AODs and Anxiety Disorders

Psychoactive drugs can markedly arouse intense psychomotor stimulation and numerous manifestations of anxiety, including generalized anxiety and panic attacks. Stimulant and marijuana use and depressant withdrawal can prompt the emergence of anxiety symptoms. Hallucinogenic drugs can cause intense emotional excitement and subsequent anxiety.

Case Example

While Molly and a group of her friends were preparing to attend a rock concert, they each consumed a tablet that was described as Ecstasy (methylenedioxymethamphetamine or MDMA). About an hour later, Molly began to experience potent emotional sensations, and felt an internal pressure to talk about her feelings. Once inside the coliseum, Molly gravitated toward the stage. At some point, she became increasingly aware of the loudness of the music, the brightness of the stage lights, and the intense crowding of concert attendees. Molly began to sweat heavily, tremble, and feel dizzy. She turned to escape the overstimulation, but the crowd of people made her passage difficult. She became fearful and nauseous, and her hands and feet tingled and became somewhat numb. By the time she reached the first-aid tent, she felt that she was losing her mind.

By taking a history from Molly and speaking with her friends, the emergency medical technician determined that she had taken MDMA, which along with the explosion of sight, sound, and crowding, prompted a severe panic attack. Molly was treated by moving her to a quiet room without bright lights, letting her walk off some of the nervousness, and using "talkdown" techniques. The acute panic symptoms resolved within minutes, although she was anxious for the next hour. About 3 hours after taking the MDMA, the stimulant effects diminished, and Molly felt only a sense of mild anxiety and frustration for having missed much of the concert.

AOD-Induced Conditions

The addiction counselor should not assume that anxiety symptoms, especially those emerging or persisting after 30 days in treatment, or depersonalization are related to AOD abuse. Staff in mental health programs, on the other hand, may fail to recognize that the symptoms of anxiety, caused by AOD use, may resemble a psychiatric disorder. Addiction counselors have historically been encouraged more than psychiatric personnel to seek referrals for the patient who requires treatment beyond their clinical skills. Both groups should view increased cross-referral and consultation as beneficial.

Acute withdrawal and dissociative disorder often appear similar. Dissociated people require an immediate toxicological screen and should be admitted for continued observation. Attempts to establish reality-based grounding are necessary with these patients before medications are given or other interventions are attempted. The clinician should establish a soothing atmosphere, establish eye contact with the patient, and keep the patient grounded. It is often helpful to encourage agitated patients to focus externally on things they can see and describe, instead of focusing on their internal states. This shift in attention is often effective in allaying distress.

People in outpatient treatment may be verifiably abstinent and participating in recovery but may be experiencing dissociative symptoms. Patients with these disorders may have great difficulty in establishing and maintaining abstinence. Thus, integrated (rather than parallel) treatment is especially important for this group.

The evaluation of anxiety disorders and dissociative disorders, including PTSD and MPD, should include a careful history of recent and remote traumas. An assessment of trauma should include physical, sexual, and psychological abuse, and catastrophic stresses such as combat or hostage situations. For example, a rape experience within the last year and early childhood incest both could lead to the development of anxiety disorders. People living in violent situations, such as prostitutes who have been raped, can manifest anxiety symptoms. It is a mistake to ignore violence such as rape and look solely at early traumas. Recent traumas can be the trigger for PTSD or an MPD event. Early childhood abuse of males as well as females must be considered.

Assessment of the Anxious Person

Anxiety is one of the most common symptoms of people with AOD disorders. During acute assessments, many patients who are anxious and/or depressed are experiencing the effects of AOD use. As is the case with depression, time must pass before it is possible to make a definitive differential diagnosis of either AOD abuse, anxiety, depression, or a combination thereof. Most symptoms related to AOD use usually clear within 2-4 weeks, although the generally less severe subacute withdrawal symptoms may emerge after this time.

Patients with panic disorder are more likely to give a better history and description of panic attacks than the depressed patient can give regarding episodes of depression. Many people with a history of panic or anxiety disorders will be able to describe them with impressive accuracy. Also, patients with anxiety disorders are more likely to perceive them as abnormal conditions or "illnesses" that they don't deserve, compared with depressed patients who often feel that they deserve to be depressed or may feel that being depressed is a normal condition. Both depressed and anxious patients tend to ignore the connection with AOD use.

Various states may be mistakenly called anxiety, and people often use terms such as "panic attack" to describe nonpsychiatric states. Thus, clinicians should clarify the nature of the experience described by the patient. For example, many people consider any fear as anxiety or panic: "You really scared me. I almost had a panic attack." Careful inquiry along the lines of DSM-III-R criteria will distinguish definitive characteristics of anxiety disorders from commonplace distress described with popular terms.

Anxiety can be dangerous. In combination with depression (which is frequent), the risk for suicide is markedly increased. In the emergency room or clinic, people may exhibit panic, dissociation, or PTSD; they can be very difficult to handle. Anxiety can mimic signs of heart disease such as angina, arrhythmias, heart attacks, cardiac ischemia, and congestive heart failure; it can also accompany these conditions.

In the medical examination of the anxious person, there should be a high index of suspicion of AOD use, especially withdrawal from depressants and intoxication with stimulants and hallucinogens. The seemingly dissociated individual should receive immediate toxicologic screens. AOD-induced anxiety symptoms can signal serious medical crises; for example, benzodiazepine withdrawal can cause seizures.

In cases where medications cause depression, caretakers have time to deal with them. In contrast, anxiety caused by drug use may signal a medical emergency. Nonmedical people should be familiar with warning signs and have rapid access to medical screening.

A Stepwise Approach to Using Self-Help

It is important for AOD abuse treatment staff to appreciate the difficulty and distress that are experienced by people who have social phobias and fears of speaking in public. Staff who assist such patients with 12-step group participation should become knowledgeable about the signs and symptoms, course, and treatment of generalized anxiety disorder, panic disorder, the phobias -- especially social phobia -- and other anxieties related to public speaking and social situations.

Staff can help socially anxious patients participate in 12-step group meetings by using a stepwise approach of progressively active exposure and participation -- based somewhat on the principles of systematic desensitization. Patients can be encouraged and counseled to participate in progressively intense levels of group preparation and participation.

One of the least intense levels of preparation involves the use of mock Alcoholics Anonymous meetings consisting of staff and patients. This process makes it possible to frequently stop the meeting, discuss various meeting components, examine group methods, and allow potential participants to observe and practice. This type of approach can be helpful with most other patients with dual disorders.

The next level of intensity involves the attendance at a 12-step group meeting as a nonspeaking observer. However, staff should encourage patients to understand that being a nonspeaking observer is a transitional phase, and is not a substitute for active participation.For this reason, it may be helpful to limit nonspeaking observation by the patient to a specific number of meetings.

The next level of intensity involves patients attending a limited number of 12-step meetings during which they identify themselves beyond just giving their name but do not talk about themselves.The therapist can give assistance by providing easily rehearsable suggestions for self-introductions such as, "Hi, my name is Mary. I'm an alcoholic and I am glad to be here, although I am a little nervous."

Since much of the networking and mutual support associated with the 12-step group meetings occur outside of the meeting, anxious patients should be encouraged to do more than merely attend and participate in the meetings. Rather, they should be encouraged to arrive before the meeting begins and to linger and mingle with others following the meeting. Patients can be encouraged to volunteer to help set up the room, make the coffee, or clean up afterwards. In particular, socially phobic patients can be encouraged to join others for coffee and conversation after the meetings on a more one-to-one basis, a traditional aspect of 12-step group involvement.

By participating in step-by-step, rehearsed activities, many anxious and depressed patients seem to break through an internal barrier. As they do, participation in self-help group meetings becomes an integral aspect of recovery from AOD and psychiatric problems.

The stepwise approach described for patients with anxiety disorders can be adapted for patients who are depressed. Anxious patients often avoid group participation and public speaking, saying to themselves, "If I talk or if I am noticed, I will freak out." Similarly, depressed patients often avoid group participation and other recovery activities, perhaps thinking, "I just don't have the energy to go. No one will care anyway. Why bother?"

The therapist must elicit comments, understand them, and help patients to reverse these internal barriers to recovery and participation in group and other social activities.For practical guidance on these issues, the reader is encouraged to read the information on step work and "thinking-error work" in the chapter on personality disorders, adapted from Step Study Counseling With the Dual Disordered Client by K. Evans and J. M. Sullivan.

Definitions and Diagnoses

The word personality describes deeply ingrained patterns of behavior and the manner in which individuals perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of personality and are not necessarily pathological, although certain styles of personality traits may cause interpersonal problems. Personality disorders are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are enduring and persistent styles of behavior and thought, not atypical episodes.

Several alcohol and other drug (AOD)-induced states can mimic personality disorders. If a personality disorder coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or worsen personality disorders. The course and severity of personality disorders can be worsened by the presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.

The personality disorders include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, obsessive-compulsive, passive-aggressive, and self-defeating personality disorder. Many features of the personality disorders may occur during an episode of another mental disorder. Individuals may meet criteria for more than one personality disorder.

Four personality disorders have been selected for detailed discussion: borderline, antisocial, narcissistic, and passive-aggressive.These are among the greatest challenges to treatment providers. This TIP provides information about engagement, assessment, crisis stabilization, and longer-term care, and describes a continuum of care for patients with personality disorders.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy. Borderline personality disorder is characterized by unstable mood and self-image, and unstable, intense, interpersonal relationships. These people often display extremes of overidealization and devaluation, marked shifts from baseline to an extreme mood or anxiety state, and impulsiveness.

Narcissistic personality disorder describes a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation by others. Passive-aggressive personality disorder involves covertly hostile but dependent relationships. People with this disorder commonly lack adaptive or assertive social skills, especially with regard to authority figures. They often display a passive resistance to demands for adequate social and occupational performance. They generally fail to connect their passive-resistant behavior with their feelings of resentfulness and hostility toward others. Exhibit 7-1 describes the characteristics of passive-aggressive, antisocial, and borderline personality disorders.

Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and timidity, with accompanying depression, anxiety, and anger for failing to develop social relations. Obsessive-compulsive personality disorder describes a disorder of perfectionism and inflexibility. Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings, feelings of depression, and anger about being controlled by others. Hypersensitive to criticism, these people may be excessively conscientious, moralistic, scrupulous, and judgmental.

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Behavior may include constant seeking of approval or attention, striking self-centeredness, or sexual seductiveness in inappropriate situations. Paranoid personality disorder is characterized by a pervasive and unjustified proclivity to interpret the actions of others as intentionally threatening, demeaning, and untrustworthy.Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive behavior and an intense preoccupation with possible abandonment. Persons with this disorder often feel anxious and depressed, and may experience intense discomfort when alone for more than a brief time.

Schizoid personality disorder involves a pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression. Schizotypal personality disorder entails deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior and dysphoric states such as anxiety and depression. Self-defeating personality disorder is characterized by a pattern of self-defeating behavior in work and personal relationships, often with complaints of exploitation by others; these persons are often unaware of their contributions to the outcomes of their behavior.

Personality disorders not otherwise specified (NOS) include disorders of personality functioning that are not classifiable as specific personality disorders. Instead, individuals do not meet the full criteria for any one personality disorder; yet their symptoms cause significant impairment in social or occupational functioning, or cause subjective distress. Personality disorders NOS include impulsive, immature, and sadistic personality disorders.

Diagnoses should be clinically based, and not influenced by professional, personal, cultural, or ethnic biases. For example, in the past some African Americans were stereotyped as having paranoid personality disorders; women have been diagnosed too frequently as being histrionic, but they are seldom diagnosed as antisocial or psychopathic; Native Americans with spiritual visions have been misdiagnosed as delusional or having borderline or schizotypal personality disorders.

AOD Use Among People With Personality Disorders

People with a personality disorder often use AODs for purposes that relate to the personality disorder: to diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings of guilt, and to amplify feelings of diminished individuality.

People with borderline personality disorder often use AODs in chaotic and unpredictable patterns and in polydrug patterns involving alcohol and other sedative-hypnotics taken for self-medication. People with personality disorders often develop problems with benzodiazepines that have been prescribed for complaints such as anxiety, which may lead to relapse to the primary drug of choice.

Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial symptoms. They tend to prefer stimulants such as cocaine and the amphetamines.Rapists with severe antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial personality disorder may use heroin and alcohol to diminish feelings of depression and rage.

People with narcissistic personality disorder are often polydrug users with a preference for stimulants. Alcohol has disinhibiting effects, and may help to diminish symptoms of anxiety and depression. Socially awkward or withdrawn people with narcissistic personality disorder may be heavy marijuana users. One group of people with narcissistic personality disorder uses steroids to build up a sense of physical perfection. When not using AODs, people with narcissistic personality disorder may feel that others are hypercritical of them or do not sufficiently appreciate their work, talents, and generosity. During a crisis, these people may be severely depressed and upset.

Drug preference among people with passive-aggressive and self-defeating personality disorders often varies according to gender. Women may prefer alcohol and other sedative-hypnotics to sedate negative feelings such as anxiety and depression.Although men may use these AODs, they may also use stimulants to disinhibit aggressive or risk-taking behaviors. People with passive-aggressive personality disorder often complain of somatic problems, such as migraines, muscle aches, and ulcers.They may seek over-the-counter medications as well as cocaine and amphetamines to relieve somatic symptoms.

Suicidal Behavior

All suicidal behavior, from threats to attempts, must be taken seriously and assessed immediately to determine the type of immediate intervention needed. Special attention must be given to previous attempts and their seriousness, previous intervention strategies, whether the failure of the attempt was intended or accidental, the relation of previous suicidal behavior to psychiatric symptoms, and current psychiatric symptoms. All suicidal behavior should provoke the following questions:

• How specific is the plan?
• What method will be used?
• When will it happen?
• How available are materials (drugs, weapons)?

Patient Contracting

Management of self-harm can be accomplished by creating written or oral contracts with patients. In these contracts, a patient may promise to avoid certain self-harm or high-risk behavior (such as suicide or relapse), or may promise to engage in a specific healthy behavior (such as calling his or her 12-step sponsor or a suicide prevention hotline) when self-harm or a high-risk behavior appears imminent.

Therapists should attend to the patient's need for safety. Safety may range from the need for safe shelter to escape domestic violence to the need to reside in a controlled environment in order to remain abstinent.

Transference and Countertransference

Transference and countertransference can present problems in group and individual therapy.Therapists should be prepared to manage these issues. Transference refers to positive and negative feelings and perceptions that the patient projects onto the therapist. Countertransference refers to distortions in the therapeutic process due to the therapist's unresolved conflicts. Both transference and countertransference rely on the mechanism of projection.

Projection is a combination of personal past experiences along with feelings experienced during the course of therapy.Being aware of transference issues and commenting on them when appropriate is extremely important when working with these patients.

Clear Boundaries

Boundaries are clear expectations regarding limitations or requirements in roles or behavior. Boundaries are ethical and practical ground rules that help therapists to be therapeutically helpful to patients. The clinician and patient must establish and maintain clear boundaries. Boundaries must also be set in group therapy sessions. For example, therapists should not lend money to patients or involve them in financial deals. Patients should not establish intimate relationships with others in group therapy.

Changing Roles

People with personality disorders often assume certain roles or ways of social interaction. They may shift from one role to the next, depending upon the situation. Some of these roles include: the victim, the persecutor, and the rescuer.

As these patients assume a specific role (such as the victim), other people may be prompted to assume a complementary role (such as the rescuer). Therapists should be aware of the roles that people with personality disorders may assume. They should resist assuming dysfunctional complementary roles themselves and become aware when they do assume such roles.

Resistance

Patients with personality disorders often exhibit acting-out behaviors that were developed as psychological defenses and survival techniques. The patient may be reenacting a response learned during experiences of abuse or trauma. Resistances are defenses and coping mechanisms that help patients survive in situations confronted in therapy which are perceived as threatening.

Confronting a patient's resistance without helping the patient develop other strategies for safety will probably escalate the patient's tension. Therapists should view and use resistance as a therapeutic issue, not as a challenge to treatment.

Subacute Withdrawal

It is becoming increasingly clear that alcohol and most other drugs of abuse produce acute and subacute withdrawal syndromes. Depending on the specific drug, subacute withdrawal may include mood swings, irritability, impairment in cognitive functioning, short-and long-term memory problems, and intense craving for AODs. Subacute withdrawal syndromes often trigger relapse and exacerbate existing psychiatric symptoms

Symptom Substitution

During periods of abstinence from AODs, some people will engage in other types of compulsive behaviors. Some of these behaviors include eating disorders, and compulsive spending, gambling, and sex. Relationship problems may also increase.

Somatic Complaints

Patients with addictions to prescription drugs often seek treatment because of somatic complaints. Therapists should watch for use of prescription and over-the-counter drugs and for drug-seeking behaviors.

Therapist Well-Being

Therapists should be mindful of their own well-being, which can be compromised when working with patients with personality disorders. Clinicians can be drawn into playing certain roles in the lives of patients with personality disorders. To prevent this, therapists should care for themselves by seeking outside supervision. Therapists should join or develop support systems with others in the field through 12-step program participation, regular meetings with other therapists, grand rounds, and the like.

The following sections describe specific strategies and techniques that therapists can use when working with patients who have an AOD use disorder and a borderline, antisocial, narcissistic, or passive-aggressive personality disorder.

Each section describes techniques for assessing patients and engaging them in treatment, stabilizing crises, providing long-term care, and creating a continuum of care. Each section concludes with a case example in which the reader is asked to make a treatment decision.Where appropriate, clinical tools are provided.

Engagement

Safety is an anchor for patients with borderline personality disorder, for whom abandonment and fear of rejection are often core issues.To engage and assess these patients, the therapist should acknowledge and join with the patient's need for safety. The therapist's absence, even for brief periods, can prompt acting-out behavior.

Acting-out behavior is a maladaptive survivor response that expresses a need for safety. Therapists should identify each patient's motivation for recovery, which may be rooted in safety. Further, therapists should discover what safety means to the patient.

Therapists can learn how patients create their own feelings of safety by asking them about safe spots, magic getaway places, closet-sitting, rocking or other repetitive movements, or other techniques the patient may use to generate a sense of security.To help patients with borderline personality disorder establish and maintain a sense of safety, therapists can continually ask patients: "What do you need right now?" "What do you want right now?"

Therapists may work with patients to develop a patient-generated list of the conditions that they need in order to feel safe. Therapists may ask patients: "What would have been helpful (in a specific situation) to make you feel safe?" Through teaching cognitive skills to promote patients' sense of safety, therapists can help patients with borderline personality disorder to assume personal responsibility for their own safety.

Written and verbal contracts can identify specific ways to help patients stay physically and emotionally safe and to prevent relapse. Written and verbal contracts for safety should be developed during the assessment process with simple and clear behavioral responses regarding the management of unsafe feelings and behaviors. These contracts can be very simple and direct:

• "If I feel like I want to get drunk, I will call my sponsor."
• "If I feel like getting loaded, I will go to the next NA meeting."
• "If I feel like hurting myself, I will call a crisis hotline and go to my sister's house."
• "I will report self-harm thoughts and behaviors to the therapist at the next session."

Assessment

When assessing a patient, the therapist is attempting to understand and view the patient within a holistic framework. Areas of assessment may include a history of AOD and mental health treatment, suicidal planning, dissociative experiences, psychosocial history, history of sexual abuse, and a history of psychotic thinking. Some patients may also require a neurological examination.

The assessment of patients with borderline personality disorder should look for a history of self-harm. Behaviors such as AOD use should be described as unsafe behaviors. However, clinicians should help people with borderline personality disorder to avoid black-and-white thinking, such as right/wrong and good/bad, and all-or-nothing styles of thinking. Specifically, the assessment should include the following:

• A history of previous treatment, including psychiatric medications administered, and a description of what worked and what did not work in treatment, as well as information on why the patient left earlier treatment. Patients are not always a reliable source of information about themselves, and therapists should evaluate this information accordingly. The treatment history can help the therapist avoid unnecessary repetition of treatment strategies, such as skill-building activities in which the patient is already competent (for example, relaxation strategies). The history taking is an opportunity to examine patients' strengths and weaknesses.

• A list of potential means available to patients to injure themselves in their own homes, such as a large supply of medication.

• History and evidence of dissociative experiences, such as trance states, rocking, flashbacks, nightmares, and repressed memories.Any and all parts of a memory can be repressed. One model for assessing dissociation and identifying repressed memories is the BASK model. The BASK model is a quick way to check what part of the memory is missing, and whether or not it is Behavior, Affect, Sensation, or Knowledge. Survivors of abuse may detach themselves from their feelings so that they recall memories of abuse in a robot-like fashion.

• Attachment to a special object. Anniversary reactions are also common to survivors of abuse, whose memories or feelings may be triggered by certain dates, events, or objects. For no apparent reason, the survivor may become sick or suicidal when faced with a situation similar to a past reminder of abuse.

• History of fugue states and losing time.For example, patients with borderline personality disorder might start watching a movie and suddenly reorient later in the middle of another movie, with no clear memory of the elapsed time.

• Psychosocial history and history of sexual abuse. It is common for people to feel as if they were sexually abused without having any actual memories of the abuse or trauma.Questions should be framed in a manner that facilitates the acquisition of all relevant information. By asking open-ended questions while paying attention to the patient's body language, the therapist may be able to draw useful conclusions.

• Neurological workup of individuals who have a history of self-mutilating behaviors that could have resulted in cognitive impairment such as head-slamming. Some psychologists will conduct neurological screening;in other cases, a neurologist should be consulted.

• Psychotic-like thinking and history of suicidal behavior, especially under intense stress. Psychotic-like thinking may be evident during episodes of trauma and stress. For example, a patient may state, "The walls are bleeding."

Crisis Stabilization

Safety issues are at the core of crisis stabilization.To ensure the patient's safety or to detox a patient, a brief psychiatric hospitalization may be necessary. Issues to be addressed during crisis stabilization might include an unwillingness or inability to contract for safety. A written release of medical information is important to coordinate care with physicians and addiction counselors.

At this stage, therapists should avoid psychodynamic confrontations with patients and should not engage patients in further therapy for abuse or trauma. The treatment focus should be on addressing the patient's need for safety, especially important with patients who have borderline personality disorder. More complicated and emotionally charged material should be deferred until the patient has better skills to manage emotional pain.

It may be helpful to describe out-of-control crisis behavior as a survivor response. Therapists and patients should avoid rigid black-and-white thinking. Describing events or issues as being more helpful or less helpful may circumvent the inflexibility of seeing life's challenges and problems only as black and white, while ignoring the numerous grey areas of experience.

During crisis stabilization, the continued use of written and verbal contracts is critical. These contracts should be rooted in the here-and-now, and should offer patients practical ways to manage crisis behavior. The contracts must focus on safety. Contracts written on 3-by-5-inch cards that they can carry and read when necessary are very helpful for patients with borderline personality disorder. Contracts should be simple and concrete and should emphasize problem-solving skills.

Therapists should work on relapse management strategies that are clear and concrete, such as: "Before I use cocaine, I will call my sponsor." At the same time, therapists should encourage patients to be honest about relapse. Therapists should assume a posture of concerned support about relapse and view it as an opportunity to learn from past mistakes and strengthen relapse prevention skills and the therapeutic relationship.

The family -- as defined by each patient -- should take part in this process. It may be useful to encourage contracts with family members. These contracts can dissuade family members from assuming dysfunctional roles such as the victim, the persecutor, and the rescuer. The family should learn how to set boundaries with the patient, and should learn not to play certain roles, especially the role of rescuer.

Longer-Term Care

Case Example

Rachel was 32 years old when she was taken by ambulance to the local hospital's emergency room. Rachel had taken 80 Tylenol capsules and an unknown amount of Ativan in a suicide attempt. Once stable medically, Rachel was evaluated by the hospital's social worker to determine her clinical needs.

The social worker asked Rachel about her family of origin. Rachel gave a cold stare and said, "I don't talk about that." Asked if she had ever been sexually abused, Rachel replied, "I don't remember." Rachel acknowledged previous suicide attempts as well as a history of cutting her arm with a razor blade during stressful episodes. Rachel reported that the cutting "helps the pain."

Rachel denied having "a problem" with AODs but admitted taking "medication" and "drinking socially." A review of Rachel's medications revealed the use of Ativan "when I need it." Rachel used Ativan three or four times a week. She reported using alcohol "on weekends with friends" but was vague about the amount. Rachel did acknowledge that before her suicide attempts, she drank alone in her apartment.This last suicide attempt was a response to her breakup with her boyfriend.Rachel's insurance company is pushing for immediate discharge.

Question -- Should Rachel be discharged? Where should she be sent? Exhibit 7-3 shows a recovery model for treatment of borderline personality disorder.

Engagement

In engaging the patient with antisocial personality disorder, it is useful to join with the patient's world view, which may include a need for control and a sense of entitlement. In this context, entitlement refers to people who believe their needs are more important than the needs of others. Entitlement may include rationalization of negative behavior (such as robbery or lying). People with antisocial personality disorder may evidence little empathy for their victims. If incarcerated, they may believe they should be released immediately. In an AOD treatment program, they may describe themselves as being unique and requiring special treatment.

The primary motivation of the patient with antisocial personality disorder is to be right and to be successful. It is useful to work with this motivation, not against it. Although this motivation may not reflect socially acceptable reasons for changing behavior, it does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a job, to avoid jail, and to become the chair of an AA meeting are reasonable goals, despite a self-serving appearance. Therapists may help patients by working with patients' world view, rather than by trying to change their value system to match those of the therapist or of society.

Patients should understand their role in the process. In engaging patients, therapists may want to use contracts to establish rules for conduct during treatment. The contract should explicitly state all expectations and rules of conduct and should be honored by all parties. Such an approach can be useful with people with antisocial personality disorder, who often view relationships as unfair contracts in which one person attempts to take advantage of the other. Therapists may find that once a level of interpersonal respect has been established, working with antisocial patients can lead to important gains for the patient.

Assessment

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial patient:

• Taking a thorough family history.
• Finding out whether or not the patient set fires as a child, abused animals, or was a bed-wetter.
• Taking a thorough sexual history that includes questions about animals and objects.
• Taking a history of the patient's ability to bond with others. Therapists can ask: "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
• Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
• Taking a history of head injuries, fighting, and being hit. It may be useful to perform neuropsychological testing.
• Testing urine for recent AOD use.
• HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of AOD use to behavior.

Useful assessment instruments include the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the PCL-R (Hare Psychopathy Checklist-Revised), and the CAGE questionnaire.

Crisis Stabilization

People with antisocial personality disorder may enter treatment profoundly depressed, feeling that all systems have failed them. Often, their scams and lofty ideas have failed and they feel exposed, feel like losers, and have no ego strength.They are at risk for suicide, especially during intoxication or acute withdrawal. They may require psychiatric hospitalization and detoxification.

They may become acutely paranoid. Containment in the form of a brief hospitalization may be indicated for patients experiencing acute paranoid reactions to avoid acting out against others. For less acute paranoid reactions, therapists should try to avoid cornering patients, disengage from any power struggle, offer lower stimulus levels, and create options, especially if those are supplied by the antisocial patient. During this phase, clarification without harsh confrontation is recommended.

When patients with antisocial personality disorder have crises, therapists should become cautious and careful. During crises, these patients may engage in dangerous physical behavior in order to avoid unpleasant situations or activities, and therapists should avoid angry confrontations.

Longer-Term Care

Case Example

Mark was 27 years old when he was arrested for driving while intoxicated. Mark presented himself to the court counselor for evaluation of possible need for AOD treatment. Mark was on time for the appointment and was slightly irritated at having to wait 20 minutes due to the counselor's schedule. Mark was wearing a suit (which had seen better days) and was trying to present himself in a positive light.

Mark denied any "problems with alcohol" and reported having "smoked some pot as a kid." He denied any history of suicidal thinking or behavior except for a short period following his arrest. He acknowledged that he did have a "bit of a temper" and that he took pride in the ability to "kick ass and take names" when the situation required. Mark denied any childhood trauma and described his mother as a "saint." He described his father as "a real jerk" and refused to give any other information.

In describing the situation that preceded his arrest, Mark tended to see himself as the victim, using statements such as "The bartender should not have let me drink so much," "I wasn't driving that bad," and "The cop had it out for me." Mark tended to minimize his own responsibility throughout the interview. Mark had been married once but only briefly. His only comment about the marriage was, "She talked me into it but I got even with her." Mark has no children and currently lives alone in a studio apartment. Mark has attended two meetings of Alcoholics Anonymous "a couple of years ago before I learned how to control my drinking."

Question -- What might the court counselor recommend to the judge as an appropriate treatment plan for Mark?

Exhibit 7-5 shows a treatment tool for use with patients who have antisocial personality disorder.

Engagement

In trying to engage and assess patients, therapists should remember that patients with narcissistic personality disorder will have certain traits that should be addressed therapeutically. Therapists should try to join with patients' hypersensitivity and need for control by saying such things as "I'm impressed with what a bright and sensitive person you are. If we work as a team, I think we can help you get out of this spot."

Patients with narcissistic personality disorder often have a need to be the center of attention and to control events. They crave affection and admiration from others. They are perfectionists (about themselves). They may try to create dramatic crises to obtain attention to return the focus to themselves. As with patients with antisocial personality disorder, entitlement issues are very important. Patients with narcissistic personality disorder feel as if everyone and everything owes them -- without any contribution on their part.

It is helpful for therapists to work with these personality traits in therapy. Working with narcissistic motivations for recovery, such as an improved appearance or a desire to continue in a job or to make romantic and sexual conquests, may help the patient to change inappropriate behaviors.Therapists may benefit from working with, rather than against, ego inflation.Therapists who try to squelch the narcissistic ego may be met with rage.Therapists should position themselves as trying to help the narcissistic patient reach his or her goals.

Therapists may work with patients to identify thinking errors that interfere with the patient's ability to work. These errors may include beliefs such as "Everybody loves me." Therapists may need to work with patient's victim-stance thinking. An example of such thinking is "Everybody is out to get me." The antisocial thinking-error work described in the previous section (see Exhibit 7-4) can be a very effective tool for working with the narcissist.

To manage narcissistic rage and depression, therapists may contract for patient safety as well as for the safety of others. The therapist may offer the patient a combination of empathy and reality testing. For example, when patients say, "Everything is messed up," or "Everybody is causing me trouble," therapists may empathize with patients, while also indicating the reality of the situation and the need for behavior change.

Assessment

Some examples of items to cover during the assessment include:

• A psychosocial history, including early childhood beliefs with regard to looks, behaviors, and thoughts
• A history of AOD use
• A sexual history to identify the ability to be empathic with partners
• Early Memory Procedures test (EMP)
• CAGE questionnaire
• Millon Clinical Multiaxial Inventory (MCMI-II)
• California Personality Inventory (CPI).

Crisis Stabilization

Therapists may need to assess patients' defenses, and to put those defenses to therapeutic use. For example, when a patient blames the police for "setting me up," the therapist can mention that the best way to avoid being set up again is to not drink and drive.

Patients with narcissistic personality disorder have a central concern with being perfect. For these individuals, the disease concept approach can assist in recovery by removing blame from the patient and conceptualizing the illness as a biochemical disorder. This can help to lessen the feelings of failure which can be a barrier to treatment.

People with narcissistic personality disorder may become depressed when they feel deeply wounded, when their systems have failed them, and when they sense that their world is falling apart. When wounded, they are at the highest risk for acting out against themselves and others. When in a narcissistic rage, patients may become homicidal, feeling a need to seek revenge. This rage comes from the intensity of the narcissist's wound. The counselor needs to work carefully with this rage and to avoid getting into power struggles.

When these patients are in suicidal crises, patients should sign contracts for safety. Safety may include brief psychiatric hospitalizations that are goal oriented and designed for stabilization.

When working with HIV-positive patients with narcissistic personality disorder, therapists may establish contracts with them to engage in safer-sex practices. Often sexual prowess is part of the narcissistic ego-inflation. Their need to see themselves as great lovers, coupled with self-centeredness, puts them at high risk for sexually transmitted diseases.

Longer-Term Care

Case Example

Bill is a 45-year-old male who was referred by his employer to the company's employee assistance program (EAP). The employer was concerned about Bill's temper, his difficulty accepting criticism, and his difficulty in getting along with other staff. At the EAP appointment, Bill's appearance was that of an extremely well-groomed man who paid exceptional attention to his dress and attire. His manners were impeccable, although he was critical of the receptionist at the EAP's office for not offering him coffee when he came in. Bill was friendly but cool toward the EAP counselor, tending to gloss over the importance of his boss's concerns.

When the EAP counselor asked him for more specifics about his problems with his coworkers, Bill became extremely defensive and hammered away in a raging attack on his coworkers and their jealousy of his success. Bill felt that his boss was a well-intentioned but incompetent person who frequently made mistakes. Bill also felt that his boss didn't appreciate the caliber of his work or the time he put into his work. Bill took pride in his perfectionism, attention to detail, and firm and inflexible beliefs.

Bill was not married, although he reported that he had come close a few times only to discover that these women had "fooled him" in one way or another. Bill reported to have only one male friend and indicated that he much preferred the company of women to men. Bill denied having any "problem with drugs" but did indicate that he uses marijuana and cocaine recreationally. Bill reported using alcohol most weekends and occasionally drinking to the point where he "forgot" what happened.

Question -- What should the EAP counselor suggest as a treatment plan to address employer concerns over Bill's behavior?

Engagement

As in working with all patients with personality disorders, therapists should attempt to join with the world-view of patients with passive-aggressive personality disorder, rather than work against it. Therapists may try to work with patients' need for safety and with their ambivalence toward recovery.Therapists should work with patients' indirect displays of anger and assertiveness.

Passive-aggressive patients try to avoid commitment and responsibility. All interventions should be focused on the patient's needs, wants, and desires, a strategy that promotes treatment compliance.

Assessment

Areas to address in the assessment include the following:

• Survival skills and self-care assessment
• Monitoring of use of over-the-counter drugs, such as NyQuil, Dexatrim, Benadryl, niacin, laxatives, and tryptophan (somatic illnesses are often medicated with these chemicals)
• Information on all other professionals and medical providers being seen for treatment
• Psychosocial and AOD history, and mental status
• Coexisting anxiety disorders
• Medication evaluations for antidepressants or other nonaddictive substances
• Identification of the patient's typical passive-aggressive maneuvers or "scripts."

Useful assessment instruments include the MMPI, CAGE, or MAST, to assist clinical review and/or to evaluate substance abuse.

Crisis Stabilization

Often, several issues must be managed during crises experienced by patients with passive-aggressive personality disorder, such as responses to abusive relationships, obtaining safe housing, and receiving emergency psychiatric admissions for suicidal crises.These patients may need to be detoxified from benzodiazepines and other sedative-hypnotics. To manage various crises, therapists may need to insist that patients provide release of information authorizations for all providers of care. This can help the therapist to coordinate services. Verifying all prescribed medications can prevent medical emergencies and improve patient responsibilities.

Longer-Term Care

Patients who have AOD use disorders that involve prescription drugs will find it helpful to inform their prescribing physicians of their involvement in treatment and recovery efforts. This helps to stop the supply of psychoactive medications, to learn assertive behavior, and to teach personal responsibility for recovery.

Patients with passive-aggressive personality disorder require skill building in several areas including: assertiveness, boundary setting, anger management, and identifying and expressing their feelings directly. They will also need to work through sexual intimacy problems. This might be done in a same-sex group, individual therapy, or marital or couple therapy.Treatment planning should include goals and objectives that are reasonable and measurable. For example, a goal may be set to increase the length of time during which a patient is abstinent between relapse episodes. An excellent focus for the skill-building part of therapy is developing the ability to express anger through assertiveness rather than through indirect acting out.

Passive-aggressive patients may engage in compulsive behaviors including eating disorders and compulsive shopping and spending; money management problems, as well as AOD relapse, may also occur. Throughout treatment, therapists should continue to monitor the patient's use of alcohol, prescribed and over-the-counter medications, and other drugs.