Addiction and Dual Disorders


Some psychiatric patients may be more vulnerable than others to the adverse effects of alcohol or other drugs.

Addiction may serve as a risk factor for psychiatric illness (e.g., the odds of having a psychiatric disorder among those with a drug use disorder is 4.5 according to the ECA survey).

The use of drugs can precipitate an underlying psychiatric condition (e.g., PCP or cocaine use may trigger a first manic episode in a vulnerable individual).

Symptom picture and long-term outcome (high psychiatric severity patients as measured by the Addiction Severity Index (ASI) do worse than low psychiatric severity patients; there is a strong association between relapse and psychiatric impairment among opiate addicts and some association between relapse and psychiatric impairment among alcoholics [Catalano et al. 1988; McLellan et al. 1985]).

Psychiatric symptoms may develop in the course of chronic intoxications (e.g., psychosis may follow PCP use or chronic stimulant use; suicidal tendencies and depression may follow a cocaine crash).

Psychiatric symptoms may emerge as a consequence of chronic use of drugs or a relapse (e.g., depression may be caused by an awareness of the losses associated with addiction; depression may follow a drug or alcohol relapse).

The addictive disorder and the psychiatric disorder can develop at different points in time and not be linked (e.g., a bipolar patient may become hooked on drugs years after being stable from a manic disorder; an alcoholic may develop panic disorder or major depression long after being sober).

Symptoms of one disorder can contribute to relapse of the other disorder (e.g., increased anxiety or hallucinations may lead the patient to alcohol or other drug use to ameliorate symptoms; a cocaine or alcohol binge may lead to depressive symptoms).

It is believed that total abstinence plus personality and lifestyle change are essential for full recovery. People raised in dysfunctional families often develop self-defeating personality styles (character defects) that interfere with their ability to recover. Addiction is a chronic disease that has a tendency toward relapse. Relapse is the process of becoming dysfunctional in recovery, which ends in physical or emotional collapse, suicide, or self-medication with alcohol or other drugs. Some scientists suggest incorporating the roles of brain dysfunction, personality disorganization, social dysfunction, and family-of-origin problems to the problems of recovery and relapse.

Brain dysfunction occurs during periods of intoxication, short-term withdrawal, and long-term withdrawal. Clients with a genetic history of addiction appear to be more susceptible to this brain dysfunction. As the addiction progresses, the symptoms of this brain dysfunction cause difficulty in thinking clearly, managing feelings and emotions, remembering things, sleeping restfully, recognizing and managing stress, and psychomotor coordination. The symptoms are most severe during the first 6 to 18 months of sobriety, but there is a lifelong tendency of these symptoms to return during times of physical or psychosocial stress.

Personality disorganization occurs because the brain dysfunction interferes with normal thinking, feeling, and acting. Some of the personality disorganization is temporary and will spontaneously subside with abstinence as the brain recovers from the dysfunction. Other personality traits will become deeply habituated during the addiction and will require treatment to subside.

Social dysfunction, which includes family, work, legal, and financial problems, emerges as a consequence of brain dysfunction and resultant personality disorganization.

Addiction can be influenced, not caused, by selfdefeating personality traits that result from being raised in a dysfunctional family. Personality is the habitual way of thinking, feeling, acting, and relating to others that develops in children and is unconsciously perpetuated in adult living. Personality develops as a result of an interaction between genetically inherited traits and family environment.

Being raised in a dysfunctional family can result in self-defeating personality traits or disorders. These traits and disorders do not cause the addiction to occur. They can cause a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, or make it difficult to benefit from treatment. Self-defeating personality traits and disorders also increase the risk of relapse. As a result, family-of-origin problems need to be appropriately addressed in treatment.

The relapse syndrome is an integral part of the addictive disease process. The disease is a double-edged sword with two cutting edges—drug-based symptoms that manifest themselves during active episodes of chemical use and sobriety-based symptoms that emerge during periods of abstinence. The sobriety-based symptoms create a tendency toward relapse that is part of the disease itself. Relapse is the process of becoming dysfunctional in sobriety because of sobriety-based symptoms that lead to renewed alcohol or other drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before alcohol and other drug use or collapse occurs. RP therapy teaches clients to recognize and manage these warning signs and to interrupt the relapse progression early and return to positive progress in recovery.

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