly decrease the odds of heavy substance (Hien et al., 2010).
Exposure therapy can be safe and effective at reducing trauma and SUD symptoms—although more evidence is needed (Flanagan et al., 2016). Nonexposure-based treatments have been studied more widely for co-occurring PTSD and SUD and may be moderately effective at improving both PTSD and substance symptoms, but the evidence is still premature (Flanagan et al., 2016). A Cochrane Review found individual trauma-focused psychotherapy with adjunctive SUD treatment to be effective at reducing posttreatment PTSD severity and substance use at 5 to 7 months following treatment; however, the authors deemed the current evidence base on psychological treatments for PTSD-SUD to be weak in terms of quality and methodology, underscoring the need for more rigorous research in this area (Roberts, Roberts, Jones, & Bisson, 2016). Studies of pharmacologic treatments for SUD with PTSD, and for AUD specifically, appear encouraging but, again, are understudied, often inconclusive, and require more data (Flanagan et al., 2016; Petrakis & Simpson, 2017).
See the section “Cross-Cutting Topics: Suicide and Trauma” at the end of this chapter for more information about trauma-informed care for people with CODs.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH PTSD.
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WHO BINGE DRINKS AND HAS PTSD.
A PD refers to a person's lifelong inability to form healthy, functional relationships with others and a failure to develop an adaptive sense of self. These are manifest as (a) destructive or otherwise problematic patterns of thinking and feeling about oneself, one's place in the world, and others and (b) negative ways of behaving toward others. People with PDs often lack insight into their dysfunctional cognitive, emotional, and behavioral patterns and often blame others or the world in general for their difficulties. Many people with PDs struggle to develop strong, positive relationships, because they view reality from the perspective of their own needs and therefore have a difficult time understanding, empathizing with, and connecting with others. PDs are lifelong conditions that develop in adolescence or early adulthood. They are frequently resistant to change and result in significant impairments in interpersonal functioning, work/school performance, and self-concept.
There are several types of PDs, and the precise symptoms someone exhibits will depend on which type of PD he or she has. For instance, depending on the PD type, an individual might think of himself/herself in overly negative ways or in grandiose ways, might be overly attached to others or completely indifferent to others, might constantly try to be the center of attention or might be socially reclusive. People with PDs must first meet the diagnostic criteria for a general PD (Exhibit 4.5) and then must meet additional diagnostic criteria for whatever PD type is most appropriate given their symptoms. Many individuals with PDs have features of, or meet full criteria for, other PDs.
EXHIBIT 4.5. Diagnostic Criteria for General PD.
This TIP provides details about the two PD types that are commonly comorbid with addiction—BPD and antisocial PD (ASPD). Before exploring BPD and ASPD in detail, an overview of PDs in general follows. Readers should be aware that the diagnostic approach to PDs continues to undergo refinement, as researchers in psychopathology have expressed many concerns about the meaningfulness, gender bias, accuracy, and utility of the current categorical diagnostic system for PDs (see Section III of DSM-5 for more information on alternative PD classification and diagnostic criteria).
Once a person meets criteria for a general PD, his or her diagnosis is further categorized based on several specific PD types, including paranoid PD, schizoid PD, schizotypal PD, histrionic PD, narcissistic PD, ASPD, BPD, avoidant PD, dependent PD, and obsessive-compulsive PD. If the symptoms do not meet any of the types, he or she can be diagnosed with either unspecified PD or other specified PD. Detailed descriptions and criteria for all 10 PD types can be found in DSM-5. BPD and ASPD most frequently co-occur with substance misuse (Köck & Walter, 2018). Thus, they are included in this chapter and discussed in respective subsections.
In DSM5, PD types are categorized into three distinct clusters based on their common features:
Cluster A PDs describe people who may be seen as odd or eccentric. This eccentricity can express itself in many ways (e.g., paranoia and suspicion, extreme social withdrawal/lack of interest in interpersonal relationships, unusual beliefs or behaviors). PD types included in this cluster are:
Paranoid PD.
Schizoid PD.
Schizotypal PD.
Cluster B PDs are characterized by dramatic, overly emotional, and erratic and unpredictable behavior. PD types included in this cluster are:
Histrionic PD.
Narcissistic PD.
ASPD.
BPD.
Cluster C PDs are marked by anxious and fearful behaviors. PD types included in this cluster are:
Obsessive-compulsive PD.
Avoidant PD.
Dependent PD.
WARNING TO COUNSELORS: PDS AND PROVIDER STIGMA.
Prevalence estimates for PDs among the general population are difficult to ascertain, given lack of research examining large samples from the community (as opposed to clinical samples, in which PDs are far more common and frequently studied). Estimates are 9.1 percent for any PD, 5.7 percent for any Cluster A PD, 1.5 percent for any Cluster B, and 6 percent for Cluster C (APA, 2013). In one analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the prevalence of lifetime DSM-IV PDs varied from 0.5 percent to 7.9 percent, depending on the PD type (Hasin & Grant, 2015). Prevalence rates for BPD and ASPD are discussed in separate sections.
Diagnostic criteria for PDs have long been debated among psychopathology researchers and clinicians, given multiple problems with the way PDs are classified and diagnosed (Paris, 2014; Sarkar & Duggan, 2010). Problems include a lack of empirical evidence supporting PDs; the extensive overlap between diagnostic criteria among the specific types of PDs as well as overlap with other mental disorders; the fact that PD criteria are insufficiently discriminant, which has resulted in many individuals who exhibit PD pathology receiving a DSM-IV “personality disorder not otherwise specified” diagnosis after failing to “fit in” to any of the specified PD types; and the difficulty mental health professionals have in distinguishing PD traits from variants of normal personality, which means that deciding whether a person meets PD criteria is often a subjective judgment. Thus, it is hard to know exactly how many people have a PD, including how many people with addiction have co-occurring PDs (Paris, 2014).
SLID counselors frequently see people with PD diagnoses in their treatment settings. A review found the prevalence of PDs among people with SUDs to be wide ranging but nonetheless extremely high, varying from about 35 percent to 65 percent; rates of ASPD ranged from about 14 percent to almost 35 percent (Köck & Walter, 2018). Similarly, among people undergoing detoxification for AUD, rates of co-occurring PDs vary widely from 5 percent to 87 percent (Newton-Howes & Foulds, 2018). PDs may be present in as much as 24 percent of people with AUD in the general population (Newton-Howes & Foulds, 2018).
For most people with SUDs, drugs eventually become more important than jobs, friends, and family. These changes in priorities often appear similar to a PD, but diagnostic clarity for PDs in general is difficult. For clients with substance-related disorders, the true diagnostic picture might not emerge for weeks or months. It is not unusual for PD symptoms to clear with abstinence, sometimes even fairly early in recovery.
People with PDs and SUDs differ from those with PDs only or SUDs only in important ways (Köck & Walter, 2018), including more severe mental and substance-related symptoms, longer persisting substance use, a greater likelihood of other co-occurring mental disorders (e.g., anxiety, depressive, and eating disorders), increased mortality, and higher SUD treatment dropout.
No evidence-based treatments exist for PDs themselves (Bateman, Gunderson, & Mulder, 2015), but effective treatments are available to address a variety of PD symptoms, including risk of suicide and self-harm, affective dysregulation, maladaptive thought patterns, and poor interpersonal functioning. Psychotherapy is the primary form of intervention, as no medications have been approved for the treatment of PDs. Pharmacotherapy may be useful as an adjunctive treatment for certain symptoms like affective lability, impulsivity, and psychosis, but it is not useful as a primary intervention. (See the section “Pharmacotherapy” in Chapter 7 for more information.) Dialectical behavioral therapy, dynamic deconstructive psychotherapy, and dual-focused schema therapy appear promising, particularly for BPD, and have shown to positively affect psychiatric and addiction-related outcomes, although, in general, the research literature on effective treatments for PDs, with or without co-occurring SUD, is sparse and requires further evidence (Bateman et al., 2015; Köck & Walter, 2018).
The essential feature of BPD is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, along with marked impulsivity, that begins by early adulthood and is present in a variety of contexts (Exhibit 4.6). Relationships with others are likely to be unstable—for instance, people with BPD might remark how wonderful an individual is one day but express intense anger, disapproval, condemnation, and even hate toward that same individual a week later. The severe instability people with BPD experience includes fluctuating views and feelings about themselves. Those with BPD often feel good about themselves and their progress and optimistic about their future for a few days or weeks, only to have a seemingly minor experience turn their world upside down, with concomitant plunging self-esteem and depressing hopelessness. This instability often extends to work and school.
EXHIBIT 4.6. Diagnostic Criteria for BPD.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH A PD.
When experiencing emotional states they cannot handle, clients with BPD can be at high risk of suicidal, self-mutilating, or brief psychotic states.
About three-fourths of people with BPD have a history of self-harm, and the disorder carries a 10-percent lifetime risk of completed suicide (Antai-Otong, 2016).
BPD has a prevalence of 1.6 percent to 5.9 percent in the general population but is more common in mental health settings (about a 10-percent prevalence rate for outpatient mental health clinics, about 20 percent among psychiatric inpatients, and 6 percent in primary care settings) (APA, 2013). Lifetime prevalence of DSM-IV BPD is 5.9 percent (Hasin & Grant, 2015).
Women are much more likely to be diagnosed with BPD, generally at 3 times the rate of men (i.e., about 75 percent of cases are women) (APA, 2013). However, the accuracy of this pattern is dubious as epidemiologic surveys of the U.S. general population have found the lifetime prevalence of BPD does not actually differ significantly between men and women (Hasin & Grant, 2015).
WARNING TO COUNSELORS: THE MISDIAGNOSIS OF BPD.
BPD is highly prevalent in SUD treatment settings (and especially inpatient and residential treatment), with rates averaging about 22 percent across multiple studies but as high as 53 percent in some research (Trull et al., 2018). Presence of a 1 2-month or lifetime DSM-5 drug use disorder (i.e., an SUD excluding alcohol) is associated with a 1.7 to 1.8 increased odds of having BPD (Grant et al., 2016). Approximately 45 percent of individuals with BPD also have a current SUD, and about 75 percent have a lifetime SUD (Trull et al., 2018). Opioids, cocaine, and alcohol are the substances with the strongest associations with BPD (Trull et al., 2018).
People with BPD typically seek behavioral health services based on their current life conditions and emotional state. Those who seek mental health services tend to be acutely emotionally distraught, needing some relief from how they feel. Similarly, those who choose (or are directed to choose) a program are likely experiencing the SUD as the immediate target for treatment. Consequently, the average admission of a person with BPD to a mental health program may be considerably different from the average admission of a person with BPD to an SUD treatment program.
In inpatient mental health service settings, dialectical behavior therapy for BPD is recommended to help reduce suicide risk, stabilize behavior, and help clients regulate emotions (Ritter & Platt, 2016). SUD treatment for people with BPD can be complicated, and progress may be slow, but effective interventions are available to help reduce symptoms and improve functioning. A systematic review of 10 studies on treatments for BPD and cooccurring SUDs found good support for dialectical behavior therapy, dynamic deconstructive therapy, and dual-focused schema therapy in improving outcomes of substance use, suicidal gestures and self-harm, global and social functioning, treatment utilization, and treatment retention (Lee, Cameron, & Jenner, 2015).
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH BPD.
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WITH BPD.
The core features of ASPD are a pervasive disregard for the rights, feelings, and needs of others and a failure to form long-term, fulfilling, adaptive relationships (Exhibit 4.7). Individuals with ASPD often display a host of challenging traits: deceitfulness, remorselessness, aggression, disregard for rules and laws, low conscientiousness, impulsivity, failure to adhere to social norms, delinquency, and recklessness. As a result, these individuals often lead unstable lives and are at high risk of increased mortality, violence/aggression, suicide and suicidal behavior, accidents, criminality, incarceration, and chronic illnesses (e.g., cancer, HIV) (Black, 2015; Black, 2017; Dykstra, Schumacher, Mota & Coffey, 2015; Krasnova, Eaton, & Samuels, 2018; McCloskey & Ammennan, 2018). Many people with ASPD have experienced traumatic or disruptive childhoods (Sher et al., 2015).
EXHIBIT 4.7. Diagnostic Criteria for ASPD.
A particularly stigmatizing aspect of ASPD is its history of being equated with derisive terms like “sociopath” and “psychopath.” ASPD thus carries extremely negative connotations that might well be accurate in only a small percentage of those people with the disorder. Psychopathy and sociopathy are personality traits, not mental disorders. They are related to ASPD but are usually manifest in more extreme ways than ASPD (e.g., criminal behavior). In short, psychopathy and sociopathy are not the same as ASPD. (See the TIP 44, Substance Abuse Treatment for Adults in the Criminal Justice System [CSAT, 2005b] for a full discussion of psychopathy and its relationship to ASPD.)
Twelve-month prevalence rates for DSM-IV ASPD fall between 0.2 percent and 3.3 percent (APA, 2013). Lifetime DSM-IV ASPD is estimated at 3.6 percent (Hasin & Grant, 2015). Much higher prevalence rates (up to 70 percent) have been found in studies of men in treatment for AUD and SLID treatment clinics, prisons, and other forensic settings (APA, 2013).
Men are 2 to 8 times more likely to have an ASPD diagnosis than women (Black, 2017). Lifetime prevalence of DSM-IV ASPD is estimated at 1.9 percent in women and 5.5 percent in men (Hasin & Grant, 2015).
Presence of a 12-month or lifetime DSM-5 drug use disorder (i.e., an SUD excluding alcohol) is linked with 1.4 to 2 increased odds of having ASPD (Grant et al., 2016). Prevalence of ASPD is 7 percent to 40 percent in men with existing SUDs. ASPD is significantly associated with persistent SUDs (Grant et al., 2015; Grant et al., 2016).
An analysis of NESARC data (using DSM-IV diagnoses) revealed gender differences in comorbidities with ASPD (Alegría et al., 2013). Men with ASPD were more likely to have AUD, any drug use disorder, and narcissistic PD. Women with ASPD were more likely to have any mood disorder, MDD, dysthymia, any anxiety disorder, panic disorder, specific phobia, PTSD, and generalized anxiety disorder (GAD). Women were also more likely to report childhood adverse events, such as sexual abuse.
Another study of treatment-seeking individuals assessing gender differences in individuals with an ASPD diagnosis similarly found that women with ASPD tended to be younger, had fewer episodes of antisocial behavior and higher scores on measures of trauma, including emotional and sexual abuse, than men with an ASPD (Sher et al., 2015). Both women and men with ASPD had comorbid alcohol (43.6 percent for women and 50 percent for men) and cannabis use disorders (21.8 percent and 29.7 percent, respectively), and men had higher rates of comorbid cocaine use disorder (22 percent) than women (7.3 percent). Many people with ASPD use substances in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine.
People with ASPD and SUDs have higher rates of aggression, impulsivity, and psychopathy than people with SUDs alone (Alcorn et al., 2013).
Disregard for others’ rights is a key diagnostic feature of ASPD. Yet most clients who are actively using substances display behaviors at some point that show such disregard, so perceiving the distinction between SUD and ASPD can be difficult for the mental health and the SUD treatment fields.
As with most PDs, no empirically supported treatments exist for ASPD, much less ASPD combined with SUDs (Bateman et al., 2015). Various therapies for ASPD with addiction (e.g., CBT, contingency management) may help ameliorate substance-related outcomes, like substance misuse and number of urine-negative specimens over time, but studies are few and sample sizes are small (Brazil, van Dongen, Maes, Mars, & Baskin-Sommers, 2018).
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH ASPD.
The distinguishing feature of anxiety disorders is excessive fear and worry along with behavioral disturbances, usually out of attempts to avoid or manage the anxiety. Anxiety disorders are highly comorbid with each other but differ in the types of situations that arouse fear and the content of the anxiety-provoking thoughts and beliefs. Panic attacks are a common fear response in anxiety disorders but are not limited to these disorders.
Three of the more prevalent anxiety disorders in the adult population that are likely to co-occur with addiction are GAD, panic disorder, and social anxiety disorder (SAD).
GAD is marked by excessive anxiety and worry (apprehensive expectation) about a range of topics or events, like everyday living, finances, relationships, or work/school performance (Exhibit 4.8). Anxiety is intense, frequent, chronic (i.e., lasting at least 6 months), and disproportionate to the actual threat posed by the subject of worry. The worry is accompanied by additional cognitive/physical symptoms.
EXHIBIT 4.8. Diagnostic Criteria for CAD.
Panic disorder is diagnosed in people who experience repeated panic attacks that are distressing and disabling (Exhibit 4.9). A panic attack is an abrupt but very intense occurrence of extreme fear. It often only lasts for a few minutes but the symptoms can be extremely uncomfortable and upsetting, such as hyperventilation, palpitations, trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea or choking. People experiencing panic attacks also can experience psychological symptoms, like feeling as though they are going to die, as though they are “losing their mind,” as though things are not real (derealization), or as if they have left their body (depersonalization). Because of the distressing nature of panic attacks, people with panic disorder may constantly worry about having subsequent attacks or engage in behaviors in an attempt to control the attacks (like avoiding places where they have previously had a panic attack or fear they might have one).
EXHIBIT 4.9. Diagnostic Criteria for Panic Disorder.
Panic disorder often is underdiagnosed at the beginning of treatment or else is seen as secondary to the more significant disorders, which are the primary focus of treatment. However, panic disorder can significantly impede a person's ability to take certain steps toward recovery, such as getting on a bus to go to a meeting or sitting in a 12-Step meeting. Sometimes counselors can erroneously identify these behaviors as manipulative or treatment-resistant behaviors.
One of the changes in DSM-5 concerns the separation of agoraphobia from panic disorder. Although now two distinct conditions, they are closely related and many of their symptoms overlap. In agoraphobia, people exhibit a strong fear of being in certain places or situations where escape could be difficult should the person experience panic-like symptoms or otherwise feel anxious or a loss of control. Situations typically include being in crowds, on public transportation, in open spaces (like bridges), in closed spaces (such as the movie theater), or away from home. People with agoraphobia avoid these situations for fear of having panic attacks or similar incapacitating or embarrassing symptoms (e.g., vomiting, incontinence), or they tolerate them but with great distress and discomfort.
Agoraphobia often occurs without panic disorder in community settings but frequently occurs with panic disorder in clinical settings; the two conditions are distinct yet intertwined (APA, 2013; Asmundson, Taylor, & Smits, 2014). SUDs can and do co-occur with agoraphobia (Goodwin & Stein, 2013; Marmorstein, 2012), but literature on this co-occurrence is relatively small compared with other anxiety disorders or has been examined as occurring with panic disorder (Cougle, Hakes, Macatee, Chavarria, & Zvolensky, 2015) rather than occurring alone. Furthermore, research is more focused on its co-occurrence with nicotine than other substances.
The linkage of agoraphobia with addiction may be explained by its relationship with panic disorder and not with SUD. Thus, agoraphobia is not a subject of focus for this chapter but is mentioned here because of its interrelationship with panic disorder, which addiction counselors are likely to see in their clients.
Social phobia describes the persistent and recognizably irrational fear of embarrassment and humiliation in social situations (Exhibit 4.10). The social phobia may be quite specific (e.g., public speaking) or may become generalized to all social situations. SAD, also called social phobia in DSM-5, involves intense anxiety or fear in social or performance situations. Individuals may fear being judged by others (e.g., being perceived as stupid, awkward, or boring); being embarrassed or humiliated; accidentally offending someone; or being the center of attention. As a result, the individual will often avoid social or performance situations; when a situation cannot be avoided, they experience significant anxiety and distress. Many people with SAD have strong physical symptoms (e.g., rapid heart rate, nausea, sweating) and may experience full-blown attacks when confronting a feared situation. They recognize that their fear is excessive and unreasonable, but people with SAD often feel powerless against their anxiety.
EXHIBIT 4.10. Diagnostic Criteria for SAD.
The lifetime prevalence of any anxiety disorder is estimated at over 30 percent; 12-month prevalence estimates are approximately 19 percent (Harvard Medical School, 2005). A recent World Health Organization (WHO) survey and analysis using DSM-5 diagnostic criteria found the community lifetime prevalence of GAD in the U.S. is 7.8 percent, and 12-month prevalence is 4 percent (Ruscio et al., 2017). Women are twice as likely as men to experience the disorder (APA, 2013). Lifetime prevalence of panic attacks (ascertained as part of an analysis of data collected worldwide and defined per DSM-5 criteria) with or without panic disorder is almost 28 percent (de Jonge et al., 2016). The 12-month prevalence in the general population for panic disorder is about 2.4 percent; lifetime prevalence is 6.8 percent (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). The 12-month prevalence for SAD is approximately 7 percent; rates in the community trend higher in women (1.5 times) than men, especially in young adults (APA, 2013).
The relationship between substance use and anxiety disorders is complex and multifaceted, and the two disorders commonly co-occur. Presence of a 12-month or lifetime DSM-5 drug use disorder (i.e., an SLID excluding alcohol) is associated with a 1.2 to 1.3 increased odds of having any anxiety disorder, a 1.0 to 1.3 increased odds of having panic disorder, a 1.2 to 1.3 increased odds of having GAD, and a 1.1 to 1.3 increased odds of having SAD (Grant et al., 2016). Recent analyses indicate lifetime (but not 12-month) diagnosis of drug and alcohol use disorders is associated with GAD (Grant et al., 2015; Grant et al., 2016). Twelve-month prevalence of panic disorder with co-occurring SUD is 11 percent, and lifetime cooccurrence is 28 percent (de Jonge et al., 2016).
When anxiety and SUDs co-occur, the disorders affect development and maintenance of comorbidity, and each disorder modifies the presentation and treatment outcomes for the other (Brady, Haynes, Hartwell, & Killeen, 2013). Consequently, people with anxiety disorders and co-occurring SUDs experience worse outcomes than those with either disorder alone, including greater disability, more hospitalizations and healthcare utilization, poorer functioning, more difficulties in interpersonal relationships, more severe symptoms, worse health-related quality of life, and poorer treatment response (Buckner, Heimberg, Ecker, & Vinci, 2013; Magidson, Liu, Lejuez, & Blanco, 2012). GAD and addiction are associated with higher rates of heavy alcohol use, hospitalizations, relapse, and leaving treatment against medical advice compared with people with SUDs but no GAD (Domenico, Lewis, Hazarika, & Nixon, 2018).
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH AN ANXIETY DISORDER.
CASE STUDY: CAD AND PROTRACTED WITHDRAWAL.
Anxiety symptoms and anxiety disorders are predictors of suicidal ideation and suicide attempt (Bentley et al., 2016); given that SUDs also elevate risk of suicide (Yuodelis-Flores & Ries, 2015), the combination of the two suggests efforts to mitigate suicide risk mitigation are warranted with these clients.
SUD treatment for people with anxiety should include interventions that address the anxiety as well as the addiction. Clients may report a reduction in some anxiety symptoms during detoxification or early in recovery (McHugh, 2015). That said, SUD treatment alone is not sufficient to address the co-occurring anxiety. Further, the presence of an anxiety disorder complicates SUD treatment and can make achieving and sustaining abstinence and preventing relapse more problematic (McHugh, 2015).
Concurrent, integrated treatments that include CBT or exposure therapy can safely, effectively reduce psychiatric and SUD symptoms but in some studies are no more effective than placebo (McHugh, 2015).
Psychotic disorders are characterized by a severely incapacitated mental and emotional state involving a person's thinking, perception, and emotional control. Key features include distorted thoughts in which an individual has false beliefs, sensations, or perceptions that are imagined, are very extreme, or both; and unusual emotional and behavioral states with deterioration in thinking, judgment, self-control, or understanding. Psychotic disorders are usually expressed clinically as a combination of:
Delusions: Beliefs that are fixed, resistant to change, and are directly contradicted by evidence or otherwise not grounded in reality (e.g., the belief that one is being followed
by people from Mars, or that one is a very important person to whom the President wants to speak right away).
Hallucinations: Hearing, seeing, tasting, or feeling things that are not there and being unable to recognize that what is being experienced is not real (such as hearing voices that say self-condemning or other disturbing things, or seeing a person who isn't really there).
Disorganized thinking: This is reflected in speech that is incoherent (“word salad”), illogical, uses unconventional or made-up words (neologisms and word approximations), fluctuates from topic to topic (loose associations), or is completely unrelated to subject matter at hand (tangential speech).
Grossly disorganized or abnormal motor behavior: This includes a wide range of odd behaviors, such as laughing or smiling inappropriately, grimacing, staring, talking to oneself, purposeless or peculiar movements and mannerisms, mimicking others’ speech or movements (echolalia and echopraxia), and random agitation. A specific psychomotor disturbance called catatonia—which includes immobility, stupor, and holding rigid body positions against gravity over extended periods of time (catalepsy)—can occur in schizophrenia but is also present in other mental disorders (like bipolar disorder) and some medical conditions.
Negative symptoms: A constellation of symptoms reflecting diminished emotional expression and self-motivated purposeful activities (avolition). Negative symptoms also may include diminished speech output (alogia) or poverty of speech (e.g., one-word answers), motivation, ability to experience pleasure (anhedonia), or interest in social activities (asociality).
Although schizophrenia is perhaps the most well known psychotic disorder, people with bipolar disorders may experience psychotic states during periods of mania—the heightened state of excitement, little or no sleep, impulsiveness, and poor judgment (see the section “Bipolar I Disorder”). Other conditions also can be accompanied by a psychotic state, including toxic poisoning, other metabolic difficulties (infections [e.g., latestage AIDS]), and other mental disorders (MDD, dementia, PTSD, alcohol withdrawal states, brief reactive psychoses, and others).
SUD treatment counselors typically do not see clients in the throes of an acute psychotic episode, as such psychotic patients more likely present, or are referred to, EDs and mental health services facilities. Counselors are more likely to encounter such clients in a “residual” or later and less active phase of the illness, the time at which these individuals may receive treatment for their SUDs in an SUD treatment agency. Even if the SUD treatment counselor never sees a client during an actively psychotic period, knowing what the client experiences as a psychotic episode will enable the counselor to understand and assist the client more effectively. On the other hand, counselors are increasingly treating clients with methamphetamine dependence who often have residual paranoid and psychotic symptoms and may need antipsychotic medications.
No single symptom specifically indicates or characterizes schizophrenia. Symptoms include a range of cognitive, behavioral, and emotional dysfunctions (Exhibit 4.11). Thus, schizophrenia is a heterogeneous clinical syndrome. Symptoms of schizophrenia include delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), grossly disorganized or catatonic behavior, and deficits in certain areas of functioning—for example, the inability to initiate and persist in goal-directed activities. These symptoms regularly develop before the first episode of a schizophrenic breakdown, sometimes stretching back years and often intensifying prior to reactivations of an active, acutely psychotic state. Clinicians generally divide schizophrenia symptoms into positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms like hallucinations, delusions, excitement, motor manifestations (such as agitated behavior or catatonia), disorganized speech, relatively minor thought disturbances, and positive response to neuroleptic medication. Chronic course schizophrenia is characterized by negative symptoms, such as lack of enjoyment (anhedonia), apathy, lack of emotional expressiveness (flat affect), and social isolation. Some clients will live their entire lives exhibiting only a single psychotic episode; others may have repeated episodes separated by varying durations of time.
EXHIBIT 4.11. Diagnostic Criteria for Schizophrenia.
Community prevalence rates for schizophrenia using DSM-5 criteria are not available at the time of this publication. The lifetime prevalence rate for adults with DSM-IV schizophrenia is between 0.3 percent and 0.7 percent (APA, 2013). The National Institute of Mental Health (NIMH; 2018) reports similar but slightly lower numbers, ranging between 0.25 percent and 0.64 percent. Although its prevalence is very low, schizophrenia is very burdensome and considered one of the top 15 leading causes of global disability (GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017).
Substance misuse often occurs in people with schizophrenia and other psychotic disorders. In a study of more than 1,200 people with schizophrenia (Kerner, 2015), lifetime SUD prevalence was 55 percent, including alcohol abuse at 17 percent, alcohol dependence at 26 percent, illicit drug abuse at 13 percent, and illicit drug dependence at 14 percent. The most commonly used substances were alcohol (43 percent), cannabis (35 percent), and other illegal substances (27 percent). Compared with the general population, people with severe psychotic disorders have 4 times greater risk of heavy alcohol use, 3.5 times the risk of heavy cannabis use, and 4.6 times the risk of recreational drug use (Hartz et al., 2014).
Individuals with SMI (including schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features) die approximately 10 to 25 years earlier than the general population, mostly because of the effects of physical illnesses caused at least in part by SUDs (e.g., heart disease, lung disease, infectious disease) (Hartz et al., 2014; WHO, n.d.).
The combination of substance misuse in people with schizophrenia or other psychotic disorders contributes to shortened mortality and an increased likelihood of deleterious health and functional outcomes, including a higher risk for self-destructive and violent behaviors, victimization, suicide, housing instability, poor physical health, cognitive impairment, employment problems, legal difficulties, and unstable social relationships (Bennett, Bradshaw, & Catalano, 2017; Trudeau et al., 2018). Further, substance misuse in schizophrenia can worsen disease course and may reduce adherence to antipsychotic medication (Werner & Covenas, 2017).
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WITH SCHIZOPHRENIA.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH SCHIZOPHRENIA OR ANOTHER PSYCHOTIC DISORDER.
Antipsychotic medication is the standard of care for reducing positive symptoms (e.g., delusions, hallucinations) whereas various psychosocial interventions and approaches can help address addiction recovery. Specifically, integrated CBT, group behavioral therapy, contingency management, 12-Step facilitation, motivational enhancement, motivational interviewing, assertive community treatment, or (preferably) a combination thereof may all help reduce substance use (quantity, frequency, and severity), increase abstinence, reduce number of drinking days, lower relapse rates, reduce the number of positive urine samples, and decrease negative consequences of substance use in people with SUDs and schizophrenia or other SMI (including psychotic disorders) (Bennett et al., 2017; De Witte, Crunelle, Sabbe, Moggi, & Dom, 2014). These approaches have also been associated with improvements in psychiatric symptoms (including negative symptoms), scores of global functioning, hospitalizations, and achieving stable housing (De Witte et al., 2014). Integrated treatments appear to yield more positive results than single interventions and are the recommended approach (De Witte et al., 2014).
ADHD is marked by a chronic inability to direct, control, or sustain attention; hyperactivity; or both (Exhibit 4.12). People with ADHD often have difficulty concentrating for even short periods of time. They may be disorganized and restless or seem always “on the go,” constantly moving and fidgeting. Some people with ADHD behave impulsively.
EXHIBIT 4.12. Diagnostic Criteria for ADHD.
Although ADHD is frequently associated with children, the disorder can persist into adulthood and for some individuals can begin in adulthood.
In adults, symptoms can include having a short temper, difficulty being productive at work, and an inability to sustain relationships.
The three types of ADHD are combined type (person has difficulty paying attention and hyperactivity); predominantly inattentive; and predominantly hyperactiveimpulsive.
At the time of this publication, 12-month and lifetime ADHD prevalence rates among all age groups in the general population using DSM-5 criteria are not readily available. However, data from the National Survey of Children's Health show that 6.1 million children and adolescents ages 2 to 17 years had ever been diagnosed with ADHD (Danielson et al., 2018).
The prevalence of ADHD in adults is less studied than in children. The overall current prevalence of adult ADHD (using DSM-IV criteria) is around 2.5 percent (APA, 2013; Simon, Czobor, Balint, Meszaros, & Bitter, 2009). Epidemiological population-based survey data on U.S. adults with ADHD (Kessler et al., 2005) suggest the estimated lifetime prevalence of DSM-IV ADHD in people ages 18 to 44 years is 8.1 percent.
SUDs are among the most common comorbidities of ADHD (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017), and data from clinical and epidemiological studies support this linkage (Martinez-Raga, Szerman, Knecht, & de Alvaro, 2013). Among adults with substance misuse, the prevalence of ADHD is approximately 23 percent, although this estimate is dependent on substance of misuse and assessment instrument used (van Emmerik-van Oortmerssen et al., 2012). Among a sample of more than 500 children with and without ADHD who were followed throughout adolescence and early adulthood (Molina et al., 2018), early substance use in adolescence was greater and escalated more quickly in the children with ADHD. Further, weekly and daily cannabis use and daily smoking in adulthood were significantly more prevalent in the ADHD group than the non-ADHD group. Adults with ADHD have been found primarily to use alcohol, nicotine, cannabis, and cocaine (Lee, Humphreys, Flory, Liu, & Glass, 2011; Luo & Levin, 2017).
People with addiction who have co-occurring ADHD have a heightened risk for suicide attempts, hospitalizations, earlier onset of addiction, impulsivity, more severe disease course (for both ADHD and the SUD) and polysubstance use as well as lower rates of abstinence and treatment adherence (Egan, Dawson, & Wymbs, 2017; Katzman et al., 2017). ADHD and SUDs carry an enhanced risk of comorbidity with depression, conduct disorder, bipolar disorders, anxiety disorders, and PDs (Luo & Levin, 2017; Martinez-Raga et al., 2013; Regnart, Truter, & Meyer, 2017; Young & Sedgwick, 2015; Zulauf, Sprich, Safren, & Wilens, 2014). Symptoms of ADHD hyperactivity and impulsivity are more strongly seen with substance misuse and SUDs than ADHD symptoms of inattention (De Alwis, Lynskey, Reiersen, & Agrawal, 2014).
Although it is important to rule out other causes of inattention or hyperactivity, including substance misuse, misattribution of ADHD symptoms to SUDs increases the likelihood of underdiagnosis (Crunelle et al., 2018). People with SUDs who are newly abstinent or those in active or protracted withdrawal may experience some impairments similar to ADHD. Many of the behavioral symptoms of ADHD also appear during substance intoxication and withdrawal, and functional consequences of ADHD, such as poor job performance or job loss, are also evident in people with addiction. Both alcohol and cannabis can produce symptoms that mimic ADHD. This underscores the importance of conducting a thorough assessment (see Chapter 3) to fully investigate symptoms in childhood, family history of addiction and psychiatric illness, and other biopsychosocial factors that can inform whether a diagnosis of ADHD, SUD, or both are warranted.
ADHD complicates SUD treatment because clients with these CODs may have more difficulty engaging in treatment and learning abstinence skills, be at greater risk for relapse, and have poorer substance use outcomes. The most common attention problems in SUD treatment populations are secondary to short-term toxic effects of substances, and these should be substantially better with each month of sobriety.
A consensus statement by an international panel of ADHD and addiction experts (including from the U.S.) on the treatment of ADHD and SUDs recommends (Crunelle et al., 2018):
Using a combined treatment approach comprising psychoeducation, pharmacotherapy, individual or group CBT, and peer support.
Integrating ADHD treatment into SUD treatment; integrating SUD treatment into mental health services.
Treating both disorders, but addressing the SUD first and then the ADHD shortly afterwards.
Considering residential treatment for cases of severe addiction.
Providing pharmacotherapy for ADHD (particularly with psychotherapy), but clinicians should be aware that medication alone Is usually not sufficient to treat the SUD.
Prescribing ADHD medication as needed but understand that this is a controversial topic because of the misuse liability of stimulants. Clinicians should consider all risks and weigh them against potential benefits when deciding whether to prescribe stimulant medications for people with ADHD-SUD.
Only a limited number of studies explore treatment of ADHD with comorbid SUDs (De Crescenzo, Cortese, Adamo, & Janiri, 2017). Treatment of adults with ADHD often involves use of stimulant or nonstimulant medication; although efficacious in reducing psychiatric symptoms, these medications generally do not alleviate SUD symptoms (Cunill, Castells, Tobias, & Capella, 2015; De Crescenzo et al., 2017; Luo & Levin, 2017). Thus, ADHD medication alone is an insufficient treatment approach for clients with these CODs (Crunelle et al., 2018; Zulauf et al., 2014). Stimulant medications have misuse potential, and counselors should be vigilant for signs of diversion. Use of long-acting or extended-release medication or use of antidepressants instead of stimulants can attenuate diversion and misuse liability. The advised approach to treatment involves a combination of psychoeducation, behavioral coaching, CBT, and nonstimulant or extended-release stimulant medication (De Crescenzo et al., 2017).
Little research supports concurrent treatment of these conditions. Some researchers recommend first addressing whichever condition is most debilitating to the client (Katzman et al., 2017; Klassen, Bilkey, Katzman, & Chokka, 2012). Others suggest that, to stabilize the client, treating the SUD should be prioritized (Crunelle et al., 2018). A systematic literature review and meta-analysis of pharmacotherapy for ADHD and SUD (Cunill et al., 2015) found no effect of timing of initiation of treatment but warns that treatment of ADHD symptoms may need to be delayed until after abstinence is achieved, given possible harmful interactions that can occur between ADHD medications and substances of misuse.
Feeding and eating disorders have as their common core a persistent disturbance of eating or eating-related behavior, resulting in changes in consumption or absorption of food that significantly impair physical health or psychosocial functioning. The primary eating disorders linked to SUD and discussed in this section are AN, bulimia nervosa (BN), and binge eating disorder (BED).
AN, the most visible eating disorder, is marked by a refusal to maintain body weight above the minimally normal weight for age and height because of an intense fear of weight gain (Exhibit 4.13). The term anorexia nervosa means “nervous loss of appetite,” a misnomer; only in extreme stages of inanition (i.e., exhaustion as a result of lack of nutrients in the blood) is appetite actually lost.
EXHIBIT 4.13. Diagnostic Criteria for AN.
Individuals with AN have a dogged determination to lose weight and can achieve this in several ways. Individuals with the restricting subtype of AN severely limit their food intake, engage in excessive exercise, and fast. Those with the binge-eating/purging subtype engage in episodes of binge eating or purging with self-induced vomiting, laxatives, diuretics, or enemas. They engage in these behaviors out of a marked fear of weight gain, which is reinforced by distorted perceptions of their body shape (e.g., believing oneself to be “fat” even though bodyweight is extremely low).
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WITH ADHD.
The core symptoms of BN are bingeing and purging (Exhibit 4.14). A binge is a rapid consumption of an unusually large amount of food, by comparison with social norms, in a discrete period of time (e.g., over 2 hours). Integral to the notion of a binge is feeling out of control; thus, a binge is not merely overeating. An individual with BN may state that he or she is unable to postpone the binge or stop eating willfully once the binge has begun. The binge may only end when the individual is interrupted, out of food, exhausted, or physically unable to consume more.
EXHIBIT 4.14. Diagnostic Criteria for BN.
The second feature of BN is purging. Individuals with BN compensate in many different ways for overeating. Ninety percent of people with BN self-induce vomiting or misuse laxatives as their form of purging (Westmoreland, Krantz, & Mehler, 2016). Other methods of purgation include the misuse of diuretics and emetics; saunas; excessive exercise; fasting; and other idiosyncratic methods that people believe will lead to weight loss (such as “mono” dieting, in which a person eats only a single food for extended periods of time and nothing else, like apples or eggs). Many of these auxiliary methods are dangerous and ineffective because they promote loss of water and valuable electrolytes. As with AN, individuals with BN place an undue emphasis on shape and weight in their sense of identity. To meet criteria, bingeing and purging must occur, on average, at least once per week for 3 months.
BED involves recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control (Exhibit 4.15). Someone with BED may eat too quickly, even when he or she is not hungry. The person may feel guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is linked with marked distress and occurs, on average, at least once a week over 3 months. Unlike in BN, the binge is not followed by compensatory behaviors to rid the body of food.
EXHIBIT 4.15. Diagnostic Criteria for BED.
Feeding and eating disorders in the general population are rare. Twelve-month estimates of DSM-5 AN, BN, and BED are 0.05 percent, 0.14 percent, and 0.44 percent, respectively; lifetime prevalence rates are 0.80 percent, 0.28 percent, and 0.85 percent, respectively (Udo & Grilo, 2018). These rates are generally lower than previously reported estimates using DSM-IV criteria (APA, 2013) but were drawn from a sample roughly 12 times larger than the samples used in other survey studies (Udo & Grilo, 2018).
Eating disorders are far more prevalent in women than men. Women have 12 times the odds of having AN, 5.8 times the odds of having BN, and about 3 times the odds of having BED (Udo & Grilo, 2018).
Feeding and eating disorders are highly coincident with substance misuse (SAMHSA, 2011a), likely because the conditions share numerous physical, mental, and social risk factors (Brewerton, 2014). Most studies observe comorbidity rates that exceed the general population of women of similar age. A meta-analysis (Bahji et al., 2019) found lifetime prevalence of any SLID among people with eating disorders to be 25 percent, including 20 percent for AUD, about 20 percent for any illicit drug use disorder, almost 14 percent for cocaine and cannabis use disorder (each), and 6 percent for opioid use disorder (OUD). Even if not rising to the level of addiction, licit and illicit substance use is elevated in people with eating disorders, especially individuals with bulimic features. In a sample of almost 3,000 people, 80 percent of those with BN reported using alcohol, and 50 percent used other substances; 65 percent of those with BED used alcohol, and nearly 24 percent used other substances; and 60 percent of those with AN (binge/purge subtype) used alcohol, and 44 percent used other substances (Fouladi et al., 2015).
SUD treatment-seeking women have higher rates of BN than any other feeding and eating disorder, and SUDs are more common alongside BN or AN with bulimic features than they are comorbid with restrictive AN (APA, 2013; CSAT, 2009; Fouladi et al., 2015). Some have suggested that the most common comorbidity among feeding and eating disorders and SUDs is BN (or AN with bulimic features) and AUD (Gregorowski, Seedat, & Jordaan, 2013; Munn-Chernoff et al., 2015).
Treatment outcomes of people with eating disorders and SUDs are worse than those of people without both conditions. They have higher odds of early mortality, co-occurring physical and mental illness, and delayed recovery (Root et al., 2010). People in SUD treatment with feeding/eating disorder symptoms have higher risk of treatment dropout and discharge against medical advice (Elmquist, Shorey, Anderson, & Stuart, 2015). Alcohol misuse more than doubles mortality risk in AN (Franko et al., 2013).
Feeding or eating disorders can make SUD assessment and treatment more complex—such as by raising risk of stopping SUD treatment against medical advice (Elmquist et al., 2015). Heightened mortality with feeding and eating disorders means that multidisciplinary care should include primary care providers and dietary/nutritional rehabilitation professionals in addition to SUD treatment professionals, mental health professionals (e.g., psychiatric and mental health nurses), and social workers (SAMHSA, 2011 a).
The literature does not currently describe randomized controlled trials for treatment of these CODs. In general, concurrent treatment is recommended; sequential interventions can increase likelihood of relapse or otherwise hinder recovery from the untreated CODs (Gregorowski et al., 2013). If integrated care is not possible,
SUD treatment should proceed first to halt active substance use and allow the client to fully participate in further care (SAMHSA, 2011 a).
“DRUNKOREXIA”: A NEW AND DANGEROUS COMBINATION OF EATING DISORDERS AND ALCOHOL MISUSE.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH AN EATING DISORDER.
Only 51 percent of SUD treatment programs report screening clients for feeding and eating disorders (Kanbur & Harrison, 2016).
Regardless of treatment modality, providers must first ensure medical and weight stabilization so clients are healthy and able to physically and cognitively participate in and benefit from therapy (Harrop & Marlatt, 2010). Some clients with AN or BN may require inpatient treatment or partial hospitalization to stabilize weight. Depending on the facility, staff may not be equipped to address any co-occurring substance misuse simultaneously.
The primary treatment for these disorders is psychosocial intervention, including individual, group, family therapy, or a combination thereof. CBT can be effective for feeding and eating disorders but has not been researched thoroughly in populations with co-occurring addiction (Gregorowski et al., 2013). Dialectical behavior therapy also can be useful in promoting mindfulness, improving management of negative emotions, and teaching affective and behavioral self-regulation skills in feeding and eating disorders and in SUDs separately (Ritschel, Lim, & Stewart, 2015) but, again, has not been studied extensively in both concurrently. Pharmacotherapy may be warranted for BN and BED (SAMHSA, 2011a) but is not a first-line treatment. Further studies are needed to clarify how the presence of a feeding or eating disorder affects SUD treatment and how best to integrate treatment for both conditions.
The primary aim of this section of the chapter is to describe substance-induced mental disorders and to clarify how to differentiate them from mental disorders that co-occur with SUDs.
Substance-related disorders include two subcategories: SUDs and substance-induced disorders. SUDs identify the cluster of cognitive, behavioral, and physical symptoms that occur as a result of continued and frequent use of substances. These consequences are not immediate. Rather, they occur over time as addiction progresses. Substance-induced mental disorders refer to the immediate effects of substance use (intoxication), the immediate effects of discontinuing a substance (substance withdrawal), and other substance-induced mental disorders (APA, 2013).
The essential feature of an SUD is a cluster of cognitive, behavioral, and physical symptoms indicating that the individual continues using the substance despite significant substance-related problems. All DSM-5 SUDs have their own diagnostic criteria, but criteria are largely the same across substances. Addiction counselors should be familiar with SUD diagnostic criteria and refer to DSM-5 as needed.
Lifetime and 12-month prevalence rates of DSM-5 drug use disorders (i.e., non-alcohol-related SUDs) are nearly 10 percent and 4 percent, respectively (Grant et al., 2016). Lifetime and 12-month prevalence rates of AUD are about 29 percent and 14 percent, respectively (Grant et al., 2015). Past-month prevalence rates of misuse of other substances by adults ages 26 and older include (CBHSQ, 2019):
8.6 percent for cannabis.
0.7 percent for cocaine.
1.0 percent for pain relievers.
0.5 for tranquilizers.
0.4 percent for stimulants.
0.1 percent for prescription sedatives.
0.4 percent for hallucinogens.
0.2 percent for heroin.
0.1 percent for inhalants.
The toxic effects of substances can mimic mental disorders in ways that can be difficult to distinguish from mental illness. This section focuses on a general description of symptoms of mental illness that are the result of substances or medications—a condition called substance-induced mental disorders.
DSM-5 substance-induced mental disorders include:
Substance-induced depressive disorders.
Substance-induced bipolar and related disorders.
Substance-induced anxiety disorders.
Substance-induced psychotic disorders.
Substance-induced obsessive-compulsive and related disorders.
Substance-induced sleep disorders.
Substance-induced sexual dysfunctions.
Substance-induced delirium.
Substance-induced neurocognitive disorder.
The first four of the listed substance-induced mental disorders are the most common in addiction, discussed further in the section, “Specific Substance-Induced Mental Disorders.” Exhibit 4.16 summarizes substances and the substance-induced mental disorders associated with each.
EXHIBIT 4.16. Substances and Corresponding Substance-Induced Mental Disorders.
WARNING TO COUNSELORS: INDEPENDENT VERSUS SUBSTANCE-INDUCED MENTAL DISORDERS.
Substance-induced mental disorders are distinct from independent co-occurring mental disorders in that all or most of the psychiatric symptoms are the direct result of substance use. This does not mean that substance-induced disorders preclude co-occurring mental disorders, only that the specific symptom cluster at a specific point in time is more likely the result of substance use, misuse, intoxication, or withdrawal than of underlying mental illness.
Even when the psychiatric diagnosis has not been established, the client's co-occurring symptoms should still be treated (with nonmedication). Counselors should not withhold treatment simply because a determination about the origin of the mental disorder has not yet been made.
Symptoms of substance-induced mental disorders run the gamut from mild anxiety and depression (these are the most common across all substances) to full-blown manic and other psychotic reactions (much less common). For example, acute withdrawal symptoms from physiological depressants such as alcohol and benzodiazepines are hyperactivity, elevated blood pressure, agitation, and anxiety (i.e., “the shakes”). On the other hand, those who “crash” from stimulants are tired, withdrawn, and depressed.
Because clients vary greatly in how they respond to both intoxication and withdrawal given the same exposure to the same substance, and also because different substances may be taken at the same time, prediction of any particular substance-related syndrome has its limits. What is most important is to continue to evaluate psychiatric symptoms and their relationship to abstinence or ongoing substance misuse over time. Most substance-induced symptoms begin to improve within hours or days after substance use has stopped. Notable exceptions to this are psychotic symptoms caused by heavy and longterm amphetamine misuse and dementia (e.g., problems with memory, concentration, problem solving) caused by using substances directly toxic to the brain, which most commonly include alcohol, inhalants like gasoline, and amphetamines.
Exhibit 4.17 offers an overview of the most common classes of misused substances and the accompanying psychiatric symptoms seen in intoxication and withdrawal.
EXHIBIT 4.17. Substance-Induced Mental Disorder Symptoms (by Substance).
INDUCED VERSUS INDEPENDENT MENTAL DISORDERS: THE IMPORTANCE OF TREATMENT.
Diagnoses of substance-induced mental disorders will typically be provisional and will require réévaluation—sometimes repeatedly. Many apparent acute mental disorders may really be substance-induced disorders, such as in those clients who use substances and who are acutely suicidal.
Some people who appear to have substance-induced mental disorders turn out to have a substance-induced mental disorder and independent mental disorder. Consider preexisting mood state, personal expectations, drug dosage, and environmental surroundings in understanding of how a particular client might experience a substance-induced disorder. Treatment of the SUD and an abstinent period of weeks or months may be required for a definitive diagnosis of an independent, co-occurring mental disorder. As described in Chapter 3, SUD treatment programs and clinical staff can concentrate on screening for mental disorders and determining the severity and acuity of symptoms, along with an understanding of the client's support network and overall life situation.
This section briefly discusses the most common substance-induced mental disorders in clinical populations: substance-induced depressive, anxiety, bipolar, and psychotic disorders. Diagnostic criteria for all substance-induced mental disorders, including the four mentioned, are nearly identical and comprise five general characteristics (Exhibit 4.18).
EXHIBIT 4.18. Features of DSM-5 Substance-Induced Mental Disorders.
Exhibit 4.19 lists substances most likely to induce/mimic depressive, anxiety, bipolar, and psychotic disorders.
EXHIBIT 4.19. Substances That Precipitate or Mimic Common Mental Disorders.
The lifetime prevalence of substance-induced depressive disorders in the general community is 0.26 percent (Blanco et al., 2012). Observed rates among clinical populations are much higher. For instance, in a study of people seeking treatment for co-occurring depressive disorders and SUDs, 24 percent had substance-induced depression; rates varied by substance. Among those with 12-month alcohol dependence, prevalence of substance-induced MDD was 22 percent; for past-year cocaine dependence, 22 percent; and for past-year heroin dependence, nearly 37 percent (Samet et al., 2013). In another study of people with SUDs, 60 percent of people with depression had a substance-induced rather than independent depressive disorder (Conner et al., 2014). DSM-5 notes that although about 40 percent of people with AUD develop MDD, only about one-third to one-half are cases of independent depression, meaning as much as 75 percent of occurrences of depressive disorders in the context of AUD could be because of intoxication or withdrawal (APA, 2013). Depressive disorders or their symptoms could also be because of the long-term effects of substance use.
Diagnosis of a substance-induced versus independent depressive disorder can be difficult given that many people with SUDs do have mood symptoms, like depressed affect, and intoxication and withdrawal from substances can mirror symptoms of depression. During the first months of abstinence, many people with SUDs may exhibit symptoms of depression that fade over time and are related to acute withdrawal. Because depressive symptoms during withdrawal and early recovery may result from SUDs and not an underlying depression, a period of time should elapse before depression is diagnosed. This does not preclude the importance of addressing depressive symptoms during the early stage of recovery, before diagnosis. Further, even if an episode of depression is substance induced, that does not mean that it should not be treated. Overall, the process of addiction can result in biopsychosocial disintegration, leading to PDD or depression often lasting from months to years.
Substance-induced mood alterations can result from acute and chronic drug use as well as from drug withdrawal. Substance-induced depressive 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, and sometimes is accompanied by suicidal ideation or attempts.
Stimulant withdrawal may provoke episodes of depression lasting from hours to days, especially following high-dose, chronic use. 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 (oversleeping). Depression resulting from stimulant withdrawal may be severe and can be worsened by the individual's awareness of substance use-related adverse consequences. Symptoms of craving for stimulants are likely and suicide is possible. Protracted stimulant withdrawal often includes sustained episodes of anhedonia (absence of pleasure) and lethargy with frequent ruminations and dreams about stimulant use.
Stimulant cessation may be followed for several months by bursts of dysphoria, intense depression, insomnia, and agitation. These symptoms may be either worsened or lessened depending on the provider's treatment attitudes, beliefs, and approaches. It is a delicate balance—between allowing time to observe the direction of symptoms to treating the client's presenting symptoms regardless of origin.
The prevalence of substance-induced anxiety disorders in the community is unreported and thought to be quite low (less than 0.1 percent), although likely higher in clinical samples (APA, 2013).
Licit and illicit substances can cause symptoms that are identical to those in anxiety. In addition, many medications, toxins, and medical procedures can cause or are associated with an eruption of anxiety. Moreover, these reactions vary greatly from mild manifestations of shortlived symptoms to full-blown manic and other psychotic reactions, which are not necessarily short lived.
Symptoms that look like anxiety may appear either during use or withdrawal. Alcohol, amphetamine and its derivatives, cannabis, cocaine, hallucinogens, intoxicants and phencyclidine and its relatives have been reported to cause the symptoms of anxiety during intoxication. Withdrawal from alcohol, cocaine, illicit opioids, and also caffeine and nicotine can also cause manifestations of anxiety. Similarly, withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms.
Epidemiologic data on substance-induced mania or bipolar disorders in the U.S. general population are not readily available.
A number of substances of misuse (as well as prescribed medications and several medical conditions) are also associated with manic-like phenomena. 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. Individuals experiencing acute mania with its accompanying hyperactivity, psychosis, and often aggressive and impulsive behavior should be referred to emergency mental health professionals.
Stimulant-induced episodes of mania may include symptoms of paranoia lasting from hours to days. Stimulants such as cocaine and 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 with sleep deprivation, may prompt a manic episode. Symptoms may include euphoric, expansive, or irritable mood, often with flight of ideas, severe social functioning impairment, and insomnia.
This condition is very rare; exact prevalence rates are unknown (APA, 2013). In first-episode psychosis, 7 percent to 25 percent of cases are substance induced (APA, 2013).
CASE STUDIES: IDENTIFYING DISORDERS.
Heavy users of psychoactive substances, like cannabis, amphetamines, and cocaine, are vulnerable to substance-induced psychosis, especially clients with cooccurring schizophrenia and bipolar disorders. Antidepressants can also precipitate psychotic episodes, as can medications like prescribed steroids and nonsteroidal anti-inflammatory drugs, antiviral agents, antibiotics, anti-cholinergics, antihistamines, muscle relaxants, and opioids. Any number of physical illnesses or medication reactions, from brain tumors to steroid side effects, can cause a psychotic episode or psychotic behavior. Virtually any substance taken in very large quantities over a long enough period can lead to a psychotic state.
Differential diagnosis among psychotic disorders can be challenging, even for experienced clinicians and diagnosticians, especially when substances are involved. When a client presents in a psychotic state, any immediate or recent substance use is difficult to determine, and it may be impossible to discern whether the hallucinations or delusions are caused by substance use. If the hallucinations or delusions can be attributed to substance use but are prominent and beyond what one might expect from intoxication alone, the episode would be described as a substance-induced psychotic disorder. Hallucinations that the person knows are solely the result of substance use are not considered indicative of a psychotic episode; instead, they are diagnosed as substance intoxication or substance withdrawal with the specifier “with perceptual disturbances” (APA, 2013).
Suicide risk and trauma status are relevant to care planning, client safety, and treatment outcomes across many CODs. This section briefly addresses each issue and offers guidance to help addiction counselors understand why both need to be actively considered as part of assessment and treatment.
Ample literature discusses suicide, mental disorders, and addiction. This section is not intended to thoroughly review all aspects of suicide-related assessment, management, and prevention techniques for COD populations; readers instead are directed to TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT, 2009) for more information. The aim of this text is to ensure that readers have a broad and general understanding of the high risk of suicidal thoughts and behaviors in clients with CODs and feel confident in knowing how to prevent and respond to such events.
Similarly, trauma has been a significant topic of research in the behavioral health literature. What follows is an abbreviated summary of the link between trauma and mental disorders and SUDs and how addiction counselors can offer trauma-informed services. Readers should consult TIP 57, Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b) for more guidance in this area.
For both suicide and trauma, readers are reminded to review Chapter 3 for assessment techniques and tools, Appendix B for links to suicide prevention materials and other resources, and Appendix C for counselor tools like trauma screeners.
Suicide is a common risk factor that pertains to nearly all CODs and particularly those involving addiction and MDD, bipolar disorder, schizophrenia, PTSD, or PDs (Yuodelis-Flores & Ries, 2015). Suicidality itself is not a mental disorder, but it is considered a high-risk behavior of significant public health concern (Hogan & Grumet, 2016). Substance-induced or exacerbated suicidal ideations, intentions, and behaviors are possible complications of SUDs, especially for clients with co-occurring mental disorders.
The topic of suicidality is critical for SUD treatment counselors working with clients who have CODs. SUDs alone increase suicidality (Yuodelis-Flores & Ries, 2015), whereas the added presence of some mental disorders doubles the already heightened risk (O'Connor & Pirkis, 2016). The risk of suicide is greatest when relapse occurs after a substantial period of abstinence—especially if there is concurrent financial or psychosocial loss. Every agency that offers SUD counseling must also have a clear protocol in place that addresses the recognition and treatment (or referral) of people who may be suicidal.
These populations (Department of Health and Human Services, 2012) are vulnerable to suicide risk; many are susceptible to addiction or CODs as well:
American Indians/Alaska Natives
Individuals who have lost a loved one to suicide
Clients involved in criminal justice/child welfare systems
Clients who engage in nonsuicidal self-injury
Individuals with a history of previous suicide attempt
Individuals with debilitating physical conditions
Clients with mental disorders, SUDs, or both
Individuals in the LGBTQ community
Members of the armed forces and veterans
Middle-aged and older men
Suicide is the 10th leading cause of death in the United States among people ages 10 and older (Stone et al., 2019). Suicide is the second leading cause of death for people ages 10 to 34 and the fourth leading cause of death for those ages 35 and 54 (NIMH, 2019). Per the Centers for Disease Control and Prevention (CDC), from 1999 to 2018, suicide rates in the United States increased 41 percent, from 10.5 to 14.8 per 100,000 people (CDC, 2019). Suicide rates among men remain more than 3 times higher (23.4 per 100,000 in 2018) than among women (6.4 per 100,000 in 2018) (CDC, 2020).
Almost half (46 percent) of all individuals in the United States who died by suicide between 2014 and 2016 had a known mental health condition, and 54 percent were in treatment at the time of death (Stone et al., 2019). Depression was the most common mental disorder diagnosis among those who completed suicide (75 percent); other major mental disorder diagnoses included anxiety (17 percent), bipolar disorders (1 5 percent), schizophrenia (5 percent), and PTSD (4 percent) (Stone et al., 2019).
According to NSDUH data (CBHSQ, 2019), in 2018:
About 10.7 million U.S. adults ages 18 or older thought seriously of dying by suicide (4.3 percent of adults).
3.3 million U.S. adults made suicide plans (1.3 percent).
1.4 million U.S. adults made nonfatal suicide attempts (0.6 percent).
Substance misuse makes people susceptible to self-harm; indeed, suicide is the leading cause of death among people with addiction (CSAT, 2009). From 2014 to 2016, 28 percent of people who died by suicide had problematic substance use, including 32 percent of people with a known mental health disorder (Stone et al., 2019). Of these individuals with known psychiatric problems, 39 percent tested positive for alcohol, 39 percent for benzodiazepines, 29 percent for opioids, 23 percent for cannabis, 10 percent for amphetamines, and 6 percent for cocaine (Stone et al., 2019).
Alcohol factors prominently into suicide (Darvishi, Farhadi, Haghtalab, & Poorolajal, 2015). Acute alcohol intoxication increases the risk of suicide attempt by nearly 7 times and in some studies, if use is heavy, by as much as 37 times (Borges et al., 2017). This risk appears to increase with corresponding increases in consumption; as such, populations with AUD have higher rates of suicide than people without problematic alcohol use (Yuodelis-Flores & Ries, 2015).
Other substances also carry an increased risk of self-harm, as suicidal behavior is prominent in OUD, cocaine use disorder, and polysubstance use (Yuodelis-Flores & Ries, 2015). Among individuals with a history of substance misuse who died by suicide in 2014 (Fowler, Jack, Lyons, Betz, & Petrosky, 2018), the most commonly involved nonmedication substances were alcohol (51 percent), opioids (23 percent), and cannabis (almost 14 percent). Furthermore, among all suicide cases that year, opioids were the direct cause of death in 27 percent of people and alcohol in 13 percent (Fowler et al., 2018). The overall suicide rate of U.S. veterans with an SUD is estimated at 75.6 per 100,000 people and is highest among those who misuse sedatives, followed by amphetamines, opioids, cannabis, alcohol, and cocaine (Bohnert, Ilgen, Louzon, McCarthy, & Katz, 2017). People who report misusing prescription medication, and in particular pain relievers, also appear to be vulnerable to suicidal ideation (Ford & Perna, 2015).
The link between substance misuse and suicide may relate to the capacity of substances, especially alcohol, to quell inhibition, leading to poor judgment, mood instability, and impulsiveness. Depression, comorbid with suicide risk and substance misuse, may moderate this relationship. A population-based sample of people currently using alcohol and with a history of depressed mood (Sung et al., 2016) found that those with a positive history of suicide attempt were significantly more likely than those without such a history to have problematic substance use, including 21 percent with alcohol abuse or dependence and nearly 40 percent with illicit drug abuse or dependence. Yet alcohol dependence in this sample significantly increased the odds of suicidal ideation and suicide attempt even among people without a history of depressed mood. This suggests that depressed mood alone cannot account for the relationship between alcohol misuse and risk of suicide, although it undoubtedly increases the odds.
Many psychiatric illnesses have a heightened risk of suicidal thoughts and behaviors further exacerbated in the presence of co-occurring addiction. Risk factors for suicide that have been identified in the general population, such as a family history of suicide attempt or completion and access to firearms, also apply to people with CODs and make self-harm more likely. Additionally, certain individuals with CODs may be at even further risk based on the presence of contributing factors that frequently appear in populations with mental disorders and SUDs. For instance, having a chronic physical health condition (such as traumatic brain injury or infectious disease), experiencing homelessness, being a military veteran, and past involvement in the criminal justice system are all associated with suicide-related ideation, gestures, attempts, or deaths (Ahmedani et al., 2017; Cook, 2013; Jahn et al., 2018; Kang et al., 2015; Tsai & Cao, 2019) and may further compromise the safety of people with CODs. A history of adverse life experiences, like childhood maltreatment or intimate partner violence, also significantly increases risk of self-harm (especially in people with CODs) and is addressed in the section “Trauma.”
Although a rare event, suicide is often—but not always—preventable. All SUD treatment clients should receive at least a basic screening for suicidality, and all SUD treatment professionals should know how to conduct at least basic screening and triage. (To learn more about suicide screening, see Chapter 3 of this TIP.) SAMHSA's Five-Step Evaluation and Triage (SAMHSA, 2009b) recommends using the following process for identifying and responding to threat of self-harm:
Identify risk factors.
Identify protective factors.
Conduct a suicidal inquiry into the client's thoughts, plans, behaviors, and intents.
Determine the level of risk and appropriate interventions.
Document risk, rationale, intervention, and follow-up procedures.
Addiction counselors should regularly assess and monitor all clients with CODs for suicidal ideation, gestures, plans, and attempts and especially clients with depressive disorders, bipolar disorders, PTSD, schizophrenia, or PDs. Routine assessment should be an integral part of treatment but is especially critical during times of high stress or increased substance use (including relapse) as well as at intake, following any suicidal behavior, following reports of suicidal ideation, and just before discharge. Information should be collected on the client's:
Personal and family history of suicidal thoughts and behaviors.
Plan for suicide.
Reasons for not following through with past plans for suicide.
Reasons for not following through with the current plan for suicide.
Current support system.
Means and access to lethal methods (e.g., firearms).
History and current symptoms of impulsivity.
Depressed mood, feelings of hopelessness, or both.
Protective factors (e.g., coping skills, spiritual/religious beliefs).
Asking a client directly about his or her desire to die by suicide does not make self-harm more likely and in fact can yield helpful information.
Note that people may deny such thoughts or plans despite having them. Thus, direct questioning alone is an insufficient risk mitigation strategy. Suicide risk assessment scales might be useful in this regard (see Chapter 3 and Appendix C for suicide risk and self-harm screening tools) but often lack the specificity and sensitivity to adequately detect impending suicidal behaviors (Bolton, Gunnell, & Turecki, 2015). Providers also should not rely solely on suicide measures. Instead, suicide screening should include thorough investigation of all major signs, symptoms, and risk factors associated with self-harm in mental health, addiction, or COD populations.
RESOURCE ALERT: SUICIDE PREVENTION RESOURCES FOR COUNSELORS.
Safety planning is critical in suicide risk mitigation. Suicide “contracts” are written statements in which the person who is suicidal states that he or she will not kill himself but rather call for help, go to an ED, or other seek other assistance if he or she becomes suicidal. These contracts are not effective alone for a client who is suicidal. Such contracts often help make clients and therapists less anxious about a suicidal condition, but studies have never shown these contracts to be effective at preventing suicide. Rather, safety contracts help focus on the key elements that are most likely to keep clients safe, such as agreeing to remove the means a client is most likely to use to commit suicide.
Counselors and other providers should know their own skills and limitations in engaging, screening, assessing, and intervening with suicidal clients and work out these problems with a supervisor before an emergency. Providers also should know what immediate onsite and offsite resources are available to help with someone identified as suicidal. To learn more about suicide prevention, see “Resource Alert: Suicide Prevention Resources for Counselors.”
No empirical treatments for suicide exist. However, interventions that reduce symptoms of SUDs and mental illness can help mitigate suicide risk and decrease self-harm behaviors by improving mood and enhancing support and coping skills. Some research supports the use of psychotherapies such as CBT and dialectical behavior therapy in reducing parasuicidal behavior and suicide attempts, but the overall evidence base is small (Bolton et al., 2015). Pharmacotherapy—particularly antidepressants— can reduce suicidal behavior in people ages 25 years and older. Yet paradoxically, some studies show that it actually increases suicide in people ages 25 and younger (Bolton et al., 2015). Certain mood stabilizers and antipsychotic medications also may reduce self-harm in people with bipolar disorder, schizophrenia, and other psychotic disorders (Bolton et al., 2015).
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WHO IS SUICIDAL.
The first steps in suicide intervention, and thus crisis stabilization, are contained in the process of a good engagement and evaluation. Asking suicide-related questions, exploring the context of those impulses, evaluating support systems, considering the lethality of means, and assessing the client's motivation to seek help are in themselves an intervention. Such an interview will often elicit the client's own insight and problem solving and may result in a decrease in suicidal impulses.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WHO IS SUICIDAL.
If, however, the client experiences little or no relief after this process, psychiatric intervention is required, especially if the client has a cooccurring mental disorder or medical disorder in which the risk of suicide is elevated or if the client has a history of suicide attempts. If either or both is true, arrangements should be made for transfer to a facility that can provide more intensive psychiatric evaluation and treatment. Emergency procedures should be in place so the counselor can accomplish this transfer even when a psychiatrist or clinical supervisor/director is not available. Once the client is stabilized and is safe to return to a less restrictive setting, he or she should return to the program.
DSM-5 defines trauma as “as exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: (a) directly experiencing the traumatic event; (b) witnessing, in person, an event as it occurred to others; (c) learning that the traumatic event occurred to a close family member or close friend; and (d) experiencing repeated or extreme exposure to aversive details of the traumatic event(s)” (APA, 2013, p. 271).
For many people with mental disorders, SUDs, or both, past or current trauma is a prominent driver of negative outcomes such as psychiatric hospitalizations; suicide attempts; self-harm behaviors; arrest; aggression; and substance use initiation, escalation (from occasional use, to regular use, to misuse/heavy use/addiction), treatment dropout, and relapse (Kumar, Stowe Han, & Mancino, 2016; Lijffijt, Hu, & Swann, 2014; Stinson, Quinn, & Levenson, 2016). Data from the National Longitudinal Study of Adolescent to Adult Health (Quinn et al., 2016) confirm that exposure to childhood trauma (e.g., sexual/emotional/physical abuse, neglect, witnessing violence) significantly increases the risk of adulthood prescription pain reliever misuse (PPRM) and injection drug use. This risk only grows as the number of traumas experienced increases; in the study, exposure to one trauma increased the risk of PPRM by 34 percent; two traumas, by 50 percent; three traumas, by 70 percent; and four traumas, by 217 percent. Emotional and physical abuse nearly doubled the risk of injection drug use.
WARNING TO COUNSELORS: RETHINKING TRAUMA.
Traumatic events are common in people with CODs in part because they are so widely prevalent in the general population. Almost 90 percent of people in the United States have a lifetime history of exposure to at least one traumatizing event, typically the death of family/close friend because of violence/accident/disaster; physical or sexual assault; disaster; or accident/fire (Kilpatrick et al., 2013).
As noted in the section “PTSD,” trauma in people with addiction, mental illness, or both is the norm rather than the exception (SAMHSA, 2014b). In more than 600 people receiving SUD treatment, 49 percent reported a lifetime history of physical or sexual abuse, and women were 5 times more likely than men to report lifetime trauma (Keyser-Marcus et al., 2015). In people with SMI, trauma exposure is common, with prevalence rates ranging from 25 percent to 72 percent for physical abuse, 24 percent to 49 percent for sexual abuse, and 20 percent to 47 percent for PTSD (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Twelve-month or lifetime rates of DSM-5 drug use disorder (i.e., an SUD excluding alcohol) carries increased odds of having PTSD (Grant et al., 2016), and 12-month or lifetime PTSD increases the odds of having a past-year or lifetime SUD (Goldstein et al., 2016).
Adverse life experiences are highly coincident with SUDs and mental disorders, and vice versa:
Current PTSD prevalence in addiction populations is likely 15 percent to 42 percent (Vujanovic et al., 2016).
In active duty military personnel, prevalence rates of various comorbid mental disorders and SUDs in people with PTSD have been estimated at 49 percent for depressive disorders, 36 percent for GAD, and almost 27 percent for AUD (Walter, Levine, Highfill-McRoy, Navarro, & Thomsen, 2018).
Among a sample of U.S. adults with any lifetime trauma, 47 percent screened positive for PTSD, almost 47 percent for GAD, and 42 percent for depression (Ghafoori, Barragan, & Palinkas, (2014).
Between 28 percent and 43 percent of people with PTSD have an SMI (Lu et al., 2013).
People with past-year or lifetime PTSD are at significant risk of developing any number of comorbid mental disorders, including any mood disorder (2.4 to 3 times the odds), bipolar I disorder (2.1 to 2.2 times), any anxiety disorder (2.6 to 2.8 times), GAD (2 to 2.2 times), panic disorder (2.1 times), and BPD (2.8 to 3.3 times) (Goldstein et al., 2016).
People with adverse childhood events (e.g., abuse, neglect) are more likely to report lifetime drug use, past-year moderate-to-heavy alcohol use, lifetime suicide attempt, and past-year depressed mood than people without such a history (Merrick et al., 2017). Emotional abuse in childhood is linked with 6 times the odds for a lifetime suicide attempt (Merrick et al., 2017).
Historically, trauma has not been adequately addressed in SUD treatment, given provider fear that doing so would worsen mental and addiction problems. However, research indicates the opposite—that failing to address trauma in people with SUDs leads to worse outcomes (Brown, Harris, & Fallot, 2013).
Trauma-informed care means attending to trauma-related symptoms and also creating a treatment environment that is responsive to the unique needs of individuals with histories of trauma. Treatment is focused on reducing specific symptoms and restoring functioning but also broader goals like building resiliency, reestablishing trust, preventing retraumatization, and offering hope for the future. Creating a supportive, safe treatment environment is crucial. Counselors must realize how the setting and their interactions with clients who have trauma can affect treatment adherence, retention, and outcomes.
Trauma-informed care for people with mental disorders, SUDs, or both often includes (SAMHSA, 2014b):
Psychoeducation, especially about the relationship between trauma, mental health, and addiction. Psychoeducation is also needed to help normalize symptoms and reassure clients that their experiences are not unusual, “wrong,” or “bad.”
Teaching coping and problem-solving skills to foster effective stress management.
Discussing retraumatization and developing strategies to prevent further victimization.
Helping clients feel empowered and in control of their lives.
Establishing a sense of safety in clients’ daily lives and in treatment.
Promoting resilience and offering hope for change and improvement.
Identifying and responding adaptatively to triggers, like intrusive thoughts, feelings, and sensations.
Building a therapeutic alliance, which fosters trust, confidence, and self-worth—all keys to healing.
Using trauma-specific interventions, like:
CBT.
Cognitive processing therapy.
Exposure therapy.
Eye movement desensitization/reprocessing.
Affective regulation.
Distress tolerance and stress inoculation.
Peer support services from other people who have a trauma history and are thriving.
TIP 57, Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b) and SAMHSA's “Concept of Trauma and Guidance for a Trauma-Informed Approach” (SAMHSA, 2014c) will help addiction and mental health professionals tailor their services in a way that is respectful of and sensitive to clients’ trauma-related needs. Chapter 6 discusses adapting treatments for CODs to female clients with trauma.
ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH TRAUMA.
Active duty and veteran members of the military are highly susceptible to trauma and all of its deleterious aftereffects. PTSD prevalence is significantly higher than that of the general population and civilian clinical samples, including 9 percent among a sample of more than 4 million veterans in primary care settings (Trivedi et al., 2014), 23 percent among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans (Fulton et al., 2015), 21 percent in Gulf War veterans (Dursa, Barth, Schneiderman, & Bossarte, 2015), and 8.5 percent to 12.2 percent of Vietnam War veterans (Marmar et al., 2015).
About 20 percent of veterans have CODs (Trivedi et al., 2015); 16 percent have PTSD and SUDs specifically (Mansfield, Greenbaum, Schaper, Banducci, & Rosen, 2017). In a sample of (OEF/OIF) veterans, 63 percent of people with SUD also had PTSD (Seal et al., 2011). Other common mental disorders in this population include SMI, depression, and anxiety; all tend to co-occur often (Exhibit 4.20). These illnesses are linked with increased hospitalizations, ED use, and mortality, with SMI and SUDs being particularly damaging (Trivedi et al., 2015).
EXHIBIT 4.20. Veterans and CODs.
Many veterans seek treatment outside of the Veterans Health Administration, so community addiction counselors should prepare to work with them. Counseling veteran or active duty military populations requires a slightly different knowledge base, clinical approach, and skillset than civilian populations. SUD counselors should note that (Briggs & Reneson, 2010; Teeters, Lancaster, Brown, & Back, 2017):
War zone stress reactions often require specialized care and an understanding of the experiences faced by soldiers in combat.
Military-related trauma exposure does not include only direct combat. For instance, people working in intelligence gathering and medical personnel are often deployed to war zones where they witness horrific acts of violence and are potential targets of violence themselves.
Female veterans often have specific service needs, such as those to address military sexual trauma (e.g., sexual assault, harassment), intimate partner violence, and child care. (Note that men also can be victims of military sexual trauma, albeit at far lower rates than reported by women. Do not assume that military sexual trauma is solely a women's issue.)
Many veterans are hesitant to seek SLID treatment or mental health services because of fear that doing so could negatively affect their career advancement. Concerns about confidentiality are thus understandably very high in these clients.
Shame, embarrassment, and stigma over mental health and addiction are prominent. Military culture fosters some behaviors and mindsets that can be adaptive in combat—like independence, being “masculine,” and not showing “weakness”—but make seeking treatment much harder.
Suicide risk is high in veterans. It requires active monitoring and management throughout treatment, particularly for military personnel with childhood trauma, PTSD, military sexual trauma, or depression (Carroll, Currier, McCormick, & Drescher, 2017; Cunningham et al., 2017; Kimerling, Makin-Byrd, Louzon, Ignacio, & McCarthy, 2016; McKinney, FHirsch, & Britton, 2017; Pompili et al., 2013).
Indepth discussions about prevention programming and treatment for military populations with trauma, suicide risk, SUDs, mental disorders, or a combination thereof is beyond the scope of this TIP. However, ample information is available elsewhere. The following resources offer helpful guidance about working with military professionals who engage in substance misuse or have mental illness, including trauma, suicidality, and CODs:
ACA:
Suicide Among Veterans and the Implications for Counselors (www
Comparison of Civilian Trauma and Combat Trauma (https://pdfs
Counseling Addicted Veterans: What to Know and How to Help (https://pdfs
The Department of Veterans Affairs’ National Center for PTSD (www
Practice Recommendations for Treatment of Veterans with Comorbid Substance Use Disorder and Posttraumatic Stress Disorder (www
Veteran Outreach Toolkit: Preventing Veteran Suicide Is Everyone's Business (www
National Strategy for Preventing Veteran Suicide, 2018-2028 (www
SAMHSA's Addressing the Substance Use Disorder Service Needs of Returning Veterans and Their Families (www.samhsa.gov/sites/ default/files/veterans report.pdf)
Community Anti-Drug Coalitions of America's Strategies for Addressing Substance Abuse in Veteran Populations (www.cadca.org/sites/ default/files/mckesson_toolkit_1.pdf)
The material in this chapter is intended to increase SUD treatment counselors’ and other providers’ familiarity with mental disorders terminology and criteria, as well as to provide advice on how to proceed with clients who demonstrate these disorders. The consensus panel encourages counselors to continue to increase their understanding of mental disorders by using the resource material referenced in each section (and in Appendix C), attending courses and conferences in these areas, and engaging in dialog with mental health professionals who are involved in treatment. At the same time, the panel urges continued work to develop improved treatment approaches that address substance use in combination with specific mental disorders, as well as better translation of that work to make it more accessible to the SUD treatment field.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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