12/12/13  

Treating Co-occurring Substance Use and Personality Disorders

Webinar Organizer Misti Storie, MS, NCC

Presented by:

Frances Patterson, PhD, MAC, BCPC, CCJAS, QSAP, QCS Footprints Consulting Services, LLC

NAADAC, the Association for Addiction Professionals Director of Training & Professional Development

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(615) 289-4905 [email protected] www.footprints-cs.com

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Frances Patterson, PhD, MAC, BCPC, CCJAS, QSAP, QCS Footprints Consulting Services, LLC

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Objectives 1)  Describe personality disorders commonly seen in addictions treatment

Audience Polling Question #1 Are you employed in a program that addresses client with co-occurring substance use and personality disorders?

2)  Define cultural issues to consider during assessment of Personality Disorders 3)  Identify affective treatment approaches for cooccurring SUD and PD 4)  Discuss importance of self-care for professionals treating this population

Audience Polling Question #2

Why Identify Personality Disorders?

If yes, are co-occurring substance use and personality disorders addressed in your policies and procedures?

• Between 11 & 23% of Americans are affected with PD • 50 to 60% of those with a SUD also have one or more PD • Poor client outcomes can result from not correctly identifying PD and not addressing them as part of the treatment process

Personality Disorders Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture and is manifested in at least two of the following criterion areas:

DSM 5 Criterion •  Cognition, affectivity, interpersonal functioning, or impulse control (Criterion A). •  Pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) •  Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C) •  Stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D). •  Not better accounted for as a manifestation or consequence of another mental disorder (Criterion E) •  Not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or a general medical condition (e.g., head trauma) (Criterion F).

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Audience Polling Question #3 In your experience, what has been the most difficult aspect of working with this population?

Breaking It Down: PDs are… •  Rigid, inflexible, and maladaptive behavior patterns •  Severity causes internal distress/ significant impairment in functioning •  Enduring and persistent styles of dysfunctional behavior and thought •  Destructive patterns of thinking, feeling, and behaving as way of being/living in the world

Comorbid Personality Disorders And Substance Use

Substance Use and PD

•  More problematic symptoms of substance use •  More likely to participate in risky IV drug use increasing risk of blood borne viruses (HIV, Hep) •  More likely to engage in risky sex and other high risk behaviors •  May have more difficulty staying in treatment/ treatment plan compliance •  Addictions Treatment associated with a reduction in substance use in those with PD

Substance use is most common in Cluster B type personality disorders, particularly, Borderline and Antisocial

•  Associated with a reduction in likelihood of being arrested indicating reduction in criminal activity

Caution: Identify & Diagnose with Care

Avoid: " " " " "

Preconceived ideas Assumptions Snap judgments Practicing outside scope “Throwing around” diagnoses

In General •  Present as difficult clients •  Disorders may only become apparent after previous failed treatment attempts •  Client education around problems related to substance use, how it effects particular personalities. •  Many have difficulty seeing their substance use as a problem

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Forming an Alliance •  Difficult to form genuine, positive therapeutic alliance •  Tend to frame reality around their own needs and perceptions

Audience Polling Question #4 In your experience, have you found that you often have strong reactions to the client’s acting out behaviors when working with this population?

•  Do not understand the perspectives of others •  Most are limited in ability to receive, accept, or benefit from constructive feedback

Countertransference

Counselor beware!

• Counselors and therapists may experience strong countertransference

• Client manipulation

• This population of clients skilled at “pushing buttons” in many ways

• Pushing boundaries

• Specific concerns with specific PD and other individual circumstances

• Finding a balance between client autonomy and encouraging personal responsibility

Treatment Modalities For Personality Disorders

• Client skill at avoidance, redirecting

• Testing limits

Treatment Modalities For Personality Disorders

•  Cognitive behavioral therapy - Combining cognitive & behavior therapies to help identify unhealthy, negative beliefs/ behaviors and replace them with healthy, positive ones

•  Psychoeducation - Teaches about the disorder, including treatments, coping strategies and problem-solving skills

•  Dialectical behavior therapy - Type of CBT that teaches behavioral skills to help tolerate stress, regulate emotions, improve relationships with others

•  Motivational Interviewing - For treatment engagement, goal setting, problem solving

•  Psychodynamic psychotherapy - Focuses on increasing awareness of unconscious thoughts and behaviors, developing new insights into motivations, resolving conflicts

•  Individual and group therapy - Sessions that include family and/or friends

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Medications and PD •  No medications specifically approved by FDA to treat personality disorders •  Several types of psych meds may help with various PD symptoms •  Antidepressants may be useful with depressed mood, anger, impulsivity, irritability or hopelessness •  Mood-stabilizers can help even out mood swings or reduce irritability, impulsivity and aggression •  Anti-anxiety medications may help with anxiety, agitation or insomnia

Examining

Personality disorders most commonly seen in level 2 and 3 addictions treatment settings

▫  in some cases, they can increase impulsive behavior

•  Antipsychotic medications may be helpful when symptoms include psychosis and sometimes for anxiety or anger problems

Borderline Personality Disorder Essential features: 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.

Criterion •  Frantic efforts to avoid real or imagined abandonment (Criterion 1). •  Pattern of unstable and intense relationships (Criterion 2). •  Identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). •  Impulsivity in at least two areas that are potentially self-damaging (Criterion 4). •  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5).

Criterion (cont) •  Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6).

Audience Polling Question #5 What percentage of persons diagnosed with Borderline Personality Disorder are female?

•  Chronic feelings of emptiness (Criterion 7). •  Expression of inappropriate, intense anger or difficulty controlling anger (Criterion 8). •  Transient, stress-related paranoid ideation or severe dissociative symptoms ▫  Must have 5 or more to meet diagnostic criteria

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SUD and BPD

SUD and BPD (cont)

•  May use drugs in a variety of ways and settings.

•  Often use substances in individual and unpredictable patterns

•  May use as an attempt to relieve the growing sense of tension or loss of control at beginning of crisis episode

•  Polydrug use is common

•  May use the same drugs of choice, route of administration, and frequency as peer group

Counseling a Client With BPD

•  Skilled in Rx drug seeking behaviors •  May demand prescriptions to avoid withdrawal

•  75-90% of those dx with BPD are female

Summary of Key Issues and Concerns

•  Anticipate that client progress will be slow and uneven

•  Slow progress in therapy

•  Assess the risk of self-harm

•  Anticipate suicidal, self-injury or harming behavior

▫  what is wrong, why now, is there a specific plans for suicide, past attempts, current feelings, and protective factors.

•  Maintain a positive but neutral professional relationship, ▫  avoid over-involvement in the client's perceptions

•  Seek frequent supervision/colleague feedback •  Set clear boundaries and expectations regarding limits and requirements in roles and behavior •  Skills building (e.g., deep breathing, meditation, cognitive restructuring) in negative memories and emotions management

•  Consider client contracting •  Diligence in identifying transference and countertransference •  Establish clear boundaries •  Work with resistance •  Identify somatic complaints •  Focus on therapist well-being

TX Modalities for BPD

The Case Of Katie

• DBT

•  28 yo white female in treatment by DCS referral on child custody

• CBT • Interpersonal psychotherapy (IPT) • Psychoanalytic therapy

•  cocaine and alcohol use since age 12 to 14 •  Short, intense, violent relationships with older men •  History of childhood sexual abuse •  History of cutting and suicide threats •  Claimed rape x2 while in treatment

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Essential Features of Antisocial Personality Disorder

APD

•  Pervasive pattern of disregard for, and violation of, the rights of others

▫  For diagnosis, individual must be at least age 18 (Criterion B)

▫  begins in childhood or early adolescence and continues into adulthood ▫  has been referred to as psychopathy, sociopathy, or dyssocial personality disorder

•  Because of deceit and manipulation it may be especially helpful to integrate collateral information into clinical assessment

Antisocial Personality Disorder: Diagnostic Criteria

There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by three (or more) of the following criterion:

▫  Must have had a history of some symptoms of conduct disorder before age 15 (Criterion C) ▫  Occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode (Criterion D)

Criterion ▫  Failure to conform to social norms with respect to lawful behaviors aeb repeated behavior that is grounds for arrest ▫  Deceitfulness, aeb repeated lying, use of aliases, or conning others for personal profit or pleasure ▫  Impulsivity or failure to plan ahead ▫  Irritability and aggressiveness, aeb repeated physical fights or assaults ▫  Reckless disregard for safety of self or others ▫  Consistent irresponsibility, aeb repeated failure to sustain consistent work behavior or honor financial obligations ▫  Lack of remorse, aeb being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Audience Polling Question #6 Of those persons diagnosed with Antisocial Personality Disorder, males outnumber females ______.

2 Essential features of APD • Pervasive disregard for and violation of the rights of others • Inability to form meaningful interpersonal relationships • Males outnumber females 20 to 1

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SUD and APD

SUD and APD

•  Prevalence is high •  Much of treatment particularly targeted to those with APD •  Treatment alone has been particularly effective •  Majority of people with SUD have antisocial behaviors due to addiction •  Most people diagnosed APD are not true psychopaths— ▫  predators who use manipulation, intimidation, and violence to control others and to satisfy their own needs

Summary of Key Issues and Concerns

•  Many people with APD use poly substances •  Excited by the illegal drug culture •  Pride in ability to thrive in dangerous drug culture •  Legal problems •  More effective APD may limit to exploitative or manipulative behaviors that avoid vulnerability to legal problems

The Case of Ricky

• High Possibility of countertransference/ transference

•  34 yo male doc alcohol but used any drugs

• Counselor/therapist well-being to prevent burnout

•  In and out of relationships with dependent women (caretakers)

• Strong resistance to treatment approaches

•  Charismatic – leader

• Consider behavior contracting

•  Criminal activity involved B&E, car theft, assault, drug charges

• Poor treatment outcomes

•  In and out of justice system since age 8

•  Never his fault

Figure D-6. Characteristics of People With Antisocial and Borderline Personality Disorders

Characteristic

Antisocial

Borderline

Narcissistic Personality Disorder

Comparison

Affect

Angry intimidation

Angry self-harm

World view

If you don't do what I want, you'll be sorry.

I've got to get you before you get me.

I deserve it all.

I don't deserve to exist.

They're the ones with the problem.

Help me, help me, but you can't.

Presenting problem

Legal difficulties, polysubstance abuse and dependence, parasitic relationships

Self-harm, impulsive behavior, episodic polysubstance abuse, hotand-cold relationships

Social functioning

Episodic achievement

Gross dysfunctioning

Motivation

Self-esteem

Safety

Defenses

Rationalization, projection

Splitting, projection

A pervasive pattern of grandiosity, a constant need for admiration, lack of empathy, beginning by early adulthood and present in a variety of contexts and at least 5 of the following criterion:

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NPD Criterion

NPD Criterion (cont)

•  A grandiose sense of self-importance

• A sense of entitlement

•  A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• Interpersonally exploitative • A lack of empathy

•  A belief he or she is special and unique; can only be understood by, or should associate with, other special or high-status people

• Envy of others or a belief that others are envious of him or her

•  A need for excessive admiration

• A demonstration of arrogant and haughty behaviors or attitudes

Treatment of Narcissism

Medications for Narcissism

•  Individual psychotherapy can be effective •  Can be difficult and time consuming •  Rarely seek out treatment voluntarily; ▫  often at the urging of family or to treat symptoms associated with NPD

•  Therapy can be difficult due to clients unwillingness to acknowledge the disorder

•  No psychiatric medications are tailored specifically toward the treatment of NPD •  May benefit from use of psych meds to help alleviate certain symptoms i.e. depression, anxiety, transient psychosis, mood swings, and poor impulse control

•  Compounded by third party payers focus on short-term treatment to minimize symptoms (depression and anxiety) but ignore the underlying problems

•  Many have co-occurring diagnoses of mental disorders and are taking regular psych meds

•  CBT often effective in helping to change destructive thinking/ behavior patterns

•  3 major psychiatric drug classes, antidepressants, antipsychotics, and mood stabilizers, can be used to treat certain symptoms associated with NPD

•  Goal of treatment: alter distorted thoughts and create a more realistic self-image

Histrionic Personality Disorder

HPD (cont)

•  Excessive but shallow emotions and attentionseeking behaviors

•  Generally need others to witness their emotional displays in order to gain validation or attention

•  Constantly “performing” in order to gain attention

•  May display exaggerated symptoms of weakness or illness

•  Experience fleeting moods, opinions, and beliefs

•  May threaten suicide to manipulate others

•  Very suggestible and quick to respond to fads

•  Many use sexually provocative behaviors to control others or gain attention

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Treatment for Histrionic PD

DSM 5 and Personality Disorders

•  Often difficult to treat •  Often seek treatment only when the disorder is causing major problems or stress •  Psychotherapy can be effective

Personality disorders unchanged: alternative approach to diagnosis of PD developed for further study in section III

•  Group therapy not recommended as the individual tries to seek attention from group members and exaggerates symptoms.

Looking for Personality Disorders

Differential Diagnosis Considerations

•  No longer Axis II

•  Substance use can look like PD

•  5 Axes have been taken out of DSM 5

•  Cocaine and alcohol – Borderline

Cluster A: •  Involve odd or eccentric behavior. •  Includes paranoid, schizoid, and schizotypal personality disorders.

•  Multiple substance – Antisocial

Cluster B: •  Involve dramatic, emotional, or erratic behavior. •  Includes antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C: •  Involve anxious, fearful behavior. •  Includes avoidant, dependent, and obsessive-compulsive personality disorders.

Audience Polling Question #7 Have you had the opportunity to explore the cultural considerations outlined regarding personality disorders in the new DSM 5?

•  Substance using and addictive behaviors can mimic APD •  Substance use and PTSD in females can appear as BPD •  Must consider symptomatology and history, including sober periods

Culture and the DSM 5 • Cultural considerations for symptoms and diagnoses • Section III: “Cultural Formulation” (revised) page 749-759 • Appendix: “Glossary of Cultural Concepts of Distress” page 833-837

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Clinical Considerations

SUD and Culture

Substance Use Disorders:

• Opioids: Consider increased access in medical field

• Alcohol: condoned or discouraged • Cannabis: Acceptable use in some cultures, medical use controversial across and within cultures

• Stimulants: Non-Hispanic whites have highest rates of meth use

• Hallucinogens: consider religious practices (e.g. use of peyote, psilocybin)

• Nicotine: Some ethic groups may have greater difficulty quitting

Clinical Considerations

Clinical Considerations

•  Paranoid PD: may see culturally related behaviors that could be misinterpreted as paranoid

•  Borderline PD: adolescents and young adults with identity problems may be misdiagnosed from a snapshot picture in time

•  Schizotypal PD: religious cultural milieu such as speaking in tongues, voodoo, shamanism, evil eye, and other magical beliefs may appear to be SPD

•  Dependent PD: Age and cultural considerations. Dx must only be made when behaviors are in excess of cultural norms or shows unrealistic concerns (e.g. passivity and politeness or fostering dependency in either males or females)

•  Antisocial PD: APD or protective survival strategy? (consider low socioeconomic and urban status)

•  Obsessive-Compulsive PD: Not to include culturally sanctioned habits, customs, interpersonal styles (e.g. strong emphasis on work)

In Summary

Resources

ü  Diagnose with care

•  Personality disorders and substance use - National Drug Strategy www.nationaldrugstrategy.gov.au/internet/drugstrategy/.../m718.pdf

ü  Consider differential diagnosis

•  Substance Abuse Treatment for Persons With Co-Occurring Disorders: Treatment Improvement Protocol (TIP) Series, No. 42; Center for Substance Abuse Treatment. Rockville (MD): SAMHSA; 2005.

ü  Practice within scope ü  Avoid Stereotypes and biases ü  Be aware of your own stuff ü  Take care of yourself!!

•  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5); American Psychiatric Association. 2013 •  Treating Personality Disorders; Mayo Clinic; http://www.mayoclinic.com/ health/personality-disorders/DS00562/DSECTION=treatments-and-drugs •  Personality Disorders: Review and Clinical Application in Daily Practice; http://www.aafp.org/afp/2011/1201/p1253.html. K.B. Angstman, MD, N. H. Rasmussen, EdD, Mayo Clinic College of Medicine, Rochester, Minnesota: Am Family Physician. 2011 Dec 1;84(11):1253-1260

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